Diagnostic and Surgical Advances in Obstructive Sleep Apnea

Safety is the most important consideration. We need wider experience to assess the risk of complications, Dr. Friedman said. If additional studies support preliminary findings, this procedure will improve treatment results dramatically, he added.

Another tongue-based procedure under development is suspension of tongue tissue with sutures, called tongue-based suspension. Several companies are studying modifications of this procedure, developed originally by Influent. These promising techniques are under FDA review, Dr. Friedman noted.

Outpatient or Inpatient Procedure?

Opinions on UPPP vary, with some physicians considering it a high-risk procedure and others who think it is safe if patients are appropriately selected. General anesthesia is required for UPPP, and the anesthesiology literature advocates performing the procedure in an inpatient setting with an overnight stay for subsequent monitoring, while the ENT literature suggests the procedure is safe with a low incidence of complications.

A study presented at the AAO-HNS meeting found that UPPP could be safely performed in an outpatient setting, freeing up hospital beds for longer more complicated procedures and reducing resource use. Forty consecutive patients with moderate to severe obstructive sleep apnea and median RDI of 40 underwent UPPP and 80% had tonsillectomy at the same time, said senior author of the study Marilene Wang, MD, who is Professor of