Article

Surgical procedures and non-surgical devices for the management of non-apnoeic snoring: a systematic review of clinical effects and associated treatment costs

Peninsula Technology Assessment Group (PenTAG), University of Exeter, UK.
Health technology assessment (Winchester, England) (Impact Factor: 5.12). 02/2009; 13(3):iii, xi-xiv, 1-208. DOI: 10.3310/hta13030
Source: PubMed

ABSTRACT To review the evidence on the clinical effects and associated treatment costs of surgical procedures and non-surgical devices for the management of non-apnoeic snoring.
Major electronic databases were searched for relevant studies published between 1980 and 2007. All treatment costs were estimated based on data from NHS reference costs, device manufacturers and clinical opinion.
Studies were screened, data extracted and quality assessed according to standard methods. Results were broadly grouped according to the intervention and comparator when applicable, and further subgrouped according to the specific intervention type and study design. Results were combined using a narrative synthesis with relevant quantitative results tabulated. Differences between studies assessing the same intervention were explored narratively by examining differences in the intervention, study duration and study quality.
The systematic review included 27 studies (three randomised controlled trials, two controlled clinical trials and 22 pre-post studies) reported in 30 publications assessing uvulopalatopharyngoplasty (UP3) versus laser-assisted uvulopalatoplasty (LAUP), UP3 alone, LAUP alone, palatal stiffening techniques (Pillar implants and injection snoreplasty), radiofrequency ablation (RFA) of the soft palate or tongue base, continuous positive airway pressure (CPAP) devices and mandibular advancement splints (MAS). Studies were generally of a low methodological quality with small sample sizes. A total of 1191 patients was included. Both UP3 and LAUP reduced the number of snores per hour and produced a modest reduction in snoring loudness. UP3 was effective in reducing a number of subjectively reported snoring indices, but results on objective measures were equivocal. Limited evidence indicates that subjectively assessed snoring is improved after LAUP; no objective measures were assessed. RFA was associated with a reduction in partner-assessed snoring intensity, though evidence for an objective reduction in snoring sound levels was mixed. Pillar implants were moderately effective at reducing partner-rated snoring intensity, but had no effect on objective snoring indices. Use of CPAP reduced the number of snores per hour; no subjective measures were evaluated. Use of MAS improved objective snoring outcomes, including the maximal snoring sound volume, the mean snoring sound volume and the percentage of time spent in loud snoring; no subjective measures were evaluated. The cost for UP3 ranges from approximately 1230 pounds to approximately 1550 pounds. For LAUP the cost varies from 790 pounds to 2070 pounds depending on the number of stages of the procedure. The treatment costs associated with the use of Pillar implants range from 1110 pounds to 1160 pounds. The approximate annual treatment costs associated with the use of a CPAP machine and MAS are 220 pounds and 130 pounds respectively.
This study highlighted the paucity and poor quality of the evidence available on the effects of both surgical procedures and non-surgical devices for the management of primary snoring. Any conclusions to be drawn from the results are therefore somewhat tentative. There was no procedure that was clearly the least-cost option. Further research should focus on standardising methods of measuring outcomes and reporting, undertaking active controlled trials, and investigating the longer-term effects of treatments.

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    ABSTRACT: Many patients with obstructive sleep apnoea (OSA), as well as the medical community, are seeking alternative therapies to continuous positive airway pressure (CPAP). Where there are problems with CPAP adherence, surgical procedures are an option without the need for adequate compliance. A wide variety of surgical procedures is available, all of which address the differing anatomy and types of patients requiring specific evaluation of the available data. The author performed a literature search up to October 2008, the studies being evaluated according to EBM criteria. The data for some of the methods was limited. Minimally invasive surgery is helpful due to its positive efficacy vs morbidity ratio. While UPPP is still the standard procedure in mild to moderate OSA, its success is difficult to predict and often falls off with the passage of years. Additional upper airway investigations have not yet succeeded in overcoming this disadvantage. Combined surgery of the multi-level is reserved for secondary treatment after CPAP failure. Only tonsillectomy and maxillomandibular advancement are successful enough to be considered a first-line treatment in certain patients.
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