A thorough office evaluation is the only way for an expert in sleep surgery to choose the right surgery for you. In spite of what you may read or hear elsewhere, there is no single surgical procedure works well for everyone with snoring or obstructive sleep apnea. In all areas of medicine, cookie cutter approaches do not work because people are different. For snoring and obstructive sleep apnea, age, gender, body weight, race and ethnicity all affect treatment outcomes, as do differences in the structures of the head and neck. All of these have major implications for the results of surgery for snoring and sleep apnea, and it is important to recognize these and choose surgical and non-surgical treatments based on them.
How do I know what snoring or sleep apnea procedure is right for me?
This website was developed to provide an introduction, with more detailed information about specific procedures that Dr. Kezirian performs. There is a great deal of information (and some misinformation) available on the Internet, and the goal of the website was never to have a reader come away knowing what procedure or procedures were best for them. An in-person evaluation, including a discussion of medical history and physical examination, is a critical first step, and typically Dr. Kezirian will be able to discuss treatment options following an initial evaluation. In some cases, he may recommend an evaluation called drug-induced sleep endoscopy to guide the selection of procedures.
The procedures on this site are grouped into three categories, reflecting their treatment of narrowing or blockage of the breathing passages in three regions: nasal, palate, and tongue. The evaluation process is designed to determine what areas are responsible for blockage of breathing and, more specifically, what structures are playing an important role. This is somewhat complex, as research from Dr. Kezirian and other experts has shown that over 60% of people have obstructive sleep apnea related to a combination of factors. Maxillomandibular advancement is a more-involved procedure that has greater risks, but it also works well to treat obstructive sleep apnea.
Choosing procedures for snoring and sleep apnea
To explain this process briefly, Dr. Kezirian’s approach to choosing procedures relies on what the procedures actually do and how that might improve snoring or sleep apnea in an individual patient. Based on substantial research, Dr. Kezirian’s lectures to surgeons around the world about procedure selection use the same principles described here. He relies on his own experience and the best published studies when choosing procedures to treat patients. You can watch his lecture about procedure selection at the International Surgical Sleep Society meeting in May 2017.
For example, there are a number of procedures covered in the Palate Procedures section. Some of these procedures (Pillar Procedure, Palate Radiofrequency, and Uvulopalatoplasty) are excellent options for treating snoring or the mildest form of obstructive sleep apnea because they stiffen the soft palate and prevent vibration. However, many surgical websites (and advertisements) suggest these palate stiffening procedures are good for most patients with obstructive sleep apnea, which is actually not true. While palate stiffening procedures are great options for many patients, careful and well-done studies (supported by the company that developed the devices) have shown that these procedures do not work well for most patients with sleep apnea. For patients with obstructive sleep apnea, there are a number of different palate procedures that remove and/or reposition tissue (not just stiffening). The choice among these other palate procedures that are useful for sleep apnea is based on what may be best for individual patients, given the structure of their throat and soft palate. Some procedures have more removal of tissue, and others have more tissue repositioning in the soft palate and sides of the throat (lateral pharyngeal walls).
As discussed on the Tongue Region Procedures section, there is another set of procedures that are used primarily for obstructive sleep apnea. They can treat the structures that contribute to blockage in this region: the tongue, epiglottis, and lateral pharyngeal walls. Dr. Kezirian’s research and that of other experts has shown that over 60% of patients with sleep apnea appear to have blockage of breathing in both the palate and tongue regions, typically requiring a combination of two types of procedures. In addition, this research has also suggested that different patients have tongue region blockage due to different structures, further requiring selection from among various options. Among the tongue region procedures, some are directed at the tongue (tongue radiofrequency, genioglossus advancement, lingual tonsillectomy, and midline glossectomy), and some are directed at the epiglottis (epiglottis surgery and hyoid suspension). Some of the palate procedures and hyoid suspension may also treat the lateral pharyngeal walls. Choosing among these tongue region procedures requires an evaluation to determine what structures may be playing a primary role and incorporating other aspects of physical examination, such as body weight.
Dr. Kezirian is one of the relatively few surgeons in the country who offers Upper Airway Stimulation to patients with obstructive sleep apnea. This innovative therapy treats blockage of breathing in both the Palate and Tongue Regions using nerve stimulation.
The large number of available procedures can be confusing. The reason there aer so many procedures is that they accomplish different things. The choice among the procedures is based on the pattern of blockage in breathing and weighing the risks and benefits for an individual patient.
The following video presents a discussion of the selection of surgical procedures:
The following video presents a more-detailed discussion of drug-induced sleep endoscopy, including some example videos:
The following video discusses the role of drug-induced sleep endoscopy in the selection of surgical procedures and oral appliances:
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