Surgical Sleep Medicine
Welcome to our subspecialty of Sleep Medicine at Froedtert Hospital and the Medical College of Wisconsin. This subspecialty area is dedicated to the multidisciplinary, comprehensive care of patients with sleep disorders as well as developing a preeminent research and teaching program. This service is lead by a nationally recognized surgeon, B. Tucker Woodson, MD.
B. Tucker Woodson, MD, Professor and Chief of the Division of Surgical Sleep Medicine was recently featured on the CBS News discussing a new implantable device to control sleep apnea.
New England Journal of Medicine Link to paper
Meet our Surgical Sleep Medicine Physician:
B. Tucker Woodson, MD
Professor and Chief
Leader in Treating Sleep Disorders
The Froedtert & the Medical College of Wisconsin's Sleep Disorders Program is uniquely able to help patients who suffer from sleep disorders:
Froedtert and the Medical College of Wisconsin provide access to physicians who are dual certified both in Sleep Medicine and disorders of the upper airway (Otolaryngology Head and Neck Surgery). They are able to assist patients in finding the best therapy tailored to their individual needs including positive pressure therapies (simple and advanced), mandibular advancement devices (oral appliances), all other airway devices and therapies, and advanced upper airway evaluation and surgical reconstructive treatment. Depending on the individual needs of patients, treatment may range from minimally invasive office based procedures to more advanced airway reconstruction. Physicians use the best available medical evidence to guide treatment and with the use of modern tools evaluate outcomes.
The ultimate goal is to improve patient’s health and quality of life and to better integrate the care of treatment of sleep disorders into health.
Leader in Innovative Treatments for Sleep Disorders
The Froedtert & the Medical College of Wisconsin's Sleep Disorders Program leads the field in innovative treatments for sleep disorders:
First in the nation to treat a patient with Upper Airway Stimulation (hypoglossal nerve stimulation) for sleep apnea
First to use and to publish on Coblation ™ (noninvasive radiofrequency energy) to treat (shrink) lingual tonsils for sleep apnea.
First in the nation to treat obstructive sleep apnea with a tongue suspension suture, a simple procedure that helps keep the tongue base from collapsing during sleep.
First in the nation to treat sleep apnea using a technique to lengthen the jaw bone (mandibular distraction).
First in the region to treat airway obstruction using the Pillar™ implant — small polyester inserts that stiffen the soft palate.
Advanced Surgeries for Sleep Disorders
The Sleep Disorders Program is a national and international leader in advanced surgery for sleep problems caused by breathing disorders. Using a variety of techniques, Froedtert & the Medical College surgeons can reconstruct the airway to alleviate obstructions that interfere with sleep. But more importantly, they have the knowledge and experience to help find the best treatment for each patient. The goal is successful treatment which for many patients does not require invasive major surgeries.
A wide variety treatment options may include minimally invasive radiofrequency procedures, office based surgeries, and simple palatal implants. Ancillary surgeries which may not alone cure sleep apnea or snoring but improve the outcomes of other surgeries. Not all surgeries are covered by all insurance carriers. Please check with your health insurance provider to determine your coverage.
Surgery may be needed to correct a sleep disorder, particularly to correct obstructive sleep apnea (OSA). In some cases, surgery can also be done to correct abnormal snoring and severe nasal obstructions in people who suffer from insomnia.
Surgery may be recommended when other treatments do not work, or it may augment other sleep disorder therapies. Surgery is performed for people with:
Lesions (abnormalities) of the upper airway tissue
Apnea that has failed medical treatment
A lifestyle that precludes other treatments for obstructive sleep apnea
Habitual snoring in the absence of obstructive sleep apnea
The decision to perform surgery is based on the location of the collapsed tissue, the severity of the disease, associated medical risk and the likelihood of success. No single surgical procedure will work for all people.
The goal of surgery is to stabilize the upper airway by modifying its size or shape and reducing the amount of collapsible tissue in the throat to prevent collapse and obstruction. This includes removing any obstructions in the throat such as growths, polyps, or enlarged adenoids and tonsils. Oral and maxillofacial surgery may be needed to correct abnormal facial structures, such as a recessed jaw.
Surgery to correct obstructive sleep apnea is usually covered by health insurance.
Surgery, Sleep Disorders and Obstructive Sleep Apnea
The following is a brief description of surgical procedures and does not include a full description of risks and benefits of the procedures.
