SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
Obstructive sleep apnea (OSA) is a syndrome characterized
by repetitive upper airway collapse or narrowing. Sequelae in-
clude adverse cardiovascular and metabolic outcomes, decline
in quality of life, and neurocognitive impairment.1-4 In addition
to lifestyle modifications such as weight loss, avoidance of al-
cohol or other agents that can decrease upper airway patency,
and implementation of positional therapy, the main therapeu-
tic options include positive airway pressure therapy (PAP),
oral appliances, and surgical procedures.5 For most individu-
als, PAP therapy remains the preferable first-line treatment for
OSA. However, a significant proportion of patients are unable
to tolerate PAP therapy and seek alternate treatment.6 Practice
parameters for the treatment of OSA in adults by surgical modi-
fication of the upper airway were first published in 1996 by
the AASM (formerly ASDA).7 The 1996 practice parameters
were based on a systematic review that accompanied the publi-
cation.8 Recently a series of clinical guidelines for the compre-
PRACTICE PARAMETERS FOR SURGERY FOR OSA IN ADULTS
Practice Parameters for the Surgical Modifications of the Upper Airway for
Obstructive Sleep Apnea in Adults
R. Nisha Aurora, MD1; Kenneth R. Casey, MD2; David Kristo, MD3; Sanford Auerbach, MD4; Sabin R. Bista, MD5; Susmita Chowdhuri, MD6;
Anoop Karippot, MD7; Carin Lamm, MD8; Kannan Ramar, MD9; Rochelle Zak, MD10; Timothy I. Morgenthaler, MD9
1Mount Sinai School of Medicine, New York, NY; 2Cincinnati Veterans Affairs Medical Center, Cincinnati, OH; 3University of Pittsburgh, Pittsburgh, PA;
4Boston University School of Medicine, Boston, MA; 5University of Nebraska Medical Center, Omaha, NE; 6Sleep Medicine Section, John D. Dingell VA
Medical Center, Detroit, MI; 7Penn State University Hershey Medical Center, Hershey, PA and University of Louisville School of Medicine, Louisville,
KY; 8Children’s Hospital of NY – Presbyterian, Columbia University Medical Center, New York, NY; 9Mayo Clinic, Rochester, MN; 10Sleep Disorders
Center, University of California, San Francisco, San Francisco, CA
Background: Practice parameters for the treatment of obstructive sleep apnea syndrome (OSAS) in adults by surgical modification of the upper airway
were first published in 1996 by the American Academy of Sleep Medicine (formerly ASDA). The following practice parameters update the previous
practice parameters. These recommendations were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine.
Methods: A systematic review of the literature was performed, and the GRADE system was used to assess the quality of evidence. The findings
from this evaluation are provided in the accompanying review paper, and the subsequent recommendations have been developed from this review.
The following procedures have been included: tracheostomy, maxillo-mandibular advancement (MMA), laser assisted uvulopalatoplasty (LAUP),
uvulopalatopharyngoplasty (UPPP), radiofrequency ablation (RFA), and palatal implants.
Recommendations: The presence and severity of obstructive sleep apnea must be determined before initiating surgical therapy (Standard). The
patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options such as nasal
positive airway pressure and oral appliances, and the levels of effectiveness and success rates of these alternative treatments (Standard). The
desired outcomes of treatment include resolution of the clinical signs and symptoms of obstructive sleep apnea and the normalization of sleep
quality, the apnea-hypopnea index, and oxyhemoglobin saturation levels (Standard). Tracheostomy has been shown to be an effective single
intervention to treat obstructive sleep apnea. This operation should be considered only when other options do not exist, have failed, are refused,
or when this operation is deemed necessary by clinical urgency (Option). MMA is indicated for surgical treatment of severe OSA in patients who
cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances, which are more often appropriate
in mild and moderate OSA patients, have been considered and found ineffective or undesirable (Option). UPPP as a sole procedure, with or with-
out tonsillectomy, does not reliably normalize the AHI when treating moderate to severe obstructive sleep apnea syndrome. Therefore, patients
with severe OSA should initially be offered positive airway pressure therapy, while those with moderate OSA should initially be offered either PAP
therapy or oral appliances (Option). Use of multi-level or stepwise surgery (MLS), as a combined procedure or as stepwise multiple operations, is
acceptable in patients with narrowing of multiple sites in the upper airway, particularly if they have failed UPPP as a sole treatment (Option). LAUP
is not routinely recommended as a treatment for obstructive sleep apnea syndrome (Standard). RFA can be considered as a treatment in patients
with mild to moderate obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom
oral appliances have been considered and found ineffective or undesirable (Option). Palatal implants may be effective in some patients with mild
obstructive sleep apnea who cannot tolerate or who are unwilling to adhere to positive airway pressure therapy, or in whom oral appliances have
been considered and found ineffective or undesirable (Option). Postoperatively, after an appropriate period of healing, patients should undergo
follow-up evaluation including an objective measure of the presence and severity of sleep-disordered breathing and oxygen saturation, as well
as clinical assessment for residual symptoms. Additionally, patients should be followed over time to detect the recurrence of disease (Standard).
