The field of sleep medicine, especially as it relates to obstructive sleep apnea (OSA) is in its infancy. Before 1980, only a handful of published reports described this condition. A distinct clinical subspecialty has since developed around this condition. In fact, a cottage industry was born, consisting of surgical supply and diagnostic companies, to service the needs of this medical diagnosis.

Otolaryngologists first became interested in OSA after early reports of a simple surgical procedure purported to offer a cure in many patients. The uvulopalatopharyngoplasty (UPPP) described by Fujita in 19811 created a stir in the otolaryngo-logic as well as in the sleep disorders medical community. This procedure was soon heralded as a safe, quick, and permanent solution to this difficult medical condition.

As might have been predicted, not everyone who underwent this procedure benefited. Snoring was relieved in most instances (usually providing a measure of satisfaction for the sleeping partner), but the clinical success of UPPP for OSA was only within the range of 50 to 60%. Although upper airway obstruction often results from narrowing in the region of the oropharynx and velum, anatomic collapse in the hypopharynx, larynx, and tongue base can also produce OSA. It became clear that if patients could be classified according to anatomic site of narrowing and collapse, UPPP could be more appropriately and, perhaps, more successfully applied only to those patients found to have narrowing in the region of the oropharynx and velum.^{2, 3}

Many techniques have been used to help establish this possible anatomic relationship. Cephalometric measurements, anatomic descriptions of the oropharyngeal and hypopharyngeal anatomy, cine-computed tomography (CT) evaluation of the dynamic airway, and nasopharyngeal fiberoptic examination at rest and during obstructed inspiration (Muller maneuver) have all been tried to preselect patients who would benefit from UPPP. At best, these techniques for predicting surgical success have produced mixed results. One of the only groups to claim success in predicting surgical outcomes based on preoperative parameters is the Stanford University group. Riley et al.⁴ reported that the use of extensive preoperative data analysis, including physical examination, fiberoptic nasopharyngoscopy with the Muller maneuver, and lateral cephalometric analysis to determine the site of obstruction resulted in a surgical success rate of 61%, defined as a reduction of the apnea/hypopnea index (AHI) to < 20. Clearly, even in this, the best case of clinical situations, the ability to predict the surgical success of UPPP is barely acceptable.

Medical Implications of OSA

What, then, should be the clinical approach to patients with OSA? Which patients should be offered UPPP as a therapeutic alternative? To come to grips with this question, the medical implications of OSA must be clearly understood and appreciated. Both patient and physician must appreciate that this is a serious medical problem. Whereas snoring alone is generally considered a social issue, albeit often a considerable one, OSA is associated with significant health implications. The cycle of frequent nighttime arousals that accompanies OSA is rarely reported by patients. However, because these frequent interruptions in sleep disrupt normal sleep patterns, patients with OSA are often sleep deprived. This constant sleep fragmentation results in hypersomnolence and interferes substantially with the performance of routine activities and cognitive tasks.^5–8 Regulatory agencies now also recognize the danger of OSA-related hypersomnolence in the workplace and on highways. Guidelines are being developed to restrict the activities of severely affected individuals.⁹

Severe cardiovascular disease is also common in patients with OSA. Hypertension, cardiac arrhythmia, left ventricular dysfunction, myocardial infarction, pulmonary hypertension, stroke, and sudden death are all more common in patients with this condition.¹⁰ Systemic hypertension has been reported in up to 50% of patients with OSA, and one report implicated undiagnosed OSA in as many as 40% of patients with essential systemic hypertension.¹¹ In an often quoted study by He et al.¹² in 1988, a large cohort of patients with OSA were evaluated at the Henry Ford Hospital Sleep Disorders Center and followed for up to 9 years. Untreated subjects with an AHI of >20 had significantly increased mortality compared with those with less severe AHI scores. Aggressive treatment with nasal continuous positive airway pressure (CPAP) appeared to reverse this trend, clearly implicating OSA for the increased mortality.

Nonsurgical Treatment Options

Many otolaryngologists fail to recognize that UPPP is by no means the only treatment alternative for OSA, and it is far from the most clinically effective. Treatment options must include simple nonsurgical alternatives as well. Eliminating associated risk factors for OSA can often produce dramatic results. Because the use of sedative medications and alcohol is clearly associated with OSA, their use must be avoided. Obesity also has a clear relationship to OSA, however combating this problem is fraught with patient resistance and therapeutic failures.13, 14 Nevertheless, both simple interventions must be included in the treatment algorithm.

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