Upper Airway Stimulation Therapy (FDA Approved)
Inspire™ II consists of three implantable components: An Implantable Pulse Generator (IPG), a Self-Sizing Cuff Stimulation Lead, and a Pressure Sensing Lead (to sense pressure changes with breathing). The respiratory pressure waveform is monitored by the IPG algorithm and triggers stimulation therapy with breathing (respiration). The device monitors respiratory waveforms, program stimulation modes, and stimulation parameter values. These are adjusted to optimize the therapy by the physician. Patients also have ability to adjust and modify therapy.
An abnormal nasal airway is one of the major contributors to poor sleep. An abnormal nasal airway is also one of the major predictors of failure of devices such as CPAP, mandibular advancement devices, and Provent/Theravent ™. Improving the nasal airway with medical or surgical interventions improves sleep. In some individuals nasal surgery is required. When needed, sometimes this is the only intervention required to improve CPAP tolerance. Minor improvements have marked effects. No single structural abnormality explains nasal problems in sleep disorders. A careful expert evaluation of the nasal valve, nasal septum, turbinates, sinuses, and tissues of the back of the nose is important for many individuals with sleep disorders to look for correctable medical causes or to identify structural abnormalities. If surgery is required, it is most often done under local anesthesia with a rapid return to work or other normal activity.
This procedure is done for people with obstruction in the upper pharynx of the palate. UPPP may be performed in conjunction with other treatments targeted at other areas of collapse.
Various forms and surgical techniques have been developed. Surgeons at Froedtert & the Medical College of Wisconsin's Sleep Disorders Program are international leaders in the development of better reconstructive surgical procedures for OSA and snoring. The procedures which are focused on reconstructing the normal anatomy and replace the historic methods (which is still commonly performed by many surgeons) that remove the uvula, a portion of the soft palate, the tonsils, and redundant (excess) tissue from the throat. By improving airway structure (repositioning and realigning tissues) in contrast to excising and removing tissues, function and healing are better; recovery is faster; and studies show better sleep outcomes.
For modern reconstructive techniques to be successful accurate assessment of the anatomy and structure of the throat is required. Techniques to evaluate the upper airway have been pioneered by physicians and surgeons in the Sleep Disorders program. Features that are important include: the position and size of the tonsils, the anatomy of the lateral (side walls), the shape of the space behind the palate, and assessment of tissue movement with swallowing, jaw movements, and sleep.
Surgery to Correct Obstruction of the Lower Throat
Many individuals with OSA and snoring have narrowing of the airway in the lower throat that contributes to blockage during sleep. The cause of this block often varies and for this reason multiple procedures have been developed to correct or to improve the blockage. Selecting the most suitable procedure for any patient is based on many factors. No single procedure is best for all. The following procedures modify tissues of the lower pharynx when the involved tissues are obstructive or abnormal:
Mandibular (Lower Jaw) Advancement
This procedure moves the bone, soft tissue and muscles of the jaw forward to enlarge the airway. The amount of advancement may be limited by the natural position of the teeth. People with a backward positioning of the teeth and jaw may benefit from lower jaw advancement alone.
Bimaxillary (Upper and Lower Jaw) Advancement
This procedure is done for people with significant jaw deficiency, morbid obesity, and those with obstructive sleep apnea who have failed more conservative treatments. The procedure involves cutting the bones of the upper and lower jaws and lengthening them a small amount. The tongue and the palate are pulled forward, enlarging the airway. The surgery also enlarges the mouth to provide more room for the tongue. Both jaws are advanced together, retaining the person’s bite. The surgery is performed through incisions inside the mouth.
Limited Mandibular Osteotomy (Cutting the Jaw Bone) and Genioglossus Advancement
Genioglossus advancement detaches the tongue muscle from the back of the mandible (jaw bone) and move it forward to the front. Moving this attachment pulls the tongue forward and enlarges the airway. To do this, the primary tongue muscle that controls the size of the lower airway (genioglossus muscle) and a small piece of attached bone are moved. The procedure has the advantage over other mandible surgeries, that it does not surgically move the teeth and does not require braces or orthodontic procedures.
An alternative to mandibular advancement procedures that does not require osteotomies or skeletal adjustments is to perform tongue suspension. These procedures use an implantable device to help support the tongue and prevent collapse during sleep. Several different devices are used to perform the procedure. For most patients, a successful result requires that these procedures be performed with other procedures.
The hyoid bone is a small C-shaped bone in the upper neck above the Adam’s apple cartilage. Many muscles of the tongue and throat attach to the hyoid. In the procedure, a small portion of the middle of the hyoid bone is exposed in the neck. Hyoid Myotomy and suspension is a procedure to move this bone to increase the size of the lower airway. To do this two small bone anchored screws are place in the back of the chin and several “tethers” are passed around the hyoid bone which is then pulled forward towards the lower jaw. This procedure may be done under local anesthesia as day surgery or may be combined with other surgeries.
