October 06, 2009

Finding a place for the surgical option to treat Obstructive Sleep Apnea

Discussions around the subject of a surgical option for the treatment of obstructive sleep apnea are frequently passionate. One need only visit the ASAA's online support group to see the verbal fists fly over whether it is a good idea or an idea that is desperately wrong.

The most common surgical procedure for treating OSA is uvulopalatopharyngoplasty or UPPP for short. Developed in 1981 by Dr. Fujita (the same year CPAP was first described) as an alternative to what was the only treatment for sleep apnea a tracheotomy. UPPP involves removing a lot of tissue from around the opening to the upper airway. This procedure is often done in conjunction with others to improve air flow through the nose.

The success of this procedure is reported to be between 16% and 83%, depending on how you define success. Some see success or cure after surgery as a 50% reduction in the Apnea Hypopnea Index (AHI) and others say a 50% reduction with an AHI less than 20. Though an AHI in this range can still considered moderate and detrimental to health.

The medical literature has been recently had several studies looking at the efficacy of the UPPP option for sleep apnea. An article published in September issue of the Mayo Clinic Proceedings provides results of a retrospective study where lab sleep studies were reviewed on 63 UPPP patients pre and post (six months) surgery. The objective of study was to determine if there was improvement in the AHI and whether that improvement was specific to any patient type.

Quoting from the results section of the abstract... "Patients who attained an AHI of 5 or less were younger, had lower Body Mass Indexes (BMI) and had less severe OSA. Of the patients with a post-UPPP AHI greater than 5 received continuous positive airway pressure, with a mean reduction in pressure of 1.4 cm H2O."

The take-away for me from this study and from others I have seen recently is that surgery has a place in the treatment options of obstructive sleep apnea. It can be very effective in *some* cases.

But that said, in my opinion, for surgery to be appropriately more main stream the surgeon must have a way of identifying/screening the candidates for whom this invasive procedure will benefit prior to surgery. Because once it is done, there is no going back.

1 comment:

doctorstevenpark said...

Ed, you're right in that sleep apnea surgery can be an additional option for some people who have tried everything. I'm not surprised that the medical community is still spending valuable resources on studying the usefulness of the UPPP procedure for obstructive sleep apnea. We're too fixated on the notion that the soft palate the root of all the problems, when in fact it's only a small part of the problem. Most people also have tongue base collapse, as well as nasal issues. But science only measures one variable at a time, so these studies will continue.

Numerous studies and meta-analyses have shown that a UPPP alone has no better than a 40% "success" rate. The debate over the meaning of success will go on for decades. In very select patients, especially ones with very large tonsils and a relatively small tongue, and not overweight, UPPP has up to an 80% chance of success. Unfortunately, not too many people fit into this category.

If you look at the experience at Stanford and numerous other institutions and even in my own experience, addressing the entire upper airway, from the tip of the nose to the voice box, has a much higher chance of success (in the 75 to 80%). If you include skeletal (upper and lower) jaw surgery, the success rates can go as high as 90-95%.

CPAP is great when people use it, and there's a lot more that needs to be done in terms of patient education, preparation and long-term follow-up to improve CPAP success rates. But you'll have to agree that the overall long-term "success" rate for CPAP is less than 50%. This includes everyone that's given a CPAP machine to use. Even if people do succeed, initially, there's a sharp drop-off after many years.

Clearly, there's no right or wrong answer. There are certain steps that we should take, such as non-surgical before surgical, but in the end, everyone has different needs and wants. We should also take the focus off of a single modality mentality and go to a multimodality frame of mind. Many people benefit from using different combinations of CPAP, oral appliances and surgery. Lifestyle changes, stress reduction, diet and exercise programs are also critical in treating this all-too-prevalent chronic medical condition.

Steven Y. Park, MD