SURGERY FOR OSA IN ADULTS: REVIEW AND META-ANALYSIS Surgical Modifications of the Upper Airway for Obstructive Sleep Apnea in Adults: A Systematic Review and Meta-Analysis

1396 Surgical Modifications of the Upper Airway for OSA in Adults—Caples et al 1.0 INTRODUCTION For patients with obstructive sleep apnea (OSA), positive airway pressure (PAP) therapy is usually prescribed as first-line treatment, a recommendation supported by high-level evidence for efficacy of PAP in preventing upper airway collapse and relieving symptoms such as daytime sleepiness,1 and mounting data suggesting that PAP therapy may favorably impact cardiovascular outcomes.2 However, for varied reasons, some patients find it difficult to adhere to PAP therapy,3 prompting a substantial proportion to seek alternative treatment, including upper airway surgery. Surgical modifications of the upper airway have been performed for decades as a treatment for OSA.4 Yet, the role of such procedures in the management of OSA remains controversial. Critics point to the lack of high-level, controlled studies in the surgical literature and the absence of standardized criteria to define surgical “success,”5,6 while proponents cite ethical and logistical limitations to controlled surgical studies and contend that the “all or none” principle of eradication of OSA (i.e., an apnea-hypopnea index [AHI] < 5) as the standard of care is flawed and impractical for many patients.7 The end result is a lack of a firm evidence base upon which the sleep medicine clinician can rely to guide management decisions in patients with OSA. A few systematic reviews of surgical treatments of OSA have been previously published.8 Some reviews limited analysis to a small number of randomized, controlled trials (RCT),9 one excluded papers published before 2001,5 and results were rarely pooled. The last systematic review by the American Academy of Sleep Medicine (AASM) of non-randomized observational studies of the efficacy of surgical modifications of the upper airway for treatment of OSA was performed in 1996.10 A review and practice parameters specifically on laser-assisted uvulopalatoplasty were published in 2001.11 Clinical guidelines on the evaluation, management, and long-term care of OSA in adults were recently published by the AASM.12 These guidelines included several consensus-based statements regarding the surgical treatment of OSA, though the document was not designed to be a systematic literature review. The AASM convened a task force in 2007 to systematically review the available literature to provide a basis for updated standards of practice recommendations on surgical modifications of the upper airway for treatment of OSA. It was decided a priori to exclude publications of isolated nasal procedures, isolated tonsillectomy, and tracheostomy, in part because these procedures are often performed for indications other than OSA.