7 Common Procedures That Can Worsen Sleep Apnea

Millions of surgical operations are performed every year to improve your health, beauty, and even your smile, but there’s a hidden danger in some of the most common procedures that can aggravate if not actually cause obstructive sleep apnea. Sleep apnea happens when your jaws are too narrow, which constricts the internal soft tissue layer that lines your upper breathing passageways, from your nose to your throat. More than a few times a week, I see patients that underwent procedures in the past that clearly was detrimental to the quality of their sleep. Here are 7 common and uncommon procedures that can affect the way you breathe and sleep.

1. Rhinoplasty

One of the most common procedures that’s performed today is your routine nose job, or rhinoplasty. In most cases a hump is taken down, or the tip is made more narrow. In the process, certain support structures are weakened, with flimsy nostrils resulting many years later. In the 1950, the Goldman tip was one of the more popular styles, where the tip of the nose was made very narrow and lifted up slightly. With any procedure that narrows the tip, a portion of the lower lateral cartilages have to be either removed or weakened. This cartilage is one of the main support structures that keeps your nostril from collapsing inwards.

Initially after the procedure, patients can breathe well, but years or decades later, with constant inspiration and vacuum forces from routine breathing, the nostrils slowly cave inwards, worsening nasal congestion.

We know that nasal congestion can aggravate or cause obstructive sleep apnea. This is why nasal packing after any surgery is a miserable experience, and why you’ll toss and turn whenever you have a cold (from a stuffy nose). If your jaws are already narrowed, you’re more likely to have a nasal hump and narrowed nasal cavity, so worsening nasal congestion can only aggravate breathing problems downstream. Underdevelopment of the midface pulls the upper lip and the lower cartilaginous nose down, creating the classic nasal hump.

Even with contemporary rhinoplasty techniques, it’s important to prevent this from happening using proper technique and by minimizing removal of excessive cartilage.

2. Orthodontics / Headgear

I’m sure you’ve seen children wear headgear in past years, with a brace around the head and wires pushing or pulling teeth. Children with overjets (overbite) were managed by pushing the upper teeth back, thus creating the illusion of a proper bite. The fact is that in these children, the lower jaw is underformed, and the best thing to do is to pull the lower jaw or teeth forward to match the upper teeth.

Additionally, some orthodontists still extract teeth to make room for the remaining teeth. Your smile may be nice, but in the process, your jaw just became smaller. Any amount of narrowing of your jaws creates less room for your tongue, and with muscle relaxation in deep sleep, you’ll stop breathing much more often. It’s bad enough that modern human’s jaws are shrinking more and more (due to a radical change in our diets and with bottle-feeding), but when you start to extract multiple teeth, you’re definitely going to have problems breathing. The back molars also act to support the soft tissues of your throat. So removing your molars can destabilize the soft palate, aggravating more soft tissue collapse, especially later in life.

3. Jaw Surgery

Once in a while, I’ll see patients that underwent lower jaw surgery to push back a prominent lower jaw. In this situation, the upper jaw should  have be pulled forward. Since the base of your tongue attaches to you back of your mandible, any backward movement of your jaw can push your tongue back, aggravating breathing problems while you sleep.

4. Thyroglossal Duct Cyst

The thyroid gland starts at the back of your tongue and migrates down your neck in front of your voice box, and then divides into your right and left thyroid lobes with a small connection between the two over the top of the windpipe. Sometimes, a remnant of that tract from your tongue to the voice box can remain, with cysts or tracts or even thyroid tissue along this pathway. When a cyst develops, you’ll have a midline ball or swelling that won’t go away. The treatment for this condition, called thyroglossal duct cyst, it surgical removal.

