Authors <> Sundaram Supriya, Lim Jerome, Lasserson Toby J
Review Group <> Cochrane Airways Group
Abstract <> Obstructive sleep apnoea/hypopnoea syndrome(OSAHS) is the periodic reduction or cessation of airflow during sleep. The syndrome is associated with loud snoring, disrupted sleep and observed apnoeas. Surgery for obstructive sleep apnoea/hypopnoea syndrome aims to alleviate symptoms of daytime sleepiness, improve quality of life, and reduce the signs of sleep apnoea recorded by polysomnography.
The objective of this review was to assess the effects of any type of surgery for the treatment of the symptoms of obstructive sleep apnoea/hypopnoea syndrome in adults.
We searched the Cochrane Airways Group Specialised Register and reference lists of articles. We contacted experts in the field, research dissemination bodies and other Cochrane Review Groups. Searches were current as of July 2008.
Randomised trials comparing any surgical intervention for obstructive sleep apnoea/hypopnoea syndrome with other surgical or non-surgical interventions or no intervention.
Data collection and analysis
Two reviewers assessed electronic literature search results for possibly relevant studies. Characteristics and data from studies meeting the inclusion criteria were extracted and entered into RevMan 4.2.
Twelve studies (709 participants) of mixed risk of bias met the inclusion criteria. Data from ten studies were eligible for assessment in the review. No data could be pooled. Uvulopalatopharyngoplasty (UPPP) versus conservative management (one trial): An un validated symptom score showed intermittent significant differences over a 12-month follow-up period. No differences in Polysomnography (PSG) outcomes were reported. Laser-assisted uvulopalatoplasty (LAUP) versus conservative management/placebo (two trials): One study recruited mixed a population, and separate data could not be obtained for this trial. In the other study no significant differences in Epworth scores or quality of life reported. A significant difference in favour of LAUP was reported in terms of apnoea hypopnoea index (AHI) and frequency and intensity of snoring. Palatal implants versus placebo (one trial): Symptoms and AHI were lower with palatal implants. LAUP versus bipolar radiofrequency volumetric tissue reduction (one trial): Within-treatment group differences were significant for symptoms and AHI, but the between treatment group differences were not available to assess whether indirect inferences could be made regarding the effects of either treatment. UPPP versus oral appliance (OA) (one trial): AHI was significantly lower with OA therapy than with UPPP. No significant differences were observed in quality of life. UPPP versus lateral pharyngoplasty (lateral PP) (one trial): No significant difference in Epworth scores, but a greater reduction in AHI with lateral PP was reported. Expansion sphincter pharyngoplasty (one trial): Both interventions reduced AHI although statistical analysis on the difference between treatments was not reported. Tongue advancement (mandibular osteotomy) + PPP versus tongue suspension + PPP (one trial): There was a significant reduction in symptoms in both groups, but no significant difference between the two surgery types. Complications reported with all surgical techniques included nasal regurgitation, pain and bleeding. These did not persist in the long term. An additional study assessed the effects of four different techniques. No data were available on between group comparisons. Multilevel temperature-controlled radiofrequency tissue ablation (TCRFTA) versus sham placebo and CPAP (one trial): There was an improvement in primary and secondary outcomes of TCRFTA over sham placebo and but no difference in symptomatic improvement when compared with CPAP. Radiofrequency assisted uvulopalatoplasty technique versus channeling technique (one trial): Dysphagia scores were lower in the channeling group immediately post-operation, but at four months the difference was no longer significant. Snoring scores did not differ at long-term follow-up. The number of participants achieving AHI lower than 10 at four months was slightly higher with RAUP than channeling technique.
There are now a small number of trials assessing different surgical techniques with inactive and active control treatments. The studies assembled in the review do not provide evidence to support the use of surgery in sleep apnoea/hypopnoea syndrome, as overall significant benefit has not been demonstrated. The participants recruited to the studies had mixed levels of AHI, but tended to suffer from moderate daytime sleepiness where this was measured. Short-term outcomes are unlikely to consistently identify suitable candidates for surgery. Long-term follow-up of patients who undergo surgical correction of upper airway obstruction is required. This would help to determine whether surgery is a curative intervention, or whether there is a tendency for the signs and symptoms of sleep apnoea to re-assert themselves, prompting patients to seek further treatment for sleep apnoea.
Implications <> The available evidence does not currently support the widespread use of surgical interventions in the management of unselected patients with obstructive sleep apnoea. Given the proven efficacy of CPAP in patients with moderate and severe symptoms and significant sleep disordered breathing, surgery cannot be recommended as a front line therapy, ahead of positive airways pressure in these patients. Long-term follow up comparing surgery with oral appliances suggests that the initial effect of surgery on airway obstruction lessened over time. This observation requires confirmation. The appeal of an apparently curative intervention for sleep apnoea should be balanced against the uncertainty surrounding its safety, continued effectiveness and inconsistent impact on subjective and objective markers of disease in patients with OSAHS.
Citation <> Sundaram S, Lim J, Lasserson TJ. Surgery for obstructive sleep apnoea in adults. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001004. DOI: 10.1002/14651858.CD001004.pub2.