Reply: Obstructive Sleep Apnea in Adults

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We appreciate the enthusiasm of Pinto et al. in their letter regarding our recent article, “Obstructive Sleep Apnea in Adults: The Role of Upper Airway and Facial Skeletal Surgery.”1 The letter raises points regarding (1) the role of surgical intervention as a primary treatment for the obstructive sleep apnea patient, (2) the definition of surgical treatment success, and (3) tailoring surgery to the level of airway obstruction.
Patients with specific anatomical abnormalities may be candidates for primary surgical treatment; however, the decision to perform primary surgical treatment for patients with moderate to severe obstructive sleep apnea would be based largely on clinical judgment and is inconsistent with guidelines from the American Academy of Sleep Medicine. The American Academy of Sleep Medicine has advised that patients with mild obstructive sleep apnea be considered for primary surgical treatment when there is a surgically correctable anatomical cause, but continuous positive airway pressure is the treatment of choice for mild, moderate, and severe obstructive sleep apnea and should be offered as a treatment option to all patients.3 Furthermore, most insurance companies evaluating preauthorization requests for adult sleep apnea surgery will require that the patient have made an effort at noninvasive treatment first. Primary surgical management has most commonly been practiced in the general pediatric population, for whom adenotonsillectomy is the first-line treatment and has been demonstrated to be efficacious in most patients.4,5 Prospective studies evaluating the role of primary surgical management in adults would likely be necessary to gain American Academy of Sleep Medicine and third-party payor support of this practice.
With respect to defining treatment success, we agree as we stated in the article that the apnea-hypopnea index reduces the complexity of sleep apnea to a number. Nonetheless, apnea-hypopnea index improvement has been shown to correlate with benefits in neurocognitive and cardiometabolic outcomes among patients with obstructive sleep apnea, providing a metric to gauge both the immediate disease severity and potential long-term consequences.6 We agree that the apnea-hypopnea index may not reflect improvements in patient biometrics or quality of life. Further prospective studies evaluating biometric and qualitative outcomes of surgical treatments would help strengthen the argument for measuring treatment success with alternative tools.
We agree that the surgical treatment a patient receives should be tailored to his or her specific level of obstruction. As we state, “The most balanced approach may be to individualize treatment of the obstructive sleep apnea patient by targeting surgery towards the specific level of obstruction.”1 To offer patients the full spectrum of treatment options that will most comprehensively address their level(s) of obstruction, it may be necessary to expand the availability of multidisciplinary sleep clinics to facilitate patient access to providers with different areas of expertise and facilitate cross-specialty collaboration.

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