Conclusions: While there has been significant progress made in surgical techniques for the treatment of OSA, there is a lack of rigorous data evaluating
surgical modifications of the upper airway. Systematic and methodical investigations are needed to improve the quality of evidence, assess additional
outcome measures, determine which populations are most likely to benefit from a particular procedure or procedures, and optimize perioperative care.
Keywords: Obstructive sleep apnea, surgical modifications, maxillo-mandibular advancement, uvulopalatopharyngoplasty, multi-level surgery
Citation: Aurora RN; Casey KR; Kristo D; Auerbach S; Bista SR; Chowdhuri S; Karippot A; Lamm C; Ramar K; Zak R; Morgenthaler TI. Practice
parameters for the surgical modifications of the upper airway for obstructive sleep apnea in adults. SLEEP 2010;33(10):1408-1413.
Submitted for publication May, 2010
Accepted for publication May, 2010
Address correspondence to: Sharon L. Tracy, PhD, American Academy of
Sleep Medicine, 2510 North Frontage Road, Darien, IL 60561-1511; Tel:
(630) 737-9700; Fax: (630) 737-9790; E-mail: firstname.lastname@example.org
SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
hensive management of sleep apnea in adults were developed
at the request of the AASM Board of Directors. These guide-
lines included surgical modification of the upper airway but
were based largely on expert consensus and were not intended
to reflect a systematic evidence-based analysis. The Standards
of Practice Committee of the AASM appointed a task force in
2007 to assist in an update of these practice parameters, the
result of which is the accompanying review paper.9
The Standards of Practice Committee (SPC) of the AASM, in
conjunction with specialists and other interested parties, devel-
oped these practice parameters based on the accompanying re-
view paper. A Task Force of content experts was assembled by the
AASM in July 2007 to review evidence in the scientific literature
regarding surgical therapies for OSA. In most cases recommenda-
tions are based on that systematic review of evidence from studies
published in the peer-reviewed literature. Some recommenda-
tions, when appropriate, have been carried forward from the pre-
vious practice parameters document with little or no change.
The Board of Directors of the AASM approved these recom-
mendations. All members of the AASM SPC and Board of Direc-
tors completed detailed conflict-of-interest statements and were
found to have no conflicts of interest with regard to this subject.
These practice parameters define principles of practice that
should meet the needs of most patients in most situations. These
guidelines should not, however, be considered inclusive of all
proper methods of care or exclusive of other methods of care
reasonably directed to obtaining the same results. The ultimate
judgment regarding propriety of any specific care must be
made by the physician, in light of the individual circumstances
presented by the patient, available diagnostic tools, accessible
treatment options, and resources.
The AASM expects these guidelines to have an impact on pro-
fessional behavior, patient outcomes, and, possibly, health care
costs. These practice parameters reflect the state of knowledge
at the time of publication and will be reviewed, updated, and
revised as new information becomes available. This parameter
paper is referenced, where appropriate, using square-bracketed
numbers to the relevant sections and tables in the accompany-
ing review paper, or with additional references at the end of
this paper. This practice parameter represents the first AASM
document based on a systematic review which used the GRADE
method of evaluating evidence quality.10 The classification of
evidence using the GRADE process is listed in Boxes 1 and 2.11
Definitions of levels of recommendations used by the AASM
appear in Table 1. Sections titled “Values and Trade-offs” ap-
pear under each individual practice parameter. The Values
and Trade-offs discussion elucidates the rationale leading to
each recommendation. These sections are an integral part of
the GRADE system and offer transparency to the process.10
Classic upper airway surgical techniques such as nasal-septal
reconstruction, cauterization, and tonsillectomy frequently fail
to correct OSA.8 Consequently, specialized surgical techniques
for treating OSA have been developed which modify either or
both the retropalatal and retrolingual areas. Historically, pat-
terns of airway narrowing or collapse have been classified in
the following manner: Type I collapse involves narrowing of
the retropalatal region; Type II includes narrowing or collapse
of both the retropalatal and retrolingual areas; and Type III col-
lapse occurs only in the retrolingual area.12 However, it is often
difficult to definitively identify the area of collapse and multiple
sites may be involved.
