Practice Parameters for the Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults

Mount Sinai School of Medicine, New York, NY, USA.
Sleep (Impact Factor: 4.59). 10/2010; 33(10):1408-13.
Source: PubMed


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.
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.
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 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 (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).
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.

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Available from: Susmita Chowdhuri, Dec 23, 2013
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    • "Among the various surgical procedures for SDB, laser-assisted uvulopalatoplasty (LAUP) was broadly performed for the treatment of snoring or OSA in the 1990s [2,3]. However, LAUP is not presently recommended for the treatment of SDB including OSA due to insufficient evidence on its efficacy [4]. "
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    ABSTRACT: Laser-assisted uvulopalatoplasty (LAUP) was widely performed in 1990s as a surgical therapeutic procedure to improve snoring or mild obstructive sleep apnea (OSA). However, LAUP is not currently recommended as a treatment for OSA because the evidence for its efficacy is insufficient. Little is known about alternative minimally invasive surgery in patients who refuse continuous positive airway pressure or oral appliance after failed LAUP. We present a case of successful surgical treatment of persistent snoring and mild OSA with palatal implants after LAUP. This case suggests that palatal implants may be offered as an alternative surgical procedure for selective patients with persistent or recurrent snoring or mild OSA after LAUP.
    Full-text · Article · Mar 2014 · Clinical and Experimental Otorhinolaryngology
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    • "Although positive airway pressure (PAP) therapy is currently recommended for the primary treatment of OSA, some patients select surgical therapy because PAP therapy may have several adverse or side effects (e.g., nasal obstruction, mask leak, skin breakdown, pressure intolerance, and claustrophobia) [3,4]. 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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    • "Each of these methods has been met with varying degrees of success. Nasal continuous positive airway pressure (nasal CPAP) is usually effective and is now the treatment of choice in all but severe cases [1] [6]. "
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    ABSTRACT: Obstructive sleep apnea (OSA) may occur in association with obesity-hypoventilation (Pickwickian) syndrome, a disorder of ventilatory control affecting individuals with morbid obesity. Through the pressor effects of chronic hypercapnia and hypoxemia, this syndrome may result in pulmonary hypertension, right heart failure, and massive peripheral edema. We present a case of severe scrotal edema in a 36-year-old male with OSA and obesity-hypoventilation syndrome. A tracheostomy was performed to relieve hypoxemia and led to dramatic improvement of scrotal edema. No scrotal surgery was necessary. Followup at two months showed complete resolution of scrotal edema, improvement in mental status, and normalization of arterial blood gas measurements. This case demonstrates that OSA and obesity-hypoventilation syndrome may present with massive scrotal edema. Furthermore, if OSA is recognized as the cause of right heart failure, and if the apnea is corrected, the resultant improvement in cardiac function may allow reversal of massive peripheral, including scrotal, edema.
    Full-text · Article · Feb 2013 · Case Reports in Medicine
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