The procedure is classically called the Sistrunk procedure, named after the surgeon that originally described it. The critical part of this procedure involves removed the midline 1/3 of the hyoid bone, which is a c-shaped bone that sits on top of your voice box. Unfortunately, you’re also weakening and destabilizing the attachments to the tongue and voice box. Upon questioning the handful of patients that have undergone this procedure in past years (some by me and some by other surgeons), most have said that their sleep quality worsened. If you’re ever going to undergo this procedure, it’s important to reattached or reconstruct the tissues that help to support your tongue and voice box.

5. Hysterectomy

Total hysterectomy with or without removal of the ovaries is a common procedure for many women. We know that especially when the ovaries are removed, this creates a state of surgical menopause. I’ve described in past articles that as progesterone naturally drops in normal menopause, sleep quality can diminish, mainly due to the effects of progesterone on tongue and upper airway muscle tone. As the tongue muscle tone slowly drops, obstructions and arousals become more frequent, and you won’t sleep well.

This is also one of the main reasons why hormone replacement therapy (HRT) helps many women sleep better. However, with the recent finding that HRT can increase rates of cancer, it’s not generally recommended anymore. If you’re thinking about undergoing a hysterectomy, be prepared not to sleep as well.

6. Breast Implants

If you’re a woman and like to sleep on your stomach, then getting breast implants can definitely worsen your sleep quality. For a few weeks after this procedure, most surgeons will ask you to sleep on your back. The problem is that when on your back, your tongue will fall back more often, leading to more frequent breathing obstructions and arousals. Until you’re able to go back to stomach sleeping, be prepared to lose a lot of sleep. Unfortunately, some women are never able to sleep on their stomachs again, being forced to sleep on their sides or back.

7. Any Type of Surgery

No matter what type of surgical procedure you undergo, if you’re forced to sleep on your back, then your sleep apnea will be worse. If you never had sleep apnea or sleep-breathing problems, then being on your back may bring on your first experience, especially if you’re a natural side or stomach sleeper.

As you can see, millions of people undergo these procedures every year. Sometimes, the effect on sleep occurs immediately, whereas in others, it can take months or years to surface. If you’re planning any of the above procedures, or if you’ve undergone any in the past, think about how it can potentially affect your quality of sleep. It’s something you should definitely sleep on.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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23 thoughts on “7 Common Procedures That Can Worsen Sleep Apnea

  1. So, should my son not have his wisdom teeth puled? They are blocking his molars from coming out.

  2. Roseanne,

    That’s a question that one of the specialized dentists (OSB, ALF, DNA) can possibly answer. Without looking at his particular situation, it’s difficult to give to an accurate answer. In theory, if you can expand the jaws and make more for the molars, then it’s possible to preserve your wisdom teeth. In real life, that’s a difficult outcome to predict.

  3. I had septoplasty surgery because I had labored breathing and while laying down I could not breath the “side down” of my nose. I was dx’d with OSA a few years after this……would this or should this septoplasty have helped my OSA?

    Also I have a diviated septum and even though it was “corrected” I’m told it’s deviated ….how does this happen?

  4. Hi, this is the first time I have seen that a narrow jaw has been mentioned. My dentist has often commented about my narrow jaw but nothing was said by my doctor when sleep apnea was diagnosed. All that he said was that I should lose some weight (which I agree with) but my neck size is normal and even when I was a normal weight about 10 years ago I still snored loudly then, and probably think I had sleep apnea even then. I have suffered an early menopause too and take HRT but the impact of that was not discussed either. I feel that I was just dismissed because I am slightly overweight. Any suggestions?
    Thank you

  5. Caroline,

    Most doctors still believe that you have to be overweight to have obstructive sleep apnea. While it’s true that being overweight can aggravate things, sleep apnea is ultimately an anatomic jaw underdevelopment problem. You can be young, thin, female and not snore, and have significant sleep apnea. Poor sleep quality from sleep apnea can diminish reproductive hormones as well.

  6. George,

    Nasal surgery alone typically doesn’t cure sleep apnea (although it can happen occasionally). Your septum was probably not fully corrected. What actually more important is the size and shape of your nasal turbinates, as well how flimsy your nostrils are. Did you ever try using Breathe Rite strips? You just need to address all three of these areas and you should be able to breathe better through your nose. This will also help you with your other treatment options for obstructive sleep apnea.

