1
Background and Rationale for Surgical Therapy
The rationale for and the objectives of surgical treatment for obstructive sleep apnea (OSA) are fundamentally analogous to those of medical management: to improve sleep-related symptoms and quality-of-life measures and to reduce cardiovascular morbidity and other health consequences associated with untreated moderate to severe OSA. The potential success of primary airway reconstructive surgery has a unique advantage over most medical treatments in that it is not dependent on adherence to a device. Inadequate adherence or nonacceptance of medical therapy due to adverse equipment-related side effects is the most common reason for failure of continuous positive airway pressure (CPAP), oral appliance therapy, and other medical devices. Additionally, surgical therapy for OSA can be employed in an adjunctive role to improve the adherence to and effectiveness of these medical treatments.
2
Clinical Context of Surgical Therapy
OSA should be approached as a chronic long-term medical condition, similar to asthma or hypertension, which is managed in a longitudinal, and often multidisciplinary, care model. The goals of treatment, as well as the treatment options that are most clinically applicable, anatomically relevant, and likely to be successful or accepted by the patient, all may vary across the lifespan. In most cases of OSA, the goal of surgical treatment is not to provide “cure.” Except perhaps for tracheotomy, the majority of surgical treatments, even maxillomandibular skeletal advancement, usually do not cure OSA. Sleep physician, surgeon, and patient understanding of OSA management in this context is the cornerstone for proper preoperative expectations and successful postoperative outcomes.
With that in mind, however, the standard first-line therapy, CPAP, also does not usually cure OSA. In a study using ambulatory sleep testing on CPAP users, the authors reported 27% CPAP efficacy rate, defined as an Apnea/Hypopnea Index (AHI) less than or equal to 5. Although CPAP substantially improves OSA and has the most robust data on reduction of cardiovascular risk, cure rates are actually low when factoring in both adherence and pressure effectiveness. Evaluating the effectiveness of surgery for OSA and drawing comparisons to medical treatments is complicated by the wide variety of procedures and different surgical techniques available, as well as the ethical and practical concerns with instituting randomized controlled sham-procedure studies. Further confounding the ability to evaluate the efficacy of surgical therapy is the finding that the polysomnographic indexes that are commonly used as metrics for OSA disease severity and treatment outcomes have little, if any, correlation with patient-reported symptoms and quality-of-life measures.
Nevertheless, it is clear that airway reconstructive surgery has benefits in many patients with OSA. A large Veterans Affairs (VA) population study showed a 31% reduced mortality rate in OSA patients treated with uvulopalatopharyngoplasty (UPPP) compared with those treated with CPAP, even after controlling for medical comorbidities and other clinical factors ( Fig. 11.1 ). These findings do not suggest that UPPP is more effective than CPAP; rather, they suggest that in certain OSA patient populations, reduction in OSA disease severity with surgical therapy may provide similar benefits to medical device treatments burdened by significant nonadherence concerns. In summary, no medical or surgical treatment, except perhaps tracheotomy, consistently cures OSA.
3
Paradigm Shift in OSA Surgery
In its simplest form, OSA is characterized by an upper airway that is too narrow and/or too collapsible, and is often described in a Starling resistor model. As such, upper airway reconstructive surgery to enlarge and stabilize the upper airway certainly can and should play a role in the treatment of patients with this upper airway condition, particularly those who fail treatment with other medical device therapies. Proper management of OSA is dependent on the sleep surgeon’s ability to obtain a proper sleep history, to thoroughly examine each individual’s unique airway anatomy, and to be proficient in the selection and execution of a variety of both medical and surgical treatment options.
In the past, surgery for OSA has been synonymous with the traditional excisional UPPP from the perspective of many practicing sleep specialists, as well as their patients. On the contrary, sleep-disordered breathing surgery encompasses dozens of surgical procedures and approaches for a wide variety of clinical applications. In addition to several primary therapy indications, surgery can play an effective role as part of a multimodality combination treatment plan and as an adjunct to medical device therapy ( Box 11.1 ).