Enlargement of tonsils at the base of the tongue (lingual tonsils) may be a common contributor to airway obstruction in OSA. Removing lingual tonsils was markedly improved with the application of plasma surgical technology and endoscopic minimally invasive techniques. Many of these procedures were pioneered at Froedtert & the Medical College of Wisconsin's Sleep Disorders Program.
Midline Glossectomy (MLG)
For many individuals, the back of the tongue is too large for the airway. For some this may be due to large lingual tonsils, and excessively small lower jaw, increased fat, or other causes. For some patients reducing the size of the tongue increases the size of the lower throat (pharyngeal) airway.
When described in the 1990’s, these procedures were done with traditional surgical tools or lasers. These resulted in excessive pain and recovery for many patients. Newer plasma and radiofrequency surgical tools provide less damaging methods to reduce the size of the tongue and to increase the airway size with lower side effects, improved healing, and faster recovery. For some patients these procedures can be done as outpatient or office based procedures.
In rare or unusual situations, other tissues cause airway blockage in sleep apnea and snoring. For these, modifying tissues surrounding the voice box (redundant epiglottis and redundant supraglottic tissues) may be required to successfully treat obstructive sleep apnea.
Historically, tracheotomy was the only treatment for severe life threatening sleep apnea and breathing failure at night. This is now rarely required with modern medical and surgical alternatives. A tracheotomy is a surgical “hole” from the skin of the neck to the windpipe below the voice box. A tracheotomy is done for people with severe obstructive sleep apnea and those who are not candidates for other therapies. Because the hole bypasses the throat, blockage does not occur during sleep. Tracheotomy is very successful in the treatment of apnea and its complications. Since the upper airway is open during wakefulness, after healing, the tracheotomy hole may be closed except during sleep.
Despite the benefits of tracheotomy, the psychosocial implications, risks of infection and other potential complications may make it unacceptable for many patients. In patients who accept a tracheotomy, there is a reduction in the incidents and mortality associated with sleep apnea.
Surgery to Correct Snoring
The following are procedures that can be done to alleviate excessive snoring that interrupts sleep patterns.
Palatal Stiffening Procedures (UP)
This surgery, for treatment for benign snoring, is commonly done as a laser-assisted procedure. It involves removing tissue of the soft palate and the uvula under local and topical anesthesia in an outpatient setting. The soft palate is “sculpted” by creating “trenches” around the uvula and reshaping the soft palate.
This is done for nasal blockage. Although nasal obstruction and abnormal blockage of the nose is not the primary cause of sleep apnea and snoring, they are pivotal and very important contributors to these problems. The anatomy of the nose is complex. Some people misunderstand that for most patients with snoring and sleep apnea, the problems are not in the sinuses but in the nasal cavity itself. The anatomy of the nose is complex. Problems may involve the septum, the nasal valve tissues, the turbinates, the nasopharynx (especially in children), or the nasal passage itself. Every patient with sleep apnea and snoring deserves a thorough evaluation of the nose. Assessment for allergies, inflammation, polyps, as well as structural abnormalities is important. If problems are identified and medical treatments are not successful, both in office and outpatient surgeries may be done (often without the need for general anesthesia). For many patients who fail or poorly tolerate nasal CPAP, nasal treatments alone provide dramatic improvements in ability for medical treatments such as CPAP to be tolerated.
Selected Published References from the Froedtert and Medical College Wisconsin Sleep Disorders Program
Upper Airway Stimulation
Strollo PJ, Soose RJ, Maurer JT, de Vries N, Cornelius J, Froymovich O, Hanson RD, Padhya TA, Steward DL, Gillespie MB, Woodson BT, Van de Heyning PH, Goetting MG, Vanderveken OM, Feldman N, Knaack L, Strohl KP, Upper Airway Stimulation for Obstructive Sleep Apnea . N Engl J Med 2014;370:139-49.