  7. I am 55 I have been diagnosed with

    ADD (age 42),
    Acid Reflux (age 46),
    OSA (age 48),

    When I was a teenager I had braces and they pulled 4 teeth. A few years later my wisdom teeth became impacted and they were all removed. Periodically I notice that my jaw “pops” when I clench my teeth. This comes and goes.

    Is this all connected?

  8. You may have been predisposed to obstructive sleep apnea, but pulling excessive teeth can make things much worse. Obstructive sleep apnea, reflux, TMJ and ADD all go hand in hand.

  9. Hi Dr. Park,

    First off I want to say that I really respect you. You speak volumes of wisdom about the material that you practice. It truly reflects your empathetic approach towards helping to positively change the lives of thousands. And I wish you were in Canada, because I would love to come and see you with my dad (who has severe sleep apnea). If only private health insurance was international I would come in a heartbeat to have my father and I assessed by you.

    I really have a question for you. I believe I have sleep apnea. I am getting a sleep study next month to verify whether I do or not. I have many of the connections that you speak of. I am currently finding it difficult to sleep, especially on my back, and with a mild congestion from a cold/allergies I feel like I can’t take any deep breathes all day long. I feel like I’m suffocating and I don’t even have a visible cold, its very slight with a mild touch of sore throat and light mucus nasal blockage (although not enough to promote a runny nose or sneezing).

    I am celiac, I have pcos, my progesterone is low, I have an overbite (my mom has forever teased me about having beaver teeth), I have a small jaw, my nose is slightly crooked bending to the left, I have insulin resistance, I can’t sleep on my back because I can’t breathe well, I always have to sleep on my right side, I’m tired all day long, I have to sleep minimum 10 hours to function, if I sleep 7-8 I need a nap in the afternoon, and my dad has sleep apnea as does his nephew. Also, the other day I woke up to myself choking/gasping for air as I tried to have a nap. My mother says I snore, but I truly do not know.

    Specifically, I have impacted wisdom teeth on only my lower jaw. I am interested in getting them removed because I am scared of getting infections, pronounced inflammation (as I have had gingivitus), and I am a bit vain about my bottom teeth becoming crooked (to reduce the chance of them matching my nose of course). By getting my teeth removed will I be putting myself at more risk for worse sleep apnea? I feel very conflicted. Also, could the wisdom teeth be pressing backwards into my throat thereby narrowing the passage way even more? I don’t know what to do. Not feeling rested when I wake up in the morning has been a life-long struggle. Does exercising strengthen the chest muscles and allow for better breathing at night in any situation involving sleep apnea? I am just new to the idea of me having sleep apnea. For the past few years I’ve been researching celiac, pcos, and reversing insulin resistance when maybe my pain root problem has been sleep apnea.

    Thanks for any insight Dr. Park.

  10. Cali,

    Thanks for sharing your story. It seems like getting the sleep study is the right step for you. As for your wisdom teeth, it probably won’t make that much difference with your possible sleep apnea. It’s when you take out other teeth in addition to your wisdom teeth that can make things worse. One option to consider (after starting standard sleep apnea treatment) is to consider one of the jaw-expanding orthodontic options that I talk about (see past Expert Interviews). Good luck, and please keep in touch.

  11. To everyone who has a constantly blocked or stuffy nose.. I think if you have a blocked nose you will never be able to have a good nights sleep. having a clear nasal airway is of great importance to health. I think it is stupid to have a sleep a study done when you know you have a blocked nose as this will be the reason that you are tired fatigued depressed……address your blocked nose then worry about everything else, because chances are that is going to clear up everything else. The nose is extremely important to us, you will not meet a person who is thriving and truly happy with a stuffy or blocked nose they don’t exist. We need to breathe through our noses.

