Obstructive Sleep Apnea in Adults: The Role of Upper Airway and Facial Skeletal Surgery

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We read with great interest the recent article by Garg et al. entitled “Obstructive Sleep Apnea in Adults: The Role of Upper Airway and Facial Skeletal Surgery.”1 We congratulate the authors on an outstanding scientific work. Nevertheless, we feel very strongly that the work is partially based on one major error that may lead to a misleading message. Part of the article is based on the misconception that surgical therapy is used to replace continuous positive airway pressure therapy and therefore that surgical intervention for patients with sleep apnea is reserved only for those who cannot or will not accept continuous positive airway pressure therapy.
Although continuous positive airway pressure is the first-line treatment in most patients with moderate to severe obstructive sleep apnea, the American Academy of Sleep Medicine formulated the indications for alternative treatment options to continuous positive airway pressure as follows: “It is recommended that evaluation for primary surgical treatment may be considered in selected patients who have severe obstructing anatomy that is surgically correctible and that in other cases, surgery should be offered only when other noninvasive treatments (CPAP and oral appliances) have been unsuccessful or rejected.”2
This means that surgical treatment is indicated, as a first-line therapy, to treat those patients who have an underlying specific surgically correctable abnormality that is causing the sleep apnea. In these well-selected patients, surgery permits results similar to those with continuous positive airway pressure to be achieved.
Indeed, polysomnography alone is not an ideal measure of treatment success because it is poorly correlated with health outcomes. The apnea-hypopnea index is the most common primary study endpoint, but success cannot be judged by strict criteria of apnea-hypopnea index reduction. Other health-related and behavioral parameters may be more reliable and physiologically more important. In spite of relatively poor success in apnea-hypopnea index reduction, surgery has been shown to be effective in improving quality of life for a majority of patients.3
There are a few other points of concern that we would like to highlight. Despite the fact that maxillomandibular advancement represents one of the most successful surgical treatments for sleep apnea patients, it is not the only surgical treatment beyond tracheotomy that is indicated for patients with severe obstructive sleep apnea refractory to continuous positive airway pressure.
Pharyngeal collapse is the key event leading to obstructive sleep apnea, and given the structure’s importance, diagnosing the site of obstruction would seem imperative to direct and select surgical treatment. Localized obstruction at the level of the soft palate may lead to mild, moderate, or severe apnea-hypopnea index, and patients who have obstruction localized to the palate would be excellent candidates for palatal surgery. Several studies have shown that severity is not a prognostic factor in determining success after palatal procedures.4
Finally, the success of airway surgery depends on an accurate diagnosis of the sites of obstruction and the appropriate selection of procedures to address these sites. Rather than applying a standardized approach to the surgical management of obstructive sleep apnea, it seems preferable to tailor treatment to the specific needs of each patient.

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