Clinical ReviewSurgical therapy for adult obstructive sleep apnea
Introduction
Obstructive sleep apnea syndrome (OSA) is the result of upper airway obstruction from repetitive airway narrowing and closure during sleep. It is associated with increased cardiovascular morbidity and mortality.1, 2 The psychomotor sequelae of OSA such as excessive daytime sleepiness, daytime fatigue and poor sleep quality due to sleep fragmentation are also well established.3, 4 Currently, nasal continuous positive airway pressure (CPAP) is the first line of treatment. Indeed, the effectiveness of nasal CPAP in improving the sequelae of OSA is irrefutable.5, 6 Nevertheless, patient compliance represents a clear problem.7 Furthermore, even in compliant patients who are using CPAP on a ‘regular basis’, the actual usage is only approximately 50% of the ideal.8 Due to the limitations of CPAP, surgical treatment of OSA should be considered as a viable treatment option.
This review will present the current state of art in sleep apnea surgery, beginning with evaluation of the patient as surgical candidate to formulation of a surgical plan through procedural selection based on published surgical outcomes. Future research direction for sleep apnea surgery will also be presented.
Section snippets
Preoperative assessment
Numerous surgical procedures are currently available for the treatment of OSA. However, the following issues present a formidable challenge to the sleep apnea surgeon: (1) the complex interplay of the soft and hard tissues that contribute to upper airway obstruction, (2) the crucial role of this anatomic region to speech and swallowing, and (3) the subsequent edematous response after surgical intervention. Moreover, it is well accepted that successful surgical outcomes depend on proper patient
Nasal surgery
The relationship between nasal obstruction and sleep-disordered breathing has been demonstrated by numerous investigations. Both daytime nasal obstruction and nocturnal nasal congestion have been shown as risk factors for sleep-disordered breathing.14, 15 Therefore, the treatment of nasal obstruction plays an important role in sleep apnea surgery. However, it must be emphasized that although OSA can be improved in some patients, only slight improvement has been shown.16, 17 Three anatomic areas
Surgical planning
Clearly, prior to any sleep apnea surgery, the diagnosis of OSA based on sleep study results is essential. Although some may debate whether a formal polysomnography should be mandatory, the use of an ambulatory sleep study is an acceptable practice under current standards. The selection of surgical procedure(s) is based on numerous factors (Table 1). Patient's desire and preference as well as the health status can clearly influence outcomes and must be taken into consideration. Additionally,
Conclusion
Successful surgical outcome depends on proper patient selection as well as the choice of surgical procedure(s). The adaptation of a logical and systematic approach to clinical evaluation, treatment planning and surgical execution is necessary in order to maximize safety and improve surgical results. New surgical techniques and evolving technology may potentially offer less invasive treatment modalities with broader patient acceptance and improvement in results (Box 1 and Box 2)*
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