Surgery Disparaged as First-Line Treatment for Sleep Apnea

By John Gever
ADELAIDE, Australia, Jan. 4 -- Surgeons should take a pass on uvulopalatopharyngoplasty as first-line treatment for obstructive sleep apnea, researchers here concluded. Several recent meta-analyses and literature reviews found inconsistent benefits and high rates of adverse effects from uvulopalatopharyngoplasty, which is growing in popularity as first-line therapy, according to Adam G. Elshaug, Ph.D., of the University of Adelaide, and colleagues.
"Upper airway surgery should not be first-line treatment for obstructive sleep apnea in adults," they wrote in the Jan. 5 issue of BMJ.
Surgical therapies as first-line treatment should be confined to controlled clinical trials, they added. Continuous positive airway pressure (CPAP) along with weight and alcohol management should remain the preferred initial treatment, with mandibular advancement devices as a second-line choice, they recommended.
Despite little evidence from controlled trials that it works safely among general sleep apnea patients, uvulopalatopharyngoplasty is growing in popularity, Dr. Elshaug and colleagues said.
They analyzed five published systematic reviews, including two they had conducted themselves. None of the reviews found unalloyed benefit for uvulopalatopharyngoplasty.
For instance, a 2005 review by the Cochrane Collaboration of seven randomized trials, with a total of 412 patients, revealed inconsistent results. Only three trials with 225 patients demonstrated significant improvement with polysomnographic recordings following uvulopalatopharyngoplasty. Four studies with 138 patients found improvements in health-related quality of life.
Impact on sleep apnea symptoms was confirmed in only two of the seven trials. "The studies assembled in the review do not provide evidence to support the use of surgery in sleep apnea/hypopnea syndrome, as overall significant benefit has not been demonstrated, and overall significant benefit was not shown," the Cochrane reviewers wrote.
Another review by Scandinavian researchers of 48 mostly nonrandomized studies covering 21,346 patients, published last year, found that as many as 62% of patients had persistent adverse effects. These included dry throat, globus sensation, difficulty in swallowing, voice changes, and disturbances in smell and taste. As many as 22% of patients said they regretted having surgery.
A meta-analysis published in 2007 by the Adelaide group on 18 surgical studies determined that treatment success was "limited." They defined success as post-surgical apnea-hypopnea index scores of five or less.
The analysis found success rates of 13% for phase I procedures including uvulopalatopharyngoplasty (14 studies with 347 patients) and 43% for phase II procedures including osteotomies (four studies with 38 patients).
Akram Khan, M.D., of the University of Florida in Jacksonville, said the 13% figure "is very low."
Dr. Khan reported substantially higher success rates for uvulopalatopharyngoplasty at the American College of Chest Physicians meeting last October.
He found that 24.2% of patients had apnea-hypopnea index scores of five or less after upper airway surgery in a review of 978 patients treated at the Mayo Clinic.
The surgery also had benefits for patients who did not achieve complete success, he added. "Uvulopalatopharyngoplasty also helped lower the CPAP pressure needed by the patients subsequent to surgery," he noted later.
Dr. Khan agreed that uvulopalatopharyngoplasty is not appropriate first-line treatment for everyone with sleep apnea. But for patients in relatively good overall condition, it could be considered, he said.
"An ideal patient for uvulopalatopharyngoplasty is someone who is young, e.g. less than 40, is not very heavy (body mass index less than 32), and has an apnea-hypopnea index less than 40," he said. "If these patients are chosen for surgery their response rate is likely going to be much higher."
Dr. Elshaug and colleagues said about 6% to 7% of people in high-income countries have moderate or severe obstructive sleep apnea, and 20% have mild symptoms.
Successful treatment is important because sleep apnea is associated with a range of morbidities, including car crashes.
Funding sources for the study were not disclosed. Drs. Elshaug and Khan declared no financial conflicts of interest. Two of Dr. Elshaug's co-authors serve as directors of AHTA and ASERNIP-S, organizations that evaluate health technologies including surgical procedures. One consults on health technology assessment for the Australian Government Department of Health and Aging.
Primary source: British Medical JournalSource reference:Elshaug A, et al "Upper airway surgery should not be first line treatment for obstructive sleep apnea in adults" BMJ 2008; 336: 44-45.