Obstructive sleep apnea affects around 20 million Americans and can lead to hypertension, heart attack, stroke, depression, muscle pain, fibromyalgia, morning headaches, and excessive daytime sleepiness.

Thursday, September 23, 2010

CPAP FAILURE: Recent article discusses surgical options.

A recent article (abstract below) discusses surgical options for treating sleep apnea in patients who do not tolerate CPAP. The author states " Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA" This statement is untrue and dangerous. Numerous studies have shown minimal reduction in apnea from UP3 surgery, high morbidity and most patients still need CPAP or oral appliances.

AVOID UVULOPALTOPHARYNGEALPLASTY AS A FIRST LINE TREATMENT OF APNEA!

Patients who undergo UP3 surgery first are more likely to have problems with velo-insufficiency related MaxilloMandibular Advancement surgery which according to the author "is as effective as CPAP in severe OSA"

The author also stated "Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients."

Again probably poor advice in most adults. The exception may be the patient with a severely recessive maxilla and mandible. In general, Maxillomandibular advancement should usually be preceded by oral appliance therapy to find an effective position of the jaw to eliminate apnea before doing surgery.

Tonsilectomy is a first line treatment for pediatric apnea but new studies show it should usually be done in conjunction with maxillary expansion.

The author never mentioned oral appliance therapy, but many physicians arre still taking the ostrich approach to oral appliances. Pretend it doesn't exist and it will go away.

Curr Opin Pulm Med. 2010 Sep 14. [Epub ahead of print]

Surgical treatment of obstructive sleep apnea: standard and emerging techniques.
Maurer JT.

Department of Otorhinolaryngology, Sleep Disorders Center, University Medicine Mannheim, Medical Faculty Mannheim of the Ruprecht-Karls-University Heidelberg, Mannheim, Germany.

Abstract
PURPOSE OF REVIEW: Patients with obstructive sleep apnea (OSA), as well as their physicians, seek alternative therapies to continuous positive airway pressure (CPAP) due to problems with CPAP adherence. A large variety of surgical options exist, and each intervention must be individually evaluated. The author performed a literature search concerning surgery for sleep apnea until May 2010. The studies were evaluated according to evidence-based medicine criteria.

RECENT FINDINGS: An increasing number of controlled and even randomized controlled trials are available. Minimally invasive surgery remains under debate due to the very limited efficacy versus very low morbidity. Uvulopalatopharyngoplasty is still the standard procedure for many patients with moderate OSA, whereas maxillomandibular advancement is as effective as CPAP in severe OSA. Multilevel surgery is reserved to secondary treatment after CPAP failure. Tonsillectomy and maxillomandibular advancement may be offered as a first-line treatment in certain patients. There is increasing evidence that upper airway surgery has a positive impact on arterial hypertension, markers of cardiovascular disease, insomnia, daytime symptoms, quality of life, and CPAP adherence.

SUMMARY: Patients who are nonadherent to CPAP must be thoroughly evaluated before choosing any of the available surgical options. Upper airway surgery may improve disease markers of OSA, if appropriately chosen and properly indicated and performed.

PMID: 20842037 [PubMed - as supplied by publisher]

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posted by Dr Shapira at 1:07 PM