What is the Role of Soft Palate Surgery in OSA? Edward M. Weaver, MD, MPH Seattle VA Medical Center University of Washington Harborview Medical Center Acknowledgments This material is the result of work supported in part by the U.S. Department of Veterans Affairs, Office of Research & Development, Clinical R&D Program. Dr. Weaver is a staff physician, surgery service line, Department of Veterans Affairs Medical Center, Seattle, Washington. Grants: VA Epidemiologic Research & Information Center Pilot Study Grants (Weaver) American Geriatrics Society Jahnigan Award funded by the John A. Hartford Foundation of NYC and Atlantic Philanthropies (Weaver) NIH K23 HL068849 (Weaver) 1
Disclosures No industry disclosures I am a surgeon Question: Should we do UPPP? 2
Answer: Yes Role of Palate Surgery Treat palatal obstruction When CPAP not successful With realistic expectations 3
Should We Do UPPP? 1. What is UPPP 2. The case against UPPP 3. ThecaseforUPPP 4. A synthesis Normal Oral Exam 4
Abnormal Oral Exam Extended Uvulopalatal Flap 5
UPPP Variants Uvulopalatal l l Flap Extended Uvulopalatal Flap Expansion Sphincter Pharyngoplasty Lateral Pharyngoplasty Lateral Palatopexy Palatal Advancement Pharyngoplasty Why We Should Not Do UPPP UPPP rarely cures OSA 6
Level 4 Elshaug, Sleep 2007; 30:461-7 Surgery Rarely Cures OSA Figure 1 Level 4 Elshaug, Sleep 2007; 30:461-7 7
TRUE! But Surgery Helps OSA Figure 1 Level 4 Elshaug, Sleep 2007;30:461-7 8
Appropriate Goals of Salvage Surgery If UPPP is PRIMARY therapy: CURE is an appropriate goal If UPPP is SALVAGE therapy: IMPROVEMENT is an appropriate goal Appropriate Goals of Salvage Surgery Improve CLINICAL OUTCOMES: Mortality risk Cardiovascular disease risk Motor vehicle accident risk Quality of life 9
UPPP & Death Level 2 Marti, Eur Resp J 2002;20:1511-18 10
OSA Survival Treated Untreated Figure 1 Level 2 Marti, Eur Resp J 2002;20:1511-18 OSA Mortality Adjusted* Hazard Ratio of Death 1.0 0.5 00.0 1.00 0.20 0.00 None CPAP UPPP P = 005 0.05 (N=98) (N=124) (N=88) *Adjusted for age, sex, smoking, BMI, AHI, AHT, CHD, COPD. Adapted from Table 4 Level 2 Marti, Eur Resp J 2002;20:1511-18 11
How Can It Be? PSG outcomes modest vs. clinical outcomes good AHI misses important effects Level 2 Punjabi, AJRCCM 2008;177:1150-5 12
How Can It Be? PSG outcomes modest vs. clinical outcomes good AHI misses important effects Reduced desaturations Conversion of apneas to hypopneas p Improved sleep architecture (REM) How Can It Be? PSG outcomes modest vs. clinical outcomes good AHI misses important effects OSA progression slowed, even if not halted 13
Level 2 Weaver, Sleep 2004;27:A208 1.00 075 0.75 0.50 0.25 Survival UPPP = 3,977 CPAP = 28,612 No Tx = 116,678 UPPP CPAP No Tx 0.00 0 3 6 9 12 Years Level 2 Weaver, Sleep 2004;27:A208 14
How Can It Be? PSG outcomes modest vs. clinical outcomes good AHI misses important effects OSA progression slowed, even if not halted Effect occurs 100% of time Snoring reduced UPPP & Cardiovascular Dz 15
Level 2 Peker, AJRCCM 2002;166:159-65 UPPP & Cardiovascular Dz CPAP UPPP 64% 50% 36% 50% Figure 2 Level 2 Peker, AJRCCM 2002;166:159-65 16
UPPP & Cardiovascular Dz CPAP+UPPP 32% 68% Figure 2 Level 2 Peker, AJRCCM 2002;166:159-65 UPPP & Motor Vehicle Accidents 17
Level 2 Haraldsson, Laryngoscope 1995;105:657-61 Accident Type Relative Risk: OSA/Control Before UPPP After UPPP (5 Years) (5 Years) Single-car 96 9.6 13 1.3 Corrected for driving exposure. P<0.001. Level 2 Haraldsson, Laryngoscope 1995;105:657-61 18
UPPP & Quality of Life Level 4 Weaver, OtoHNS 2011;144:623-31 19
UPPP: Quality of Life FOSQ Score 20.00 15.0 10.0 14.3 * * 17.2 17.5 *p<0.001 5.0 0 mos 3 mos 6 mos Time from UPPP Level 4 Weaver, OtoHNS 2011;144:623-31 UPPP: Quality of Life Level 4 Weaver, OtoHNS 2011;144:623-31 20
Which Is Better? Untreated Partially Treated Sleep Apnea Sleep Apnea Which Is Better? Untreated Sleep Apnea Partially Treated Sleep Apnea 21
Realistic Expectations Improved clinical outcome NOT cure Difficult acute recovery Complications Complications Pain a Bleeding Velopharyngeal Incompetence Dysphagia Stenosis Voice change Failure Life-threatening complications 22
Why We Should Not Do UPPP UPPP risks too much harm Level 4 Franklin, Sleep 2009; 32:27-36 23
Level 4 Franklin, Sleep 2009; 32:27-36 Level 4 Franklin, Sleep 2009; 32:27-36 24