Box 2—Final assessments of evidence of grade
High (Level 4): Further research is very unlikely to change confidence
in the estimate of effect
Moderate (Level 3): Further research is likely to have an important
impact on the confidence in the estimate of effect and may change the
Low (Level 2): Further research is very likely to have an important
impact on our confidence in the estimate of effect and is likely to
change the estimate
Very low (Level 1): Any estimate of effect is very uncertain
Box 1—Criteria for assigning grade of evidence11
Type of evidence
• Randomized trial
• Observational study
• Any other evidence
Decrease grade if:
• Serious (−1) or very serious (−2) limitation to study quality
• Important inconsistency (−1)
• Some (−1) or major (−2) uncertainty about directness
• Imprecise or sparse data (−1)
• High probability of reporting bias (−1)
Increase grade if:
• Strong evidence of association – significant relative risk >2 (< 0.5)
based on consistent evidence from two or more observational
studies, with no plausible confounders (+1)
• Very strong evidence of association – significant relative risk of > 5
(< 0.2) based on direct evidence with no major threats to validity (+2)
• Evidence of a dose response gradient (+1)
• All plausible confounders would have reduced the effect (+1)
Table 1—AASM levels of recommendations
Assessment of benefit/harm/burden
Overall quality of evidence
HighModerate LowVery Low
StandardStandard Standard Standard
the estimates of
SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
Tracheostomy can be described as an upper airway bypass
procedure. Soft tissue ablation procedures intended to enhance
patency of the retropharyngeal area include uvulopalatopharyn-
goplasty (UPPP) and laser-assisted uvulopalatoplasty (LAUP).
Retrolingual tissue ablation procedures include laser midline
glossectomy/lingualplasty (LMG), radiofrequency tongue base
ablation (RFTBA), and tongue base reduction with hyoepiglot-
toplasty (TBRHE). Uvulopalatopharyngoglossoplasty (UP-
PGP) performs tissue ablation to enhance both the retropalatal
and retrolingual spaces. Procedures to reposition soft tissue to
improve retrolingual patency include mandibular advancement
(MA), genioglossal advancement (GA), hyoid myotomy and
suspension of hyoid from mandible (HM-1), and hyoid myot-
omy and attachment of hyoid to thyroid cartilage (HM-2). Fi-
nally, maxillomandibular advancement (MMA) is intended to
improve patency of both retropalatal and retrolingual spaces.12
The literature related to this wide array of procedures is
largely descriptive in nature and is not amenable to a systematic,
evidence-based review of efficacy and/or safety. Therefore, the
current practice parameters are limited to a subset of procedures
that are performed more frequently and for which some evalu-
able literature is available. Seventy-nine papers were included
in the accompanying review9 of which 4 were RCT (3 single
procedures and 1 multi-level procedure) and 75 were case series.
Of the case series, 44 were single procedures and 31 multi-level.
Therefore, there were 47 papers that looked at single procedures.
The following procedures will be reviewed here:
3.1 Tracheostomy: This procedure consists of creating an
opening in the trachea for placement of a long term
indwelling tube or stoma for ventilation, thereby by-
passing upper airway obstruction causing OSA.
3.2 Maxillomandibular advancement (MMA): this opera-
tion involves simultaneous advancement of the max-
illa and mandible through sagittal split osteotomies. It
provides enlargement of the retrolingual airway and
some advancement of the retropalatal airway.
3.3 Uvulopalatopharyngoplasty (UPPP): This procedure en-
larges the retropalatal airway through trimming and re-
orienting of the posterior and anterior tonsillar pillars and
excision of the uvula and posterior portion of the palate.
3.4 Laser assisted uvulopalatoplasty (LAUP): This pro-
cedure consists of placing bilateral vertical incisions
or trenches directly along both sides of the uvula fol-
lowed by laser ablation of the uvula.
3.5 Radiofrequency ablation (RFA): Radiofrequency abla-
tion consists of placement of a temperature controlled
radiofrequency probe typically in the tongue and/or
soft palate in an effort at palatal stiffening.
