Tracheotomy is a standard technique performed by every general, ENT, or maxillofacial surgeon. We always perform a complete mucocutaneously anastomized tracheostomy to avoid granulation and difficulties when changing the tubes. However, patients who require a tracheotomy for OSA often are morbidly overweight. Standard-sized tracheostomy tubes often are too short because of increased submental or anterior cervical girth. The surgeon has two options to overcome the problem: modify the tracheostomy tube or recontour the neck to accommodate a standard tube. As the patients are supposed to be able to handle the tracheostomy tube on their own, we prefer the latter approach. Gross et al. [244] described their surgical technique and retrospectively estimated their complication rate after 23 months as 43%, including wound infections, neck abscess, and hemorrhage.

Today an increasing number of percutaneous dilating tracheotomies are performed especially in intensive care units. It is a promising tool for patients who require their tracheotomies for short-term periods. In the treatment of OSA, there are two groups of patients requiring tracheotomies. For the first group, tracheotomies are performed to protect the upper airway during the immediate postoperative period after invasive procedures within the upper airway. Most surgeons perform conventional surgical tracheostomies in these patients as they are already in the operation theater. This is what we also recommend and do. The other group of patients needs their tracheostomies for long-term periods. This points to a clear advantage for the conventional surgical approach.

Partinen et al. [546] studied the survival rates of 198 patients with OSA, of whom 71 were treated with tracheotomy, while the rest were managed conservatively with weight reduction. Over a follow-up period of 5 years, there were 14 deaths, all of them in the group undergoing conservative therapy.

Ledereich et al. [389] compared 30 patients with permanent tracheostomies with 71 patients who had received other therapies (temporary tracheotomy, UPPP, tonsillectomy, nasal operations, or conservative treatment with medications stimulating respiration). Patients were observed for 5 years. Excessive daytime sleepiness was reported by only 24% of those in the tracheostomy group but by 59% of those who had undergone other treatments. Apnea phases were recorded in 3% of the tracheotomized patients and in 35% of the other patients. Snoring was reported by 13% of patients with tracheostomy but by 58% of the comparison group.

Data providing polysomnographic figures is summarized in Table 11.1. Although there are no randomized, controlled studies, tracheotomy can be regarded as a very effective treatment modality for OSA.

In a study by Kim et al. [360] all patients that were classified as nonresponders after tracheotomy showed evidence of cardiopulmonary decompensation as defined by an initial PaCO₂ greater than 45 mmHg already prior to surgery.

Cohen et al. compared 13 pediatric tracheostomy patients with 50 children who had undergone other kinds of sleep apnea surgery. Clinical success was achieved in 100% after tracheostomy and in 59% of the sleep apnea surgery group [116]. However, the tracheotomized children showed impaired quality of life for 95% of the items investigated.

Thatcher and Maisel [742] observed a decannulation in 16 out of 79 patients 2 months to 13 years after tracheostomy for OSA: 5 patients chose CPAP-ventilation, 3 grew intolerant of their tracheotomies, 3 underwent successful UPPP, and 2 experienced significant weight loss.

Guilleminault et al. [252] followed 50 tracheotomized OSA patients over a period of on average 32 months (range: 9 months to 6 years). Following tracheotomy, all patients exhibited an Apnea Index below 5, but all experienced persistent central respiratory events during the first postoperative year. Kim et al. [360] report that in patients with cardiopulmonary decompensation, tracheotomy led to improvement but not elimination of OSA in seven of 13 patients studied. One reason cited was the increased incidence of central respiratory events, while another related to the occlusion of the tracheostomy by chin and neck adipose tissue. A similar case with occurrence of severe central sleep apnea 4 years after initially successful tracheostomy for OSA was reported by Fletcher [203].