Jennifer was adamant that her son’s tonsils were not to be removed. They were 4+ “kissing” tonsils, the size of two golf balls, and he was choking 12 times every hour. I recommended surgery. His mother asked about alternative options. I mentioned CPAP and functional dental appliances as alternative options.
Shaking her head, she asked, “Are there any other options?”
I mentioned that there are studies showing that both acupuncture and tongue exercises were found to lower sleep apnea severity by 50% on average. She did not think her 4 year old could be disciplined enough for tongue exercises and she was not interested in acupuncture.
“What about herbs or supplements? “
I mentioned that I’m not aware of any proven options that I know of that’s published in mainstream sleep or ENT journals.
She also rejected topical steroids, which are found to help somewhat to lessen sleep apnea scores in children.
At this point, I was feeling a bit frustrated, since she was rejecting every option that I had to offer. I finally asked her why she didn’t want to have her daughter’s tonsils removed.
She paused for a few seconds to think, and revealed that she read on the internet that the tonsils are part of the immune system and helps to fight infections.
“If you remove the tonsils, then you can’t fight infections.”
This is one of many such discussions I have with patients every day. In this post, I will describe 7 of the most common myths about sleep apnea surgery, in no particular order.
1. Sleep apnea surgery doesn’t work
This is a common misperception based on generalized results of historical surgery on the soft palate only. The same 40% success rate figure is quoted repeatedly, but this is an old study looking at the traditional version of the uvulopalatopharyngoplasty, or UPPP. We know have much more refined UPPP variations with significantly higher success rates. However, no matter how well you do the palate procedure, you won’t be successful if there are other areas of obstructed breathing that’s not addressed. These areas include the tongue base, tonsils, epiglottis, or the lingual tonsils. Most people will have multiple areas of obstruction.
One commonly cited tool that’s used to predict UPPP success is the Friedman classification, which predicts that if you have relatively large tonsils and a low sitting tongue, and you’re not very overweight, your chances of “surgical success” is about 80%.
Even if you only have only one area of obstruction, doing a standard procedure doesn’t guarantee that the obstruction is completely addressed.
We also know that weight loss surgery, double jaw surgery (maxilla-mandibular advancement, tongue pacemaker surgery or even tracheotomy can have profoundly positive results. So to say that sleep apnea surgery doesn’t work is not an accurate statement. What that statement is really saying is that the patient states that it didn’t work for him or her.
I also have to stress that sleep apnea surgery of any kind must be considered only after trying non-surgical options first.
2. If your tonsils help to fight infections, why take them out?
This is another common misconception that’s used to justify not undergoing tonsil surgery. Yes, the tonsils are a part of the immune system that educates the body. A common reason for taking out the tonsils is due to recurrent tonsil infections. In this case, the tonsils are prone to repeat infections with pain and misery, requiring antibiotics. Applying the logic to leave the tonsils in place just doesn’t make sense.
If you have large tonsils which are aggravating obstructed breathing at night, then the benefits of improved breathing and sleep far outweigh any theoretical benefit to your immune system. Your tonsils make up a small fraction of your body’s lymphatic tissues, such as in in your neck, gut, skin, groins and armpits. When two large lymph nodes in your mouth (tonsils) obstructs your breathing repeatedly at night causing oxygen levels to drop less than 80%, then the benefits of surgery far outweighs any theoretical benefits of leaving them in.
3. Uvulopalatopharyngoplasty (UPPP) causes swallowing or choking problems
Regardless of how well the UPPP works to address sleep apnea, there are always potential risks for any surgical procedure. Bleeding, infections, and anesthesia complications are unusual, but important issues to think about with any operation. In particular to the UPPP, swallowing problems are known complications that are well documented. Fortunately, in the vast majority of cases, even if these symptoms do happen, is usually temporary, lasting only a few days to weeks at most. Rarely, symptoms may last months to years. The most feared long-term side effect of the UPPP operation is what’s called velo-pharyngeal incompetence, when food or air or water leaks up into your nose when you swallow or talk. Taking out too much of the soft palate may prevent proper closure of your soft palate against the back of your throat, leading to something similar to having a cleft palate.
Fortunately, these complications after UPPP surgery are rare, but should be considered in light of the risk to your health if you have severe sleep apnea and can’t tolerate CPAP at all.
