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For refractory obstructive sleep apnea, surgery may be effective

Reuters Health - 05/09/2020 - In adults with moderate or severe obstructive sleep apnea (OSA) in whom conventional therapy fails, combined palatal and tongue surgery may help reduce the number of apnea and hypopnea events, as well as patient-reported daytime sleepiness, a new study suggests.

In a preliminary study of nearly 100 adults who were randomized to receive either medical management or modified uvulopalatopharyngoplasty and radiofrequency tongue reduction, the number of apnea and hypopnea events per hour were cut by nearly half, while the medical management saw a decline of less than a quarter, according to the report published in JAMA to coincide with a presentation at the virtual European Respiratory Society Congress.

For the many patients who have difficulty with continuous positive airway pressure (CPAP), "this trial shows that surgery is a good alternative," said lead author Dr. Stuart MacKay of the University of Wollongong and Illawarra Head & Neck Clinic.

Almost one billion people are estimated to have OSA globally, and it's estimated that half are not able to tolerate CPAP.

Dr. MackKay and his colleagues recruited 102 patients to receive surgery or medical management (average age 44.6); 99 completed the trial.

"The surgery involves the removal of tonsils, re-positioning of the palate and low risk radiofrequency to the tongue," Dr. MacKay explained in an email. "It helps by opening the airway WITHOUT removing important tissue for function (like 'bad' old surgeries)."

Patients in the control arm were managed with a range of evidenced-based treatments, including weight loss, alcohol reduction, sleep posture modification, medical management of nasal obstruction coupled with another shot at the use of CPAP or mandibular advancement device therapies if participants were willing.

In the surgery group, the apnea-hypopnea index (AHI) was 47.9 at baseline and 20.8 at six months (a reduction of 56%). The AHI for the medical management group was 45.3 at baseline and 34.5 at six months (a reduction of 23%).

The average Epworth Sleepiness Scale (ESS) was 12.4 at baseline and 5.3 at six months in the surgery group. In the medical management group, the ESS was 11.1 at baseline and 10.5 at six months. Two participants (4%) in the surgery group had serious adverse events: one had a myocardial infarction on postoperative day five and one was hospitalized for observation following hematemesis of old blood.

MacKay recommends considering "surgery as an option if the adult OSA patient is unable to tolerate or adhere to devices via an appropriately trained sleep apnea surgeon."

While the surgery can help with OSA, patients need to be carefully selected, said Dr. Ryan Soose, an associate professor of otolaryngology at the University of Pittsburgh and director of the division of sleep medicine and upper airway surgery at UPMC.

"I think the potential benefits of the surgery have to be carefully weighed against the risks in each individual patient," Dr. Soose said. "For some, surgery makes sense, in others it might be a little more murky. I don't think it's worth doing in someone who is morbidly obese or has a bad heart and is on blood thinners."

For some, a less invasive surgery might make sense, Dr. Soose said, such as someone having trouble using a CPAP because they feel they can't breathe through their nose because of a deviated septum. "In those cases, targeted less invasive nasal surgery can fuel success with the CPAP," Dr. Soose said. "I think (the study) supports that the field of sleep apnea is shifting toward personalized multimodality treatment."

With CPAP use, apnea events are brought down to virtually zero, said Dr. Andrew Vargas, an assistant professor of pulmonary, critical care and sleep medicine at the Icahn School of Medicine at Mount Sinai in New York. With the surgery, "the level to which the apnea was reduced on the whole still left it in the moderate range overall," Dr. Vargas said. "And to my knowledge that's pretty similar to what people have shown with uvulopalatopharyngoplasty alone, a roughly 50% drop."

"Another thing worth thinking about is that the follow-up of six months, while a decent amount of time, may not be enough," Dr. Vargas said. "Some of that soft tissue does grow back. Some patients who had uvulopalatopharyngoplasty alone had their snoring completely gone and they were happy. But that lasted about three to five years. At that point the soft palate tissue had grown back."

By Linda Carroll

SOURCE: https://bit.ly/357IFyg and https://bit.ly/35cS9sl JAMA, online September 4, 2020.

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