By Dr Abdulmohsen Ebrahim Alterki
In the past, sleep related breathing disorders were often considered minor or simply a nighttime nuisance. However, modern medicine has revealed that many of these conditions represent a serious disease known as obstructive sleep apnea. In this condition, breathing repeatedly stops or becomes significantly reduced during sleep due to upper airway obstruction.
This disorder does not only affect sleep quality. Its impact extends to the cardiovascular system, brain function, metabolism and overall quality of life. Today, it is recognized as one of the most important chronic sleep disorders strongly associated with modern diseases such as obesity, hypertension and type 2 diabetes. Within the field of otolaryngology head and neck surgery, a new subspecialty has emerged over the past three decades known as “sleep surgery”. This field has evolved from simple procedures aimed at symptom relief into a comprehensive, highly individualized approach based on precise diagnosis and patient specific treatment planning.
In the early 1980s, uvulopalatopharyngoplasty (UPPP) was introduced as one of the first surgical procedures aimed at enlarging the upper airway by removing tissue from the soft palate and surrounding structures. Although this procedure represented an important milestone, outcomes were variable, and some patients experienced complications such as swallowing difficulties or changes in voice. Over time, it became clear that obstructive sleep apnea is not a single pattern obstruction but a complex, multi-level condition that varies between patients and even within the same patient over time, influenced by weight and other health factors.
This understanding shifted surgical philosophy from broad tissue removal toward reconstructive and function preserving approaches, supported by advanced diagnostic tools such as endoscopy and imaging to tailor treatment to each individual patient. One of the most significant advances in sleep surgery has been the introduction of drug induced sleep endoscopy (DISE). This technique allows direct visualization of the airway during a sleep like state induced by sedation, enabling precise identification of the exact site of obstruction.
DISE was introduced by me after an extensive training in Holland, where it started in Kuwait at Zain Hospital within the Sabah Medical Area in 2014. It has become a key diagnostic tool for identifying obstruction at different levels, including the soft palate, tongue base and lateral pharyngeal walls. This has allowed clinicians to move away from one size fits all surgery toward highly personalized treatment strategies.
DISE has also helped identify complex collapse patterns, such as complete concentric collapse of the airway, which may influence the success of certain surgical interventions or neurostimulation therapies. With improved understanding of airway anatomy, surgical management has expanded beyond soft tissue procedures to include skeletal framework modification.
Maxillomandibular advancement (MMA) is one of the most effective surgical treatments for selected patients. By advancing the upper and lower jaws forward, the airway space is significantly enlarged, reducing the likelihood of collapse during sleep. Multiple studies have demonstrated that MMA offers high success rates in appropriately selected patients, with durable long-term improvement in breathing, sleep quality, and overall health outcomes.
Since around 2014, sleep surgery has entered a new phase with the introduction of hypoglossal nerve stimulation (HNS). This therapy involves implantation of a small device that stimulates the nerve controlling tongue movement during sleep, preventing airway obstruction caused by tongue collapse. HNS has become an important alternative for patients who cannot tolerate continuous positive airway pressure (CPAP) therapy, particularly in moderate to severe cases, provided that strict anatomical and functional selection criteria are met, often assessed through DISE.
This represents a major step toward precision based “personalized sleep medicine”, where treatment is tailored to individual airway dynamics rather than a uniform approach. Obesity is one of the most significant contributors to obstructive sleep apnea. Excess fat deposition around the neck, tongue, and pharyngeal structures narrows the airway and increases its tendency to collapse during sleep. Therefore, weight reduction has become a cornerstone of modern management, not only to improve breathing during sleep but also to reduce cardiovascular risk, metabolic complications and the progression of insulin resistance and diabetes.
Recently, newer pharmacological agents for weight loss have shown promising results in selected patients, improving both metabolic profile and sleep related breathing parameters. While these medications are not a replacement for other therapies, they have become an important component of a multidisciplinary treatment strategy. Obstructive sleep apnea lies in its silent nature. Many patients remain undiagnosed for years, attributing symptoms such as chronic fatigue, morning headaches or poor concentration to lifestyle stress. In reality, these symptoms may reflect repeated drops in blood oxygen levels occurring hundreds of times each night.
Over time, this can lead to serious complications, including: Chronic hypertension, cardiac arrhythmias, heart attacks and strokes, cognitive decline and memory impairment, daytime sleepiness leading to traffic accidents, worsening diabetes and insulin resistance, heart failure and pulmonary hypertension, sexual dysfunction and infertility, increased perioperative and anesthetic risk.
A message to the public: Today, sleep disordered breathing is no longer viewed as a benign nighttime condition but as a chronic, treatable disease. Early diagnosis significantly improves outcomes and reduces long term complications. Advances in sleep surgery and sleep medicine have created a wide range of treatment options, from lifestyle modification and weight loss, to CPAP therapy, to targeted surgical interventions and nerve stimulation techniques. The most important message remains clear: Persistent fatigue, excessive daytime sleepiness and witnessed breathing pauses during sleep by your partner should never be ignored. They are not simply lifestyle complaints, but potential warning signs of a serious, yet treatable condition that affects the heart, brain and overall quality of life.
NOTE: Dr Abdulmohsen Ebrahim Alterki is the Chairman of Otolaryngology, Head & Neck Surgery Faculty, Kuwait Board of Postgraduate Training Program, Kuwait Institute for Medical Specialization (KIMS), Ministry of Health, Kuwait