Why We Should Not Do UPPP UPPP risks too much harm FALSE! 25
* * * * * *Patients asked if satisfied with surgery: 11% not satisfied Level 4 Franklin, Sleep 2009; 32:27-36 Benefits Outweigh Harms Few regretted surgery Patients informed Side effects minor Side effects often temporary Patients adapted or not bothered Benefits outweighed harm 26
Mortality Risk Overall survival improved Low 30-day mortality risk (low risk of harm) Improved long-term benefit (large benefit) Immediate net benefit 30-d Mortality Rate: 7/3130 = 0.2% (95% CI 0.1%, 0.4%) Level 2 Kezirian, Laryngoscope 2004; 114:450-3 27
Level 2 Weaver, Sleep 2004;27:A208 1.00 075 0.75 0.50 0.25 Surgery Survival UPPP = 3,977 CPAP = 28,612 No Tx = 116,678 UPPP CPAP No Tx 0.00 0 3 6 9 12 Years Level 2 Weaver, Sleep 2004;27:A208 28
Surgery Survival UPPP CPAP No Tx 1 month Level 2 Weaver, Sleep 2004;27:A208 Which Is Worse? Risk of Risk of Untreated Surgery Sleep Apnea 29
Which Is Worse? Risk of Surgery Risk of Untreated Sleep Apnea Why We Should Not Do UPPP UPPP rarely cures OSA UPPP risks too much harm 30
Why We Should Do UPPP UPPP improves outcome UPPP benefits outweigh harms Role of Palate Surgery Treat palatal obstruction When CPAP not successful With realistic expectations Benefits Potential harms 31
What is the Role of Soft Palate Surgery in OSA? REFERENCES CITED IN SYLLABUS 1. Elshaug AG, Moss JR, Southcott AM, Hiller JE. Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence. Sleep 2007;30(4):461-7. 2. Marti S, Sampol G, Munoz X, et al. Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 2002;20(6):1511-8. 3. Punjabi NM, Newman AB, Young TB, Resnick HE, Sanders MH. Sleep-disordered breathing and cardiovascular disease: An outcome-based definition of hypopneas. Am J Respir Crit Care Med 2008;177(10):1150-5. 4. Weaver EM, Maynard C, Yueh B. Mortality of veterans with sleep apnea: untreated versus treated. Sleep 2004;27:A208 (Abstract). 5. Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 2002;166(2):159-65. 6. Haraldsson PO, Carenfelt C, Lysdahl M, Tingvall C. Does uvulopalatopharyngoplasty inhibit automobile accidents? Laryngoscope 1995;105(6):657-61. 7. Weaver EM, Woodson BT, Yueh B, Smith T, Stewart MG, Hannley M, Schulz K, Patel MM, Witsell D. Studying life effects & effectiveness of palatopharyngoplasty (sleep) study: Subjective outcomes of isolated uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 2011;144(4):623-31. 8. Franklin KA, Anttila H, Axelsson S, et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea A systematic review. Sleep 2009;32(1):27-36. 9. Hagert B, Wikblad K, Odkvist L, Wahren LK. Side effects after surgical treatment of snoring. ORL J Otorhinolaryngol Relat Spec 2000;62(2):76-80. 10. Grontved AM, Karup P. Complaints and satisfaction after uvulopalatopharyngoplasty. Acta Otolaryngol Suppl 2000;543:190-2. 11. Lysdahl M, Haraldsson PO. Uvulopalatopharyngoplasty versus laser uvulopalatoplasty: prospective long-term follow-up of self-reported symptoms. Acta Otolaryngol 2002;122(7):752-7. 12. Jaghagen EL, Berggren D, Dahlqvist A, Isberg A. Prediction and risk of dysphagia after uvulopalatopharyngoplasty and uvulopalatoplasty. Acta Otolaryngol 2004;124(10):1197-203.
13. Li HY, Lee LA, Wang PC, et al. Taste disturbance after uvulopalatopharyngoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 2006;134(6):985-90. 14. Kezirian EJ, Weaver EM, Yueh B, et al. Incidence of Serious Complications After Uvulopalatopharyngoplasty. Laryngoscope 2004;114:450-3. ADDITIONAL SUPPORTING REFERENCES NOT CITED IN SYLLABUS 15. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19(2):156-77. 16. Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 2004;130(6):659-65. 17. Keenan SP, Burt H, Ryan CF, Fleetham JA. Long-term survival of patients with obstructive sleep apnea treated by uvulopalatopharyngoplasty or nasal CPAP. Chest 1994;105(1):155-9. 18. Peker Y, Carlson J, Hedner J. Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J 2006;28(3):596-602. 19. Walker-Engstrom ML, Wilhelmsson B, Tegelberg A, Dimenas E, Ringqvist I. Quality of life assessment of treatment with dental appliance or UPPP in patients with mild to moderate obstructive sleep apnoea. A prospective randomized 1-year follow-up study. J Sleep Res 2000;9(3):303-8.