Controversies in Surgical Management of Sleep Apnea One of the more controversial issues in otolaryngology deals with the sleep-obstructive patient. This spectrum ranges from patients with the noise-only snore, to patients who frequently awaken with sleep interruption disorder of snoring, to patients with full-blown apnea with documented obstruction and desaturation. Several standards are established for the criteria for apnea, on the basis of frequency of pauses and degree of oxygen desaturation stated as the clinical parameters of sleepiness. It remains puzzling that when one compares symptoms of sleepiness with research data, patients who are frequently awakened by their own snoring, or who awaken from nocturnal restless periods, are often more fatigued and symptomatic than are patients with mild to moderate apnea. I find the best parameters to follow are persistent fatigue after sleep and daytime fatigue with sleepiness. This chapter compares clinical assessment and patient counseling regarding continuous positive airway pressure (CPAP) with the results achieved with palatal surgery or dental appliances. Office-based palatal reduction and tongue base reduction remain either unproven for true sleep apnea patients or somewhat experimental.1 The initial controversy faced by many of us is the value of CPAP and its effectiveness in the long-term management of sleep apnea. The trend of managed care has been to require patients to use CPAP as first-line therapy before considering surgery. CPAP has proved the most effective and safest form of therapy, but compliance and patient acceptance are usually dismal, with the patient often remaining untreated with the machine at the bedside.1, 2 Patients I do not consider candidates for CPAP, and who I do not feel obliged to have fail this modality before surgery, are those with nasal obstruction3 or significant tonsil hypertrophy. These patients have obstruction that can be dealt with by time-proven surgical techniques, with a high potential for cure. In the overweight patient with no significant nasal obstruction, CPAP is by far the most effective and possibly only effective treatment other than tracheostomy. Unfortunately, even this population is reticent to accept the lifelong commitment to CPAP. In addition, nasal tip instability or tip collapse may often be worsened by CPAP, making this modality a non-option requiring tip-lift rhinoplasty or tip reconstruction as well. The effectiveness of surgery as successful treatment of apnea has been established.4
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