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BMJ. 2008 January 5; 336(7634): 44–45.
PMCID: PMC2174756
Change Page

Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults

Adam G Elshaug, lecturer,1 John R Moss, associate professor and head,1 Janet E Hiller, professor of public health,1 and Guy J Maddern, director of surgery2

Key points

  • Upper airway surgery for obstructive sleep apnoea in adults is resource intensive with low and inconsistent clinical effectiveness
  • Continuous positive airway pressure (CPAP) plus conservative weight and alcohol management should be first line treatment
  • When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment
  • Surgery for obstructive sleep apnoea should be done within controlled clinical trials; patients should be informed about the trial, as well as of the inconsistent results of surgery, its potential side effects, and the potential for relapse

The clinical problem

The prevalence of obstructive sleep apnoea in high income countries is estimated to be 20% for mild disease and 6-7% for moderate or severe disease. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health related quality of life.1 Clinical guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management (if indicated) as first line treatment for symptomatic, moderate to severe obstructive sleep apnoea.2 3 Upper airway surgery (such as uvulopalatopharyngoplasty) may also be done, but evidence does not support its use.4 However, use of surgical procedures is widespread and increasing in Australia and elsewhere (such as the Nordic countries).5 6 We propose that upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults.

The evidence for change

An array of surgical procedures is used either concurrently or stepwise over multiple operations. A recent multicentre retrospective audit revealed substantial procedural variability; the observed cohort (n=94) received 41 varying combinations of surgical procedures.5 In a Cochrane review of seven randomised controlled trials (n=412) in 2005, the results of surgery were inconsistent: significant improvement in polysomnography occurred in only three trials (combined n=225), and health related quality of life improved in only four trials (combined n=138).4 Comments on the clinical significance of both these measures were limited, and the review concluded that surgery had a lack of an impact on symptoms (except in two trials) and that overall significant benefit was not shown.4 Even where improvements in quality of life have been shown immediately after surgery, these were rarely sustained beyond 12-24 months.2 4 6

A recent systematic review of 48 studies (4 randomised controlled trials, 17 prospective studies of various designs, 23 retrospective case series, 4 unspecified design) found that up to 62% of 21 346 patients who had surgery reported persistent adverse effects,6 such as persistent dry throat, globus sensation, difficulty in swallowing (including spontaneous nasal regurgitation), voice changes, and disturbances of smell and taste. Up to 22% regretted having surgery.

An additional meta-analysis evaluated 18 surgical studies (n=385; 17 level four audits, one randomised controlled trial).7 Success, as measured by the number of patients achieving a post-surgery apnoea/hypopnoea index of 5 or less (a clinically significant standard against which CPAP is judged), was limited.8 Pooled success rates were 13% for phase I procedures including uvulopalatopharyngoplasty (14 studies, n=347) and 43% for phase II procedures including osteotomies (four studies, n=38).

Barriers to change

Conservative weight management is recommended as an adjunctive treatment, as it tackles a primary risk factor for obstructive sleep apnoea (on the basis of two randomised trials, combined n=91, and two non-randomised concurrently controlled studies, n=41).9 Weight loss and other lifestyle modification can be difficult to achieve, however. CPAP also depends on acceptance and adherence by patients; its benefits in mild to moderate obstructive sleep apnoea seem inconclusive,3 10 making surgical “cure” seem more attractive. Furthermore, in Australia, such surgery is mainly done in the private sector, which has different incentive mechanisms from the public system. However, given the lack of clear benefit from surgery and the potential for harm indicated by currently available evidence, guidelines recommend CPAP as first line treatment for obstructive sleep apnoea generally.2 3 When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment (16 randomised trials, n=745).2 11

How should we change our practice?

CPAP remains the recommended first line treatment for obstructive sleep apnoea in adults.2 3 10 Conservative weight management (as a primary risk factor) is recommended as adjunctive treatment.9 When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment.2 11 Surgery for obstructive sleep apnoea should be done within controlled clinical trials. Patients should be informed about the trial, as well as of the inconsistent results of surgery, the associated pain, the potential side effects, and the potential for relapse.