3.6 Soft palatal implants: this procedure consists of im-
planting malleable plastic rods into the soft palate un-
der local anesthesia.
3.7 Multi-level or stepwise surgery (MLS): This category
includes a wide array of combined procedures to ad-
dress narrowing of multiple sites in the upper airway.
MLS frequently consists of phase I utilizing UPPP,
and or genioglossus advancement and hyoid myotomy
(GAHM). Phase II surgeries consist of utilizing maxil-
lary and mandibular advancement osteotomy (MMO),
offered to those failing phase I surgeries.
The classification of evidence was made using GRADE
(Boxes 1 and 2).11 Recommendations are given as Standards,
Guidelines, and Options, as defined in Table 1.
4.1.1 The presence and severity of obstructive sleep apnea must be
determined before initiating surgical therapy (Standard).
Detailed diagnostic criteria for obstructive sleep apnea are
available and include signs, symptoms, and the findings of
Values and Trade-offs: This recommendation has not
changed from the previous practice parameter paper. A proper
diagnosis of OSA ought to be determined prior to surgery for
sleep apnea; to do otherwise exposes patients to needless risk.
Thus, even though there is not “evidence” in the sense of stud-
ies evaluating the performance of surgery for sleep apnea in
patients with and without OSA, this recommendation deserves
the “Standard” level.
4.1.2 The patient should be advised about potential surgical
success rates and complications, the availability of alternative
treatment options such as nasal positive airway pressure and oral
appliances, and the levels of effectiveness and success rates of
these alternative treatments (Standard).
Values and Trade-offs: This recommendation is not changed
from the prior practice parameter paper. The committee values
the ethical principles of patient autonomy and safety, and thus
feels that it is imperative that all reasonable treatment alterna-
tives for OSA be discussed in a manner that allows the patient
to make an informed decision.
4.2 Treatment Objective
The desired outcomes of treatment include resolution of the
clinical signs and symptoms of obstructive sleep apnea and the
normalization of sleep quality, the apnea-hypopnea index, and
oxyhemoglobin saturation levels (Standard).
Values and Trade-offs. This recommendation is unchanged
from the previous practice parameter. OSA is a multisystem
disorder affecting neurocognitive, metabolic, and cardiovascu-
lar function as well as quality of life. The AHI does not en-
compass all dimensions of OSA. However, an abnormal AHI
is currently necessary for disease classification, and normal-
ization is logically an important treatment objective. Normal-
ization of AHI does not necessarily reverse all components of
OSA. Up to 22% have residual hypersomnia after normaliza-
tion of the AHI with PAP therapy,14 and some studies indicate
there are permanent neuroanatomic effects of OSA in some
individuals.15 Nonetheless, even modest elevations of the AHI
correlate with elevated risk of cardiovascular sequelae, symp-
toms, and neurocognitive effects.16 Most studies demonstrating
benefit in cardiovascular risk, mortality, symptoms, and neu-
rocognitive effects show substantial improvement in AHI.17,18
Other endpoints such as subjective and objective symptom
melioration and improved quality of life are also important di-
mensions of health, and their correlation with mortality has not
been well studied. For all these reasons, we have placed a high
SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
4.3.3 Uvulopalatopharyngoplasty (UPPP) as a single surgical
procedure: UPPP as a sole procedure, with or without
tonsillectomy, does not reliably normalize the AHI when treating
moderate to severe obstructive sleep apnea syndrome. Therefore,
patients with severe OSA should initially be offered positive airway
pressure therapy, while those with moderate OSA should initially
be offered either PAP therapy or oral appliances. [Review Section
3.2.1; 3.2.2; Figure 4, 5; Table 2] (Option).
This is a change from the previous practice parameter which
recommended UPPP for patients with narrowing or collapse of
the retropalatal area. We now recommend that more reliable
treatment modalities be preferred in patients with moderate to
severe OSA. It is important to note that this recommendation
applies to the use of UPPP as a single surgical procedure to
treat moderate to severe OSA; for use of UPPP combined with
other surgical procedures, refer to section 4.3.4 below. The evi-
dence concerning UPPP is very low quality (Level 1), consist-
ing of 13 observational studies and 2 randomized trials which
were judged to have significant flaws. The meta-analysis dem-
onstrated that patients with initially moderate to severe OSA
had residual AHI of 30/hr, leaving patients with criteria defin-
ing moderate to severe OSA. Objective outcome parameters for
assessment of surgical success in OSA other than AHI remain
ill defined and not uniformly accepted. None of the articles re-
trieved for the evidence review addressed use of UPPP in mild
OSA. The absence of stronger supporting evidence for UPPP
published in the decade since the previous practice parameters
is significant. Indeed, evidence for using UPPP as a singular
therapy in treating OSA, regardless of severity, is very weak,
and patients who undergo UPPP for therapy require close fol-
low-up to ensure efficacy. (See section 5.0 below.)
