The Laryngoscope Lippincott Williams & Wilkins © 2008 The American Laryngological, Rhinological and Otological Society, Inc. The Efficacy of Multilevel Surgery of the Upper Airway in Adults With Obstructive Sleep Apnea/Hypopnea Syndrome Hsin-Ching Lin, MD; Michael Friedman, MD; Hsueh-Wen Chang, PhD; Berk Gurpinar, MD Objective: Many patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are incapable of us- ing continuous positive airway pressure. These patients therefore turn to surgical options as a salvage treatment. Early studies and reviews focused on the efficacy of uvu- lopalatopharyngoplasty, a single-level procedure for the treatment of OSAHS. Since OSAHS is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose of this paper is to provide an overview of the literature on mul- tilevel surgery for OSAHS patients. Study Design: Systematic review of the literature and meta-analysis focusing on subjective and objective outcomes of patients with OSAHS treated with multilevel surgery of the upper airway. Methods: We searched PubMed, the Cochrane da- tabase, and MEDLINE bibliographic databases up to March 31, 2007, for studies dealing with multilevel sur- gical modification of the upper airway for the treat- ment of OSAHS. Additional studies were identified from their reference lists. Articles were included only if the surgical intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx, and hypopharynx. Results: After applying specific inclusion criteria, 49 multilevel surgery articles (58 groups) were identified. There were 1,978 patients included in the study. The mean minimal follow-up time was 7.3 months (range, 1 to 100 months). A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria, namely “a reduction in the apnea/ hypopnea index (AHI) of 50% or more and an AHI of less than 20.” “Success” implies an improved condition and is not meant to imply cure. The recalculated success rate was 66.4%. The overall complication rate was 14.6%. The evidence-base medicine (EBM) level of these 49 studies revealed that only one study was EBM level 1, two papers were EBM level 3, and the other 46 papers were ranked as level 4 evidence. Conclusions: Multilevel surgery for OSAHS is obviously associated with improved outcomes, al- though this benefit is supported largely by level 4 evidence. Future research should focus on prospective and controlled studies. Key Words: Obstructive sleep apnea, surgery, mul- tilevel treatment, meta-analysis, effectiveness, outcomes, multilevel OSAHS surgery, OSAHS surgery review. Laryngoscope, 118:902–908, 2008 INTRODUCTION Continuous positive airway pressure (CPAP) is the primary treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS). Although studies 1,2 on CPAP compli- ance report results that vary from 28% to 80%, research- ers agree that a certain number of OSAHS patients cannot or will not use CPAP. Surgery for OSAHS is not a substitute for CPAP, but it is a salvage procedure for those who failed CPAP and other conservative therapies and therefore have no other options. The goal of surgical correction in the upper air- way is to reduce the number and severity of obstructive events when complete elimination of these events is not possible. The term “classical cure” is used to comply with standard language of the literature but should be restated as “classical improvement” or “success.” Previous studies on the efficacy of surgery for OSAHS have focused on the most commonly performed procedure, uvulopalatopharyn- goplasty (UPPP). 3 This procedure only corrects obstruc- tion of the palate and tonsils. Since it is clear that most OSAHS patients have multilevel disease including nasal and retrolingual obstructions, the appropriate surgical treatment should be multilevel. In the last decade, a sig- nificant increase in publications on multilevel approach From the Department of Otolaryngology (H.C.L.), Chang Gung Me- morial Hospital–Kaohsiung Medical Center, Chang Gung University Col- lege of Medicine, Kaohsiung, Taiwan; the Department of Otolaryngology and Bronchoesophagology (M.F.), Rush University Medical Center, Chicago, Illinois; the Department of Otolaryngology (H.C.L., M.F., B.G.), Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center, Chi- cago, Illinois, U.S.A.; the Department of Biological Sciences (H.W.C.), Na- tional Sun Yat-Sen University, Kaohsiung, Taiwan; and the Department of Otolaryngology (B.G.), Kasimpasa Military Hospital, Istanbul, Turkey. Editor’s Note: This Manuscript was accepted for publication Decem- ber 4, 2007. Send correspondence to Michael Friedman, MD, 30 N. Michigan Ave., Suite 1107, Chicago, IL 60602, U.S.A. E-mail: hednnek@aol.com DOI: 10.1097/MLG.0b013e31816422ea Laryngoscope 118: May 2008 Lin et al.: Multilevel Surgery for OSAHS Patients 902