Search methods

We searched Medline, the Cochrane Library, and the International Network of Agencies for Health Technology Assessment database. We selected randomised controlled trials, systematic reviews, and practice guidelines that assessed the safety and efficacy of upper airway surgical procedures in the treatment of obstructive sleep apnoea in adults. We did bibliometric searches of identified articles, including our own published results, and communicated with specialist surgeons and sleep medicine physicians to identify relevant published evidence.

Useful reading

  • Young T, Peppard P, Gottlieb D. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med 2002;165:1217-39
  • Li KK. Surgical therapy for adult obstructive sleep apnoea. Sleep Med Rev 2005;9:201-9
  • Powell N. Upper airway surgery does have a major role in the treatment of obstructive sleep apnea: “the tail end of the dog.” J Clin Sleep Med 2005;1:236-40
  • Phillips B. Upper airway surgery does not have a major role in the treatment of sleep apnea. J Clin Sleep Med 2005;1:241-5
  • Kezirian EJ, Goldberg AN. Hypopharyngeal surgery in obstructive sleep apnea: an evidence-based medicine review. Arch Otolaryngol Head Neck Surg 2006;132:206-13

Notes

Change Page aims to alert clinicians to the immediate need for a change in practice to make it consistent with current evidence. The change must be implementable and must offer therapeutic or diagnostic advantage for a reasonably common clinical problem. Compelling and robust evidence must underpin the proposal for change.

Notes

Contributors: JRM and AGE had the idea for the paper. AGE and JEH developed the first substantive draft with input from JRM. GJM contributed guidance on several drafts. All authors read and approved the final version.JRM is the guarantor.

Competing interests: JEH and GJM are respectively directors of AHTA and ASERNIP-S, organisations that evaluate health technologies including surgical procedures. JRM is a consultant on health technology assessment to the Australian Government Department of Health and Ageing. AGE: none declared.

Provenance and peer review: Commissioned on the basis of an idea from the author; externally peer reviewed.

References

1. Young T, Skatrud J, Peppard P. Risk factors for obstructive sleep apnea in adults. JAMA 2004;291:2013-6. [PubMed]
2. Scottish Intercollegiate Guidelines Network. Management of obstructive sleep apnoea/hypopnoea syndrome in adults: a national clinical guideline Edinburgh: SIGN, 2003
3. Kushida CA, Littner MR, Hirshkowitz M, Morgenthaler TI, Alessi CA, Bailey D, et al. Practice parameters for the use of continuous and bilevel positive airway pressure devices to treat adult patients with sleep-related breathing disorders. Sleep 2006;29:375-80. [PubMed]
4. Sundaram S, Bridgman SA, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea. Cochrane Database Syst Rev 2005;(4):CD001004.
5. Elshaug AG, Moss JR, Southcott A, Hiller JE. An analysis of the evidence-practice continuum: is surgery for obstructive sleep apnoea contraindicated? J Eval Clin Pract 2007;13:3-9. [PubMed]
6. Report of a Joint Nordic Project. Obstructive sleep apnoea syndrome: a systematic literature review Stockholm: SBU, 2007. www.sbu.se/Filer/Content0/publikationer/1/somnapne_fulltext.pdf
7. Elshaug AG, Moss JR, Southcott A, Hiller JE. Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence. Sleep 2007;30:461-7. [PubMed]
8. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The report of an American Academy of Sleep Medicine Task Force. Sleep 1999;22:667-89. [PubMed]
9. Morgenthaler TI, Kapen S, Lee-Chiong T, Alessi C, Boehlecke B, Brown T, et al. Practice parameters for the medical therapy of obstructive sleep apnea. Sleep 2006;29:1031-5. [PubMed]
10. Giles TL, Lasserson TJ, Smith BH, White J, Wright J, Cates CJ. Continuous positive airways pressure for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 2006;(3):CD001106.
11. Lim J, Lasserson TJ, Fleetham J, Wright J. Oral appliances for obstructive sleep apnoea. Cochrane Database Syst Rev 2006;(1):CD004435.

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