Values and Tradeoffs: This recommendation has changed as
the committee valued normalization of the AHI, improvements
in other clinically important outcomes, and safety. There is now
a convergence of very low level evidence that UPPP alone (with
or without tonsillectomy) does not reliably normalize the AHI
and has only modest impact on pre-operative values. Other clini-
cal outcomes such as improvement in sleepiness or cardiovascu-
lar events and/or risks are not well developed in the literature.
UPPP entails some morbidity and rarely, mortality. In highly
selected patients, UPPP may be an appropriate supplement to
PAP or OAs, but evidence for this is also not well developed.
Therefore, although UPPP alone may seem more convenient and
desirable for some patients, routinely other more proven treat-
ments such as PAP or OAs ought to be considered first.20,21 There
is a pressing need for comparative outcomes research regarding
UPPP and other treatment modalities, as the benefits compared
with harms of UPPP are unclear at this time.
4.3.4 Multi-Level or Stepwise Surgery (MLS): Use of MLS, as
a combined procedure or as stepwise multiple operations, is
acceptable in patients with narrowing of multiple sites in the upper
airway, particularly if they have failed UPPP as a sole treatment.
[Review Section 3.6; 3.7; Figure 12, 13] (Option).
Although a large volume of literature was found addressing
MLS, the approaches and surgical procedures were hetero-
geneous. Furthermore, these reports were observational case
series or comparisons of one procedure to another without
randomization or control groups; therefore the evidence was
value on normalization of the AHI in rating efficacy of treat-
ments for OSA.
4.3 Surgical Procedures
4.3.1 Tracheostomy: Tracheostomy has been shown to be an
effective single intervention to treat obstructive sleep apnea. This
operation should be considered only when other options do not
exist, have failed, are refused, or when this operation is deemed
necessary by clinical urgency (Option).
Although the Task Force did not find any additional papers
on tracheostomy [indirectly in Review Section 2.2], the con-
sensus of the Standards of Practice Committee holds that this
intervention is appropriate in the aforementioned setting.
Values and tradeoffs: This recommendation is unchanged
from the prior practice parameter paper. Although there is
strong consensus that tracheostomy is nearly uniformly suc-
cessful in bypassing upper airway obstruction and normalizing
AHI in patients with OSA and may be life-saving in some cas-
es, the decision to not recommend tracheostomy as a primary
therapy is based on placing high value on patient safety, au-
tonomy, and quality of life. For most patients, other treatments
such as oral appliances (OAs) or positive airway pressure are
effective yet less deforming and require less ongoing care and
lifestyle modification than tracheostomy.19
4.3.2 Maxillo-Mandibular Advancement (MMA): MMA is indicated for
surgical treatment of severe OSA in patients who cannot tolerate
or who are unwilling to adhere to positive airway pressure therapy,
or in whom oral appliances, which are more often appropriate in
mild and moderate OSA patients, have been considered and found
ineffective or undesirable [Review Section 3.1; Figure 2, 3] (Option).
Although the evidence is very low quality (Level 1), com-
prised of nine case series, the studies tend to demonstrate con-
sistent effectiveness in severe OSA. Traditional “stepped” care
often employs MMA as a final approach for surgical correc-
tion of OSA (see 4.3.7). However, in certain cases MMA may
be considered as an initial or sole surgical approach in treating
OSA. A multidisciplinary evaluation to clarify which patients
would benefit from MMA as initial or sole therapy is recom-
mended. Evidence supporting this or other alternatives to the
usual stepped approach is lacking. Additionally, MMA is not
well described in mild and moderate OSA making recommen-
dations in less severe OSA unclear.
