Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults

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Surgery for obstructive sleep apnoea has no clear benefit and should not be offered as a first treatment, argue researchers in this week's BMJ.

Obstructive sleep apnoea is a common disorder caused by the collapse of the upper airways during sleep. This leads to loud snoring and sometimes breathing stops temporarily. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health related quality of life. It mainly affects middle-aged, overweight men.

Guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management, if appropriate, as the first line treatment. But upper airway surgery is becoming increasingly popular in Australia and elsewhere.

So Dr Adam Elshaug and researchers at the University of Adelaide conducted their own investigations and analysed existing evidence for upper airway surgery and found the results of surgery were inconsistent.

One review of seven randomised trials concluded that surgery had a general lack of impact on symptoms and, even where improvements in quality of life have been shown immediately after surgery, these were rarely sustained beyond 12-24 months.

Another review of 48 studies found that up to 62% of patients who had surgery reported persistent adverse effects, such as dry throat, difficulty in swallowing, voice changes, and disturbances of smell and taste. Up to 22% regretted having surgery.

Weight loss and other lifestyle modification is recommended as an adjunctive treatment to CPAP, but can be difficult to achieve, write Dr Elshaug and colleagues. CPAP therapy also depends on acceptance and adherence by patients and its benefits in mild to moderate sleep apnoea seem inconclusive, making surgical “cure” seem more attractive.

Furthermore, in Australia, such surgery is mainly done in the private sector, which has different incentive mechanisms from the public system.

However, given the lack of clear benefit from surgery and the potential for harm indicated by currently available evidence, guidelines recommend CPAP as first line treatment for obstructive sleep apnoea generally.

Surgery for obstructive sleep apnoea should be done within controlled clinical trials, they write. Patients should be informed about the trial, as well as of the inconsistent results of surgery, the associated pain, the potential side effects, and the potential for relapse.

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