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Surgery or Medical Management for OSA

Effect of Multilevel Upper Airway Surgery vs Medical Management for OSA

There are sparse randomized clinical trials data evaluating surgical options for patients with obstructive sleep apnea (OSA). Further, previous trials have been limited by targeting only specific anatomic phenotypes. Therefore, if patients are unable to tolerate CPAP or mandibular advancement therapy, they are left without many durable treatment options.

The current study by MacKay et al. took place at six Australian centers. They sought to demonstrate the effect of a multilevel upper airway surgery versus ongoing medical management on apnea-hypopnea index associated with a 3% desaturation or arousal (AHI), or Epworth Sleepiness Scale score (ESS). This multicenter, parallel-group, open-label, randomized controlled trial enrolled 102 participants age 18-70 years with AHI ≥15. Participants had to meet the following additional criteria for inclusion: BMI <38, ESS >8, attempted use of CPAP, and consideration or failure of a mandibular advancement device. The multilevel surgery consistent of both a modified uvulopalatopharyngoplasty as well as radiofrequency therapy to the tongue.

At 6-month follow-up the authors found that surgery resulted in a statistically significant reduction in AHI (47.9 events per hour at baseline to 20.8 events per hour at follow-up) as compared to the usual care group (45.3 events per hour at baseline to 34.5 events per hour at follow-up). There was also a significant reduction in ESS after surgery (12.4 to 5.3) as compared to the usually care group (11.1 to 10.5).

In the accompanying editorial by Caples et al. the authors were commended for their rigorous methodology, stating that the study “should be considered a platform for a new era in clinical trials of upper airway surgery for OSA”. However, they also noted that while there was a significant reduction in AHI, the majority of participants in the surgical arm still had moderate-to-severe sleep apnea at 6-month follow-up. They advocated for future consideration of longer-term follow-up data as well as comparison of this surgery to other techniques and devices (such as upper airway stimulation).


Find the article @ https://jamanetwork.com/journals/jama/fullarticle/2770361

Find the accompanying editorial @ https://jamanetwork.com/journals/jama/article-abstract/2770360

(Post by: Oren Cohen)