Values and tradeoffs: The AHI was reduced to at least 10/h
in most patients in published series, especially in more recent-
ly published studies. Yet, PAP therapies remain more reliably
effective in normalizing AHI, and there is ample evidence for
improvement in other measures of outcome such as sleepiness
and quality of life with PAP that are lacking for MMA. Some
patients may benefit cosmetically from MMA, but short and
long term risks of MMA are not well described in the extant
literature. Therefore, PAP or oral appliance therapy should gen-
erally be suggested ahead of MMA in appropriate candidates.20,21
Surgical risks and adverse effects of MMA have not been sys-
tematically analyzed or reported. There is a need for further clar-
ification about the relative risks and benefits of MMA compared
with other treatment modalities, and given the current very low
levels of evidence, an Option recommendation is appropriate.
SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
in whom oral appliances have been considered and found ineffective
or undesirable [Review Section 3.5; Figure 10, 11] (Option).
There is limited research that adequately assesses the effi-
cacy of palatal implants for the treatment of OSA. One RCT
and 2 case series met the criteria for inclusion in the review
and suggest marginal efficacy. Overall, this represents very low
quality (Level 1) evidence.
Values and Tradeoffs: This is a new treatment option that
has emerged since the previous practice parameter. While this
procedure may be an alternative mode of therapy for mild OSA,
at the present time it is difficult to predict if it will be ultimately
be found to be a reliably effective intervention.
Postoperatively, after an appropriate period of healing, patients
should undergo follow-up evaluation including an objective
measure of the presence and severity of sleep-disordered breathing
and oxygen saturation, as well as clinical assessment for residual
symptoms. Additionally, patients should be followed over time to
detect the recurrence of disease (Standard).
Values and Trade-offs: This recommendation has been
upgraded to Standard since the previous practice parameter.
Insufficient evidence exists to predict the duration that any im-
mediate postoperative improvement is likely to be maintained.
Cases of relapse after successful operations have been de-
scribed.25,26 Clearly, the hazards of not recognizing recrudescent
sleep apnea, with its associated comorbidities and complica-
tions, far outweigh any conceivable benefits from not following
post operative patients closely. Unfortunately, little guidance is
available in the medical literature to recommend any particular
monitoring strategy. The optimal interval and duration of this
follow up are also not clear in the literature. The development
of relapse is likely to be related, in part, to weight gain, inter-
current illnesses, and/or changes in medication but may occur
without any clear cause.27
6.0 CONCLUSIONS AND FUTURE RESEARCH
The paucity and low quality of evidence concerning the sur-
gical treatment of the upper airway for OSA in adults is con-
spicuous. Both PAP and OA therapy have more robust data
upon which to develop treatment recommendations. The largest
body of evidence provided by a systematic search and meta-
analysis refers to UPPP alone, which is unfortunately not highly
relevant to current practices wherein UPPP is either modified
from its original description or is combined with other surgi-
cal modifications of the upper airway. Given the importance of
surgical options for management and the expense and potential
morbidities that are unique to surgical management, it is im-
perative that key questions be resolved by sound clinical re-
search. From the available evidence, there were very few RCT
or even case-control studies. Although the RCT is difficult to
perform using surgical management strategies, it remains the
most reliable standard upon which practice recommendations
can be made.
Since ongoing innovations in surgical management are ex-
pected, standardized approaches to preoperative classification
including demographic, anatomic, and polysomnographic base-
lines at a minimum, a detailed analysis of what anatomic and/or
very low quality Level 1. Without more data on specific MLS
procedures, a higher recommendation cannot be made. En-
couraging improvements in OSA severity following phase II
surgery may support performing phase II surgeries first in se-
lected cases; however, research regarding a reversed phase II
followed by phase I approach is not available in the literature.
Values and tradeoffs: The accompanying review9 notes that
non-randomized studies of multi-phase procedures are subject
to bias by the self-selection of patients willing to undergo mul-
tiple surgeries. While a multilevel approach may eventually
result in a significant decline in the AHI, available data for a
stepwise approach are heterogeneous, clinical outcomes such
as cardiovascular events are not well studied, and multiple pro-
cedures could be associated with an increase in morbidity and
4.3.5 Laser Assisted Uvulopalatoplasty (LAUP): LAUP is not
routinely recommended as a treatment for obstructive sleep apnea
syndrome [Review Section 3.3; Figure 6, 7] (Standard).
The evidence related to the use of LAUP was judged to be
low quality (Level 2) based on 2 randomized trials and 6 ob-
servational studies. LAUP was addressed in a separate practice
parameter update in 2001,22 which included a Guideline-level
recommendation against the use of LAUP for the treatment of
sleep-related breathing disorders including OSA.
