Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults: A Systematic Review and Meta-Analysis

Center for Sleep Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester MN, USA.
Sleep (Impact Factor: 4.59). 10/2010; 33(10):1396-407.
Source: PubMed


A substantial portion of patients with obstructive sleep apnea (OSA) seek alternatives to positive airway pressure (PAP), the usual first-line treatment for the disorder. One option is upper airway surgery. As an adjunct to the American Academy of Sleep Medicine (AASM) Standards of Practice paper, we conducted a systematic review and meta-analysis of literature reporting outcomes following various upper airway surgeries for the treatment of OSA in adults, including maxillomandibular advancement (MMA), pharyngeal surgeries such as uvulopharyngopalatoplasty (UPPP), laser assisted uvulopalatoplasty (LAUP), and radiofrequency ablation (RFA), as well as multi-level and multi-phased procedures. We found that the published literature is comprised primarily of case series, with few controlled trials and varying approaches to pre-operative evaluation and post-operative follow-up. We include surgical morbidity and adverse events where reported but these were not systematically analyzed. Utilizing the ratio of means method, we used the change in the apnea-hypopnea index (AHI) as the primary measure of efficacy. Substantial and consistent reductions in the AHI were observed following MMA; adverse events were uncommonly reported. Outcomes following pharyngeal surgeries were less consistent; adverse events were reported more commonly. Papers describing positive outcomes associated with newer pharyngeal techniques and multi-level procedures performed in small samples of patients appear promising. Further research is needed to better clarify patient selection, as well as efficacy and safety of upper airway surgery in those with OSA.

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    • "Regarding the surgery method versus glaucoma risk, pharyngeal surgery (HR = 1.86) is higher than nasal surgery (HR = 1.14). As far as we know practice parameters for surgical treatment for OSA in adults were first published in 1996 by the American Academy of Sleep Medicine (AASM) [3]; and clinical guidelines on the evaluation, management, and long-term care of OSA in adults were recently published by the AASM [13–15]. These guidelines 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 [13–15]. "
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    ABSTRACT: Objective. To investigate if different treatment strategy of obstructive sleep apnea (OSA) was associated glaucoma risk in Taiwanese population. Methods. Population-based retrospective cohort study was conducted using data sourced from the Longitudinal Health Insurance Database 2000. We included 2528 OSA patients and randomly selected and matched 10112 subjects without OSA as the control cohort. The risk of glaucoma in OSA patients was investigated based on the managements of OSA (without treatment, with surgery, with continuous positive airway pressure (CPAP) treatment, and with multiple modalities). The multivariable Cox regression was used to estimate hazard ratio (HR) after adjusting for sex, age, hypertension, diabetes, hyperlipidemia, and coronary artery disease. Results. The adjusted HR of glaucoma for OSA patients was 1.88 (95% CI: 1.46–2.42), compared with controls. For patients without treatment, the adjusted HR was 2.15 (95% CI: 1.60–2.88). For patients with treatments, the adjusted HRs of glaucoma were not significantly different from controls, except for those with CPAP (adjusted HR = 1.65, 95% CI = 1.09–2.49). Conclusions. OSA is associated with an increased risk of glaucoma. However, surgery reduces slightly the glaucoma hazard for OSA patients.
    Full-text · Article · Jul 2014 · Journal of Ophthalmology
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    • "Methodological quality of the included reviews (AMSTAR checklist). AMSTAR checklist Caples et al 2010 27 Choi et al 2012 28 Elshaug et al 2007 29 Franklin et al 2009 30 Holty and Guilleminault 2010 3 Kezirian et al 2006 31 Li et al 2011 32 Lin et al 2008 5 Pirklbauer et al 2011 33 Sher et al 1996 26 Sundaram et al 2011 1 "
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    ABSTRACT: Objective There is an extensive amount of literature on surgeries as treatment for obstructive sleep apnea syndrome on adults. Previous systematic reviews have been performed to summarize the outcomes for sleep surgeries, with conflicting results. The objective of this study was to critically evaluate these systematic reviews to provide an overview of their quality, strengths, and conclusions.Data SourcesMEDLINE, Scopus, and the Cochrane Collaboration databases were searched from inception to April 2013.Review Methods An overview of systematic reviews was undertaken. Studies included in this review are the systematic reviews whose primary objective was to evaluate the outcomes of sleep apnea surgery on adults. The methodological quality of the studies was analyzed with AMSTAR checklist, and the quality of evidence was evaluated using the GRADE assessment tool. Primary outcome measures assessed the effect of surgery on snoring, sleepiness, and the apnea-hypopnea index.ResultsA total of 11 studies were included in this study, and the pooled overview includes 378 studies. The systematic reviews were mostly graded as low quality using the GRADE tool and low to moderate according to the AMSTAR checklist. Outcome for apnea-hypopnea index demonstrated substantial variation leading to conflicting results. Despite a high amount of heterogeneity, outcomes for sleepiness and snoring demonstrated significant improvement across included reviews.Conclusions Although obstructive sleep apnea surgery is associated with improved outcomes in most studies, the level and quality of evidence reviews requires improvement.
    Full-text · Article · Oct 2013 · Otolaryngology Head and Neck Surgery
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    • "There are numerous OSA surgical procedures according to the obstructive level, including the nasal cavity (e.g., turbinate surgery, septoplasty, and endoscopic sinus surgery), nasopharynx (e.g., adenoidectomy), oropharynx (e.g., tonsillectomy, palatal implants, radiofrequency ablation of the soft palate, uvulopalatopharyngoplasty [UPPP] and uvulopalatal flap [UPF]), hypop harynx (e.g., lingual tonsillectomy, partial glossectomy, radiofrequency ablation of the tongue base, and genioglossus advancement) and the upper airway (e.g., maxillomandibular advancement) [4-7]. Of these, UPPP is one of the most popular procedures for resolving oropharyngeal obstruction [6]. "
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    ABSTRACT: The aims of this study were 1) to evaluate the effect of isolated uvulopalatopharyngoplasty (UPPP) on subjective obstructive sleep apnea (OSA) symptoms in adult patients regardless of the response to surgery, and ultimately 2) to investigate the differences in changes in subjective OSA symptoms between successful and unsuccessful surgery groups. Twenty consecutive adult patients who underwent isolated UPPP were enrolled. Pre- and postoperative subjective OSA symptoms (snoring, witnessed apnea, daytime sleepiness, morning headache, daytime fatigue, restless sleep, difficulty with morning arousal) and polysomnographic data were evaluated in all subjects. Changes in subjective OSA symptoms before and after surgery were investigated in the successful (n=11) and unsuccessful (n=9) groups. Surgical success was defined as a reduction of at least 50% in the preoperative apnea-hypopnea index (AHI) and a postoperative AHI less than 20 per hour. After isolated UPPP, all subjective OSA symptoms changed significantly in the patients, especially in the successful group. In the unsuccessful group, snoring, witnessed apnea and daytime fatigue changed significantly, while other symptoms did not change significantly after surgery. Isolated UPPP may improve subjective OSA symptoms in adult patients whom surgery was successful or unsuccessful. However, after isolated UPPP, the improvements in subjective OSA symptoms in the unsuccessful group may be different from those in the successful group.
    Full-text · Article · Sep 2013 · Clinical and Experimental Otorhinolaryngology
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