Sleep-disordered breathing (SDB) is a collective term, which encompasses snoring, upper airway resistance syndrome (UARS), obstructive sleep apnea-hypopnea syndrome, and obstructive sleep apnea (OSA). These terms describe a partial or complete obstruction of the upper airway during sleep. Patency of the pharyngeal airway is maintained by two opposing forces: negative intraluminal pressure and the activity of the upper airway musculature. Anatomical or central neural abnormalities can disrupt this delicate balance with resultant compromise of the upper airway. This reduction of airway caliber may cause sleep fragmentation and subsequent behavioral derangements, such as excessive daytime sleepiness (EDS) (1-3). Thus, medical and surgical therapy attempt to alleviate this obstruction and increase airway patency.
Surgical management was the first therapeutic modality employed to treat SDB. Kuhlo (4) described placement of a tracheotomy tube in an attempt to bypass upper airway obstruction in Pickwickian patients. Although effective, tracheotomy is not readily accepted by most patients and does not address the specific sites of pharyngeal collapse. These regions include the nasal cavity/nasopharynx, oropharynx, and hypopharynx. Often, multilevel obstruction is present. Consequently, the surgical armamentarium has evolved to create techniques, which correct the specific anatomical sites of obstruction. The objective of surgical intervention is to eliminate SDB. To achieve this goal, it is necessary to alleviate all levels of obstruction in an organized and safe protocol. Ultimately, it is the obligation of the surgeon to counsel the patient regarding all surgical techniques, risks, complications, and alternative medical therapies.
Medical management is often considered the primary treatment of SDB, however, there are exceptions. Treatment may consist of weight loss, avoidance of alcohol, and sedating medications and manipulation of body position during sleep (5-9). Currently, continuous positive airway pressure (CPAP) or bilevel positive airway pressure devices are the preferred methods of treatment and the standard to which other modalities are compared. The efficacy of CPAP has clearly been demonstrated
(10,11). Yet, a subset of patients struggle to comply with or accept CPAP therapy (12,13). Consequently, patients who are unwilling or unable to comply with medical treatment may be candidates for surgery.
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