Values and Tradeoffs: The recommendation has been up-
graded from guideline to standard. LAUP does not generally
normalize the AHI and the literature does not demonstrate sig-
nificant improvement in secondary outcomes. Two studies, 1
RCT23 and 1 observational24 performed since the last review,22
actually saw worsening of the overall AHI. As there is no signif-
icant improvement post procedure, a possibility of worsening
exists, and perioperative pain and complications are potential
issues, the routine recommendation of this procedure would not
be in the patient’s interest.
4.3.6 Radiofrequency ablation (RFA): RFA can be considered as a
treatment in patients with mild to moderate obstructive sleep apnea
who cannot tolerate or who are unwilling to adhere to positive
airway pressure therapy, or in whom oral appliances have been
considered and found ineffective or undesirable [Review Section
3.4.1; 3.4.2; 3.4.3; 3.4.4; Figure 8, 9] (Option).
This is a new recommendation based on Level 1 very low
quality evidence (7 observational case series and 1 RCT). The
average post-procedure AHI was found to be 14.9, consistent
with residual mild OSA. RFA studies have shown improvement
in subjective sleepiness and, in one study, quality of life.
Values and Tradeoffs: In patients with mild or moderate
OSA who do not or cannot adhere to PAP or OAs, RFA may
be an alternative therapy even though not as predictably effi-
cacious. Since long-term cardiovascular complications of OSA
are associated with even lower values of AHI, patients treated
with RFA should receive follow-up assessments for residual
AHI, even if symptoms appear adequately improved. Long-
term sequelae of RFA are not published.
4.3.7 Palatal Implants: Palatal implants may be effective in some
patients with mild obstructive sleep apnea who cannot tolerate or
who are unwilling to adhere to positive airway pressure therapy, or
SLEEP, Vol. 33, No. 10, 2010
Practice Parameters—Aurora et al
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of continuous positive airway pressure on quality of life in patients with
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4. Takama N, Kurabayasi M. Influence of untreated sleep-disordered breath-
ing on the long-term prognosis of patients with cardiovascular disease.
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upper airway Sleep 1996;19:152-5.
8. Sher AE, Schechtman KB, et al. The efficacy of surgical modifications of
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9. Caples S, et al. Surgical modifications of the upper airway for sleep ap-
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functional changes are produced by the surgery, and thorough
follow-up using objective and validated assessment tools would
be important to develop so that comparative effectiveness stud-
ies might be more easily performed. Registries ought to be con-
sidered to foster further research.
Much is unknown about how to best monitor surgically treat-
ed patients. Studies are greatly needed to clarify when the first
follow-up re-assessment for cure ought to be performed (e.g.,
how many weeks postoperatively?), what treatments ought to
be maintained during the postoperative period (e.g., should PAP
to be used in the first months after therapy?), how long should
observation continue, and what are the best follow-up tools over
time (e.g., clinical assessment, standardized questionnaires,
portable monitors, other disease markers?). It is unknown if the
use of multi-level surgery influences the rate of relapse. Long-
term longitudinal data are lacking for the surgical treatments.
Many current surgical approaches only partially correct
sleep-disordered breathing, yet the remedies are in effect every
night. This contrasts with PAP or OA that might be entirely ef-
ficacious in alleviating sleep-disordered breathing, yet only do
so when they are used. Studies comparing effectiveness of these
treatment strategies are needed.
Few surgical studies address outcomes in diverse patient
populations with respect to women, different age groups, and
race/ethnicity. How BMI, more accurate descriptors of body
habitus, and other relevant anatomic considerations influence
surgical outcomes require better definition.
Adverse effects of the various surgical treatments and prog-
nostic factors over both short and long term need require better
When these research and standardization topics have been
addressed, the surgical modification of the upper airway as a
treatment of OSA in adults can be better understood, and its
indication from the multiple other approaches to OSA treatment
can be better defined for optimal patient care.
The committee would like to thank Sharon Tracy, PhD, and
Rich Rosenberg, PhD, for their efforts in the development of
This was not an industry supported study. Dr. Morgenthaler
has received research support from ResMed. Dr. Auerbach has
participated in research supported by Sepracor and participated
in a speaking engagement for Forest Pharmaceuticals. Dr. Kar-
ippot has received research support from Wyeth and is Medical
Director of Akane Sleep Solutions, Inc., a sleep disorders clinic
and laboratory. The other authors have indicated no financial
conflicts of interest.
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