Van de Heyning PH, Badr MS, Baskin JZ, Cramer Bornemann MA, De Backer WA, Dotan Y, Hohenhorst W, Knaack L, Lin HS, Maurer JT, Netzer A, Odland RM, Oliven A, Strohl KP, Vanderveken OM, Verbraecken J, Woodson BT. ,Implanted upper airway stimulation device for obstructive sleep apnea, Laryngoscope;122(7):1626-33,2012
Maurer J, Van de Heyning P, Lin H, Baskin J, Anders C, Hohenhorst W, Woodson BT, Operative technique of upper airway stimulation: an implantable treatment of obstructive sleep apnea, Operative Techniques in Otolaryngology (2012) 23, 227-233
O’Connor PD, Woodson BT Nasal and Palatal Surgery for OSA, in Bailey’s Head and Neck Surgery Otolaryngology 5th Edition,, Johnson JT and Rosen CA (Eds) Lippincott Williams and Wilkins Baltimore pp 2191-2205, 2014
Woodson BT, Palatal Advancement Pharyngoplasty, in Pang KP, Rotenberg BW, Woodson BT, (EDS) Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea, Plural Publishing, 2013
Woodson BT, Sitton,M, Jacobowitz, O, Expansion sphincter pharyngoplasty and palatal advancement pharyngoplasty: airway evaluation and surgical techniques Operative Techniques in Otolaryngology (2012) 23, 3-10
Woodson, B.T., Karakoc O.: Expansion Sphincter Pharyngoplasty for Obstructive Sleep Apnea. In, Sleep Medicine, Yaremchuk K, Wardrop P, Plural Publishing Inc., San Diego, 2011 pg 301-309.
Pang KP, Woodson BT, Expansion Sphincter Pharyngoplasty: A New Technique for the Treatment of Obstructive Sleep Apnea, Otolaryngol Head Neck Surg; 137(1):110-4 2007
Woodson BT, Robinson S, Lim HJ, Transpalatal Advancement Pharyngoplasty Outcomes Compared to Uvulopalatopharyngoplasty, Otolaryngology Head and Neck Surgery, 133:211-17, 2005
Steward DL, Huntley TC, Woodson BT, Surdulescu V. “Palate implants for obstructive sleep apnea: multi-institution, randomized, placebo-controlled study” Otolaryngol Head neck Surg., 139:506-10, 2008
Airway Evaluation and General Textbooks
Woodson BT, “Sleep Medicine and Surgery,” In, Ballenger’s Otorhinolaryngology 17 Head and Neck Surgery, Wackym P.A., Snow J.B., People’s Medical Publishing Company, Shelton, CT, pg. 983-995, 2009
Woodson, B.T., Karakoc O.: The Evaluation of Upper Airway Structure for Obstructive Sleep Apnea. In, Sleep Medicine, Yaremchuk K, Wardrop P, Plural Publishing Inc., San Diego, 2011 pg 11-29.
Woodson, BT, Diagnosing the correct site of obstruction in newly diagnosed obstructive sleep apnea, JAMA Otolaryngology-Head and Neck Surgery (Accepted In Press, 2014)
Woodson BT, Franco RA, Physiology of Sleep Disordered Breathing, Otolaryngol Clin North Am. Aug;40:691-711, 2007
Woodson, B.T., Patel, N, Genden E.: Obstructive Sleep Apnea Syndrome-Pathophysiology, Diagnosis, and Treatment.2nd edition, SIPac, American Academy Otolaryngology-Head and Neck Surgery Foundation, Inc., 2005.
Lower Airway Surgery
Woodson BT, Stewart DL, Weaver EM, Javaheri S, “A Randomized Trial of Temperature Controlled Radiofrequency, CPAP, and Placebo for the Treatment of Mild Obstructive Sleep Apnea Syndrome” , Otolaryngol Head Neck Surg, 128:848-861, 2003
Woodson BT, Laohasiriwong S, Endoscopic Midline Glossectomy for Obstructive Sleep Apnea in Pang KP, Rotenberg BW, Woodson BT, (EDS) Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea, Plural Publishing, 2013
Woodson BT, Pang K, “Tongue suspension: Impact on quality of life, polysomnography, and excessive sleepiness”, In, Evidence-Based Otolaryngology, Shin J, Hartnick C, Randolph G, Springer Science +Business Media, LLC, New York, NY, pg. 463-469.
Woodson BT, Steward DL, Mickelson S, Huntley T, Goldberg A. Multicenter study of a novel adjustable tongue advancement device for obstructive sleep apnea. Otolaryngol Head Neck Surg., 143:585-90. 2010
Robinson S, Ettema SL, Brusky L, Woodson BT., Lingual tonsillectomy using bipolar radiofrequency plasma excision. Otolaryngol Head Neck Surg.;134:328-30. 2006
Woodson BT, Laohasiriwong S, Lingual tonsillectomy and midline posterior glossectomy for obstructive sleep apnea Operative Techniques in Otolaryngology (2012) 23, 155-161
Learn more about the diagnosis of Obstructive Sleep Apnea (OSA)
Learn more about the treatments for Obstructive Sleep Apnea (OSA).