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Surgical Management of OSA in Adults
David F. Smith, MD, PhD; Aliza P. Cohen, MA; and Stacey L. Ishman, MD, MPH
OSA is a common, often chronic, condition requiring long-term therapy. Given the prevalence
of OSA, as well as its significant health-related sequelae, a range of medical and surgical
treatments have been developed and used with varying success depending on individual anat-
omy and patient compliance. Although CPAP is the primary treatment, many patients cannot
tolerate this treatment and require alternative therapies. In this clinical scenario, surgery is
often warranted and useful. Surgical management is aimed at addressing obstruction in the
nasal, retropalatal, and retroglossal/hypopharyngeal regions, and many patients have multi-
ple levels of obstruction. This review presents a comprehensive overview of research findings
on a wide spectrum of surgical approaches currently used by sleep clinicians when other ther-
apeutic modalities fail to achieve positive outcomes. CHEST 2015; 147(6):1681-1690
ABBREVIATIONS: AHI 5 apnea-hypopnea index; DISE 5 drug-induced sleep endoscopy; ERS 5 European
Respiratory Society; HMS 5 hyoid myotomy and suspension; HNS 5 hypoglossal nerve stimulator; LAUP 5
laser-assisted uvuloplasty; MMA 5 maxillomandibular advancement; PMG 5 posterior midline glossectomy;
QOL 5 quality of life; RCT 5 randomized controlled trial; UPPP 5 uvulopalatopharyngoplasty
[ Contemporary Reviews in Sleep Medicine ]
OSA affects 2% to 4% of adults in the United
States.
1
Numerous studies have shown that
if untreated, OSA can have serious and
sometimes grave medical consequences. It
is associated with an increased incidence
of hypertension, myocardial infarction, and
stroke as well as the onset of type 2 diabetes,
neurocognitive deficits, and increased
mortality.
2-7
CPAP has long been the primary treatment
modality for OSA, and a significant body
of research indicates that effective treatment
with CPAP can reverse the negative cardiac
and neurocognitive consequences of
untreated disease.
8-10
Patients who fail this
approach may benefit from oral appliances,
lifestyle changes such as weight loss, and
various surgical interventions. Both inferior
turbinate reduction and tonsillectomy are
frequently used alone or in combination
to improve CPAP utilization, and they have
both been shown to reduce CPAP pressure
requirements.
11
Surgery may also be recom-
mended with curative intent for patients
with an obvious anatomic obstruction
such as large palatine or lingual tonsils.
1
In addition, surgery is used as a salvage
procedure to improve OSA in patients who
fail CPAP and/or other treatment measures.
e aim of surgical management is to address
obstruction in the nasal, retropalatal, and
retroglossal/hypopharyngeal regions, and,
Manuscript received August 22, 2014; revision accepted November 29,
2014.
AFFILIATIONS: From the Division of Pediatric Otolaryngology–Head
and Neck Surgery (Drs Smith and Ishman and Ms Cohen) and Division
of Pulmonary Medicine (Dr Ishman), Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH; and Department of Otolaryngology–
Head and Neck Surgery (Dr Ishman), University of Cincinnati College
of Medicine, Cincinnati, OH.
CORRESPONDENCE TO: Stacey L. Ishman, MD, MPH, Division of
Pediatric Otolaryngology–Head and Neck Surgery and Division of
Pediatric Pulmonary Medicine, Cincinnati Children’s Hospital Medical
Center, 3333 Burnet Ave, MLC 2018, Cincinnati, OH 45229; e-mail:
stacey.ishman@cchmc.org
© 2015 AMERICAN COLLEGE OF CHEST PHYSICIANS. Reproduction of
this article is prohibited without written permission from the American
College of Chest Physicians. See online for more details.
DOI: 10.1378/chest.14-2078
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