4. Uvulopalatopharyngoplasty (UPPP) makes CPAP more difficult or impossible to use
There are a handful of small studies suggesting that a UPPP can make CPAP use more difficult. However, there’s much more recent evidence suggesting the reverse. My personal experience is that even if the UPPP procedure doesn’t result in a surgical “cure” in someone who initially can’t tolerate CPAP, it may be better tolerated after UPPP. One potential explanation for this is my previous description of expiratory palatal obstruction, where the soft palate backs up into the nose causing a sudden blockage, like a valve. This prevents breathing out through the nose, potentially leading to difficulties using CPAP.
Recent studies have also shown that the soft palate is not the only area of abstraction. The tongue base, epiglottis, tonsils and lingual tonsils can also contribute to OSA, to various degrees in different combinations in different people. Treating the soft palate alone may help some patients significantly, but most patients will need other areas of obstruction addressed as well.
5. Surgery shouldn’t be done for mild sleep apnea or upper airway resistance syndrome (UARS)
I recently reported on a study that we published showing that in symptomatic patients with AHI < 5 (no sleep apnea), 83% are found to have significant multilevel obstruction. This goes along with what we see in patients with UARS, where you can stop breathing 25 times every hour and not have any apneas. This can but much worse than someone with only 5 pure apneas per hour. The prevailing recommendation is to recommend surgery only for people with moderate or severe OSA. My general philosophy is to treat the patient, not the numbers. I routinely offer surgery to people with mild sleep apnea or no apneas at all based on sleep studies.
6. CPAP is always better than surgery
While CPAP is the “gold” standard treatment for OSA, in practice, it doesn’t even reach bronze status. I’ve quoted other experts showing that at the end of one year, only a small fraction of people given CPAP are using it effectively. Everyone will agree that CPAP works but only if you use it. This reminds me of a study in 2004 looking at people with newly diagnosed OSA who were given CPAP or underwent UPPP surgery from 1997 to 2001. By 2002, patients given CPAP were 37% more likely to be dead. This study supports the argument that an inefficient treatment (UPPP) that is 100% compliant can be just as good or better than an efficient treatment (CPAP) that’s not used very often.
7. You need to find a surgeon that has done lots of procedures to be good at it
It’s commonly accepted that the more procedures you perform, the better the surgeon. This concept was popularized by Malcom Gladwell in his book, Outliers, which described Dr. Anders Ericsson’s landmark study. Ericsson, in his book Peak, studied elite violinists at a prestigious music school in Europe. If you extrapolate this finding to surgeons, it’s logical to assume that a surgeon who performs 10,000 tonsils is better than someone who has done only 2000. However, there was one major caveat that was not emphasized in Gladwell’s book: The best musicians not only practiced 10,000 hours, but 10,000 hours of intentional, focused practice. Just performing tonsillectomies over and over again doesn’t make you a better surgeon. It’s a process of constant refinement through external feedback that intentional practice that ultimately makes you fluent and proficient as a master surgeon.
I still see surgeons who have been in practice over 25 years who can perform a routine tonsillectomy, but there’s no skill or finesse involved. Like Hiro in the movie Hiro Dreams of Sushi, a surgeon must constantly strive to improve his or her skills, not just to finish faster, but to have a passion for excellence and an incessant desire to keep pushing the limits even when reaching retirement age. Reinforcing average surgical skills by repeating it 10,000 times will leave you with average surgical skills.
The surgeon’s technical skills are important, but what’s more important is your surgeon’s judgement and clinical expertise. You have to perform the right operation for the right reasons. You also have to experience enough complications to know how to handle them then they occur. in rare situations. If a surgeon tells you that she doesn’t have any complications, run away.
So the next time you have a desire to ask your surgeon the “how many” question, figure out a way to find out how well your surgeon does a particular procedure. It may be challenging to get this information, but if you do your legwork, it’s possible to figure out if you can ultimately trust your surgeon no matter how many procedures were performed.
Jennifer’s mother understood my logic behind why I recommended tonsillectomy. She even agreed with me on all my points. But she admitted that she was uncomfortable in removing something entirely from the throat if it serves a function. We compromised by going ahead with a partial tonsillectomy, which I was comfortable doing, despite the slightly higher rate of possible recurrence. Ultimately, Jennifer did very well after the procedure and her mother was happy with the results.