Tailoring surgical interventions to treat obstructive sleep apnoea: one size does not fit all

Abstract

While continuous positive airway pressure (CPAP) remains the gold standard treatment of choice in patients with moderate or severe obstructive sleep apnoea (OSA), surgery has been established as a means to improve compliance and facilitate the use of CPAP, both of which are potential pitfalls in the efficacy of this treatment modality. In a minority of cases, with obvious oropharyngeal anatomical obstruction, corrective surgery may completely alleviate the need for CPAP treatment. In this review, we summarise clinical assessment, surgical options, discuss potential new treatments, and outline the importance of investigating and addressing the multiple anatomical levels that can contribute to OSA. Research into effectiveness of these procedures is rapidly accumulating, and surgery can be an effective treatment. However, given the myriad of options available and multiple levels of anatomical pathology that can present, it is imperative that correctly selected patients are matched with the most appropriate treatment for the best outcomes.Key pointsOSA is an increasingly prevalent disorder which has significant systemic effects if left untreated.Anatomical abnormalities can be corrected surgically to good effect with a growing and robust evidence base.Drug-induced sleep endoscopy is a key tool in the otolaryngologist's armamentarium to tailor specific surgery to address specific anatomical concerns, and to facilitate appropriate patient selection.Multilevel surgical approaches are often indicated instead of a “one size fits all” model.Educational aimsTo discuss how to assess patients presenting with OSA in clinic, from an otorhinolaryngology perspective.To discuss the indications for intervention.To provide an overview of nonsurgical interventions for treating OSA, with evidence.To discuss the different surgical modalities available for treatment of OSA, with evidence.

Awake endoscopic assessment of the upper airway during tidal breathing: Definition of anatomical features and comparison with drug‐induced sleep endoscopy

“…Endoscopic assessment of the upper airway (UA) is indispensable in clinical practice to guide therapeutic decision making in patients with sleep‐disordered breathing 1 . As obstruction of the UA can occur at one or multiple levels in obstructive sleep apnoea (OSA), treatment modalities other than continuous positive airway pressure (CPAP) need to be specifically tailored to the obstruction pattern of each individual 2 . In the last two decades, drug‐induced sleep endoscopy (DISE) has gained great popularity and credibility in selecting proper candidates for non‐CPAP treatment 3 .…”

A Comparative Analysis of Cephalometric data and Drug induced sleep endoscopy in OSA patients – a Sri Lankan perspective

“…Some didn't comply due to the financial burden of owning a CPAP machine. Though the indications for surgery in OSA is secondary to failure of CPAP therapy or as an adjuvant to continuing CPAP therapy 4 , 14 patients in our study group opted for a surgical intervention due to non-compliance with CPAP trial. Hence the use of cephalometry, DISE and polysomnography to determine surgical success are more relevant to developing nations with limited resources, when deciding on treatment options and protocols.…”

“…A big part in the diagnostic evaluation entails the physical examination, not only to identify any anatomical obstruction or physiological restriction, but also co morbidities, which ultimately contributes to the final decision of management of OSA. Though CPAP therapy has been considered the gold standard of treatment in OSA 2,3 , the emergence of level specific surgical options have shown great efficacy 4 .…”

Drug-Induced Sleep Endoscopy: Clinical Application and Surgical Outcomes

“…Recent therapeutic protocols for OSA patients increasingly involve a combined/multimodal surgical and non-surgical therapy, replacing the previous focus on one main treatment option, the so called "one size fits all" approach [5,6,7].…”