  12. I’m sick of hearing about sleep apnea it is not the only thing that can ruin sleep. Those with a blocked nose 24/7 never get to feel relaxed. The brain must be doing something and put us in survival mode by triggering the release of some type of hormones, stress hormones or something like that so that we are constantly on edge. I’ve come to realise that many people are depressed/anxious as a symptom of having a long term obstructed sinus but they don’t even see the connection. People really need to wake up and see what is right in front of them.

  13. Dr Park,
    You are mistaken regarding headgear and tooth extractions as a possible contribting facter in OSA. Headgear actually only slightly decreases the amount of forward movement of the molars. In cases where extractions have been used to treat protrusion, the movement is primarly tipping the teeth back in the existing bone. The jawbone limits the amount the “body” of the tooth can move. Because the size of the jaw does not change much, the space for the tongue does not change much.

    There have been numerous studies in the Orthodontic literature regarding skeletal and dental factors contributing to OSA and neither arch length or A-P position of the incisors are corrolated with OSA. (If you have references that dispute this , I would be interested to see them). Other factors such as the position of the hyoid bone, neck size and head position play a much greater roll in OSA than arch length.

    You are correct in saying that increasing lower jaw length in cases that it is to short has a postitive effect on OSA. Unfortunatly, as Orthodontists, we are limited by genetics in this regard. Jaw surgery is required to actually make a lower jaw longer and most medical insurance today specificly excludes jaw surgery for orthodontic reasons.

    What patients should know, is that if their jaw size and relationships are determined to be a factor in OSA and they cannot tolerate CPAP, some medical insurances are beginging to cover jaw surgery in these cases.

    Getting back to my initial point, I would encourage you to check your references before making any more connections between orthodontic treatment and OSA.

    John L. McDonald, DMD
    Diplmate, American Board of Orthodontics

  14. Dr. McDonald,

    Thanks for your comment. The idea that headgear and extractions can potentially aggravate obstructive sleep apnea comes from numerous dental colleagues. I understand that there is a huge difference of opinion within the dental community regarding these issues. I’m not arguing that the molars retract from retrusive headgear. However, even with a slight amount of inward canting, the total oral cavity volume diminishes, and this can potentially cause breathing problems, especially when supine and in deeper levels of sleep. Even with premolar extractions, the existing molars may not move backwards, but the remaining front teeth will move back, creating a flatter facial profile, and smaller oral cavity volume.

    As an otolaryngologist and sleep medicine physician, I see the detrimental effects on the airway caused by traditional dentistry and orthodontics almost every day. Fortunately, I’ve seen some evidence that there are a number of functional appliances that can significantly widen (in adults) and even elongate the jaws, improving the airway, without surgery. With prevention and earlier intervention even as toddlers, there are ways of minimizing dental crowding and promoting proper occlusion. When performing maxillo-mandibular advancement surgery, it has to be performed properly to address the airway, and not just to improve occlusion.

    I recommend you take a look at Bill Hang, Dave Singh, and Ted Belfor‘s Web sites and materials. Dave Singh just published a prospective study on a small number of patents using his appliance to significantly lower AHI levels. Obviously, more studies are needed, but orthodontists must reorient on improving the airway, and not only address occlusion.

    I realize that you may still disagree with me on some of these issues. I also have similar issues with my own field. I recommend that you contact any of the named references I provided. From an airway standpoint, I’m convinced about their convictions.

  15. My husband has had a snoring problem for the last 30 years especially when he gets overly tired. Recently at age 60 he got braces on his upper and lower teeth. Since getting the braces he has not slept through the night without snoring loudly. He is always tired and looks thin and pale.
    I can’t help but relate this to the braces since he seemed in better health and better sleep prior to the braces.
    He sleeps on his back all through the night unless I wake him up and push him to his side which will stop the snoring for a few minutes but he always moves so he is on his back again and then the loud snoring and lack of sleep for both of us begins again.

    Is there a possibility that the braces are making the sleep issues worse?

    Thanks for any input you may have to help us figure out this problem.

  16. Kim,

    In my experience, braces can sometimes improve or worsen snoring and obstructive sleep apnea. Shifting teeth around can have a profound impact on breathing. My opinion is that anyone that snore regularly should be tested and treated for obstructive sleep apnea.

  17. Hi. My now 11 year old daughter has been ‘diagnosed’ with overbite and our family dentist recommended orthodontist to correct ‘the condition’. Short story….during the initial consult, we had two options: headgear and then braces, or extractions with braces to correct the allignment. We chose the first option and headgear started in June of last year. Kid was happy and I had no problems having her wear the appliance. This past January, braces came on and headgear continued. Some sensitivity and pain went away within the first few days and she was grining from ear to ear showing of her rainbow rubber bands.
    Problem (at least in my opinion) happened at the end of April (after the most recent adjustment) when within a week or so she started to snore. I was able to hear her across the hallway. It continued for as long as she was wearing a headgear. Finally i would wake her up and remove the headgear. Snoring never happened when headgear wasnt worn. We did this for +/- 2 wks. Orthodontist blamed it on allergies. I took her to pediatric eent who didnt see anything medically abnormal that would explain it.
    Well, went to orthodontist the other day and she pretty much blew off my concerns. What is your take on it?
    On a side note (as if i didnt type enough already) she does have seasonal asthma but that presents itself with a runny nose, sneezing and if we dont ‘fix’ it quick enough with nose sprays, progresses into a bark like cough (and the need for albuterol). None of that however occured since February.
    Thanks in advance for your input!

  18. Kat M,

    What you’re describing is not uncommon. Headgear and braces can significantly alter the airway, in either direction (good or bad). Nasal congestion can aggravate airway issues downstream, especially if already narrowed by having small jaws and crooked teeth. For anyone that snores, I do recommend a sleep study generally to see if they have obstructive sleep apnea. Unfortunately, I can’t make any recommendations for your daughter without examining her. Hope you are able to find help for your daughter.

  19. Hello Dr. Park,
    I have a concern, I am 32 years old and my left lower wisdom tooth is impacted and is only half way through. My dentist says there is already a light inflammation and need to remove all of my wisdom teeth. My question is, shall I leave it and see if it is necessary? Shall I only take the left bottom wisdom tooth out or do I really need to take all of them out? (the rest are fine). I am not that excited to remove all of my wisdom teeth. I already have a small septum and a hard time breathing through my nose and do not want any more breathing issues. Thanks so much for any thoughts!! Would really appreciate it!

  20. Dr. Park,
    Well this is interesting, you know all the symptoms I’ve been describing to you. Right before it started happening I had on my back teeth removed because I Sjogren’s syndrome and was getting cavities from dry mouth at night sleeping. I started having symptoms with my throat closing about a week after I had this done. I have partials but can hardly wear the bottoms because I never fit quite right no matter how many adjustments. Now I have my last wisdom tooth that needs to come out but I can’t leave back for the surgery.

  21. Hello, Dr.

    I listen to your podcast.

    I had deviated septum surgery in 2012, then I had a job for 3 years where I had to get up at 4 am. Went to sleep arounnd 10 or 11 pm.

    Now I have csa and obstructive sleep apnea. Do you think the surgery and the job could have caused it or contributed to it?

    Thank you.

  22. Hi Dr! I wish I knew of you before I did my rhino. I had rhino almost ten years ago and now km dealing with lots of congestion, nasal collapse, deviated septum. I also mouth breathe a lot and have UARS. Jaw is recessed. I was told expansion will help and jaw surgery. Any tips on this? I’m scared it’s going to make rings worst in the future. Thank you so much

  23. Jessica,

    As a temporary measure, you can use Breathe Right strips externally on your nose, or one of various internal nasal dilators which you can find online. Unfortunately, the only permanent way to treat this is with revision nasal valve repair surgery. Good luck.