Is uvulopalatopharyngoplasty effective in obstructive sleep apnea?

Obstructive sleep apnea (OSA) is a prevalent disorder and well-established risk factor for cardiovascular disease, myocardial infarction, stroke, and increased mortality. Although continuous positive airway pressure is considered the gold-standard treatment, long-term adherence is unsustainable for many patients. As a result, these patients often seek surgical treatment for their condition. Uvulopalatopharyngoplasty (UPPP) has been offered as a treatment option for OSA since it was first pioneered by Dr. Fujita in 1981. Our purpose is to review the evidence for UPPP in OSA. In 2002, Friedman et al. conducted a retrospective analysis of 134 patients who underwent UPPP for treatment of OSA to validate an anatomy-based staging system.1 Patients were staged based on their Friedman palate position, tonsil size, and body mass index (BMI) (Table 1). The study utilized a success cutoff defined by a postoperative respiratory disturbance index (RDI) < 20 and RDI reduction of ≥ 50%. The overall surgical success rate was 31.3%. Success rates for Friedman stages I, II, and III were 80.6%, 37.9%, and 8.1%, respectively (P < 0.0001). The authors found their staging system to be an effective predictor of UPPP success. They also proposed that UPPP was effective for stage I patients but counselled against UPPP alone in stage III patients. It should also be noted that, although the overall success rate was quite low, 55% of patients were stage III and no mean BMI was provided. In a 2006 retrospective review, Li et al. compared outcomes of UPPP for OSA using an apnea-hypopnea index (AHI) severity-based staging system and a modified version of Friedman's anatomy-based staging system.2 Polysomnography was performed in 110 patients before surgery and approximately 1 year following surgery. The researchers found that AHI significantly decreased following UPPP (P < 0.001), with an overall success rate of 78%. They defined success as a postoperative AHI < 20 and AHI reduction of ≥ 50%. No significant difference in success between groups was found using the severity-based staging system; however, the anatomy-based staging system found a significant difference with stages I, II, III, and IV having success rates of 100%, 96%, 65%, and 20%, respectively (P < 0.001). Friedman tongue position (odds ratio [OR] = 0.43, 95% confidence interval [CI] 0.24–0.78) and tonsil size (OR = 3.13, 95% CI 1.20–8.17) also independently predicted success. The effect of BMI was not reported. This study supported the use of an anatomy-based staging system for predicting success with UPPP. Browaldh et al. published a randomized controlled trial in 2013.3 Of note, patients classified as Friedman stage III or with BMI ≥ 36 kg/m2 were excluded. Patients were then grouped using a stratified randomization process to reduce confounding from BMI and Friedman stage. The treatment arm of 32 patients underwent UPPP, and the control arm of 33 patients received no treatment initially and then was offered surgery at the end of the trial. At a 6-month follow-up, the treatment group saw a significant reduction in AHI from a mean (standard deviation) of 53.3 (19.7) to 21.1 (16.7) (P < 0.001), whereas the control group experienced no significant change in AHI. The mean reduction in AHI in the treatment group was 60% compared to 11% in the control group (P < 0.001). The procedures were well tolerated by patients, with no serious complications or mortality. However, this study excluded patients with a BMI over 36 kg/m2, and the majority of patients had a BMI under 30 kg/m2, which limits applicability to the general public. Sommer et al. conducted a similar randomized controlled trial in 2016 to further establish the efficacy and safety of UPPP as a treatment for OSA.4 An important inclusion criteria was the presence of tonsillar hypertrophy with velopharyngeal obstruction on clinical examination, whereas patients with a BMI > 34 kg/m2 were excluded. Twenty-three patients in the treatment arm received surgery, and 19 patients in the control arm initially received no intervention. Prior to treatment, both groups underwent polysomnography, which showed no statistically significant difference in AHI between the groups. However, following the intervention, a significant improvement in AHI was found in the treatment group compared to the control, with a 54% and 12% reduction, respectively (P = 0.036). The intervention also led to significant improvement in daytime sleepiness, as measured by the Epworth Sleepiness Scale. Complications were limited to two cases of postoperative hemorrhage. Of the patients who underwent surgery, 97% were satisfied with the outcome. Unfortunately, the study just had a 3-month follow-up, which makes long-term success and complications impossible to assess. Finally, a meta-analysis was conducted by Choi et al. in 2016 to identify predictors of success in UPPP.5 A total of 1,257 studies were initially identified. Inclusion criteria were met by 15 studies, involving a total of 693 patients. Definitions of surgical success varied, although all included a > 50% reduction in AHI. Their results demonstrated a significant relationship between Friedman stage I and surgical success (OR = 4.429, 95% CI 2.316 to 8.486, P < 0.001), whereas Friedman stage III was related to nonresponders (OR = 0.164, 95% CI 0.040 to 0.663, P = 0.011). Preoperative AHI was not statistically different between surgical successes and nonresponders, implying that preoperative severity does not influence success. A number of cephalometric variables also were assessed; however, only mandibular plane to hyoid distance (MP-H) achieved statistical significance. MP-H was significantly smaller among surgical successes compared to nonresponders (SMD = −0.397, 95% CI −0.658 to −0.1376, P = 0.003), implying that a higher hyoid position is preferred. Interestingly, BMI was not found to be a predictor for failure in UPPP; however, it should be noted that many studies exclude patients with elevated BMIs, which is not well studied. There is level 1 evidence that suggests UPPP surgery is an effective treatment for OSA in the appropriately selected patient. It is recommended that an anatomy-based staging system be used in place of a severity-based staging system to predict surgical success. Patients with lower anatomy-based stages consistently demonstrate the greatest likelihood of success with UPPP alone. Our review includes one meta-analysis (level 1),5 two randomized controlled trials (level 1),3, 4 one retrospective case-control study (level 3),2 and one retrospective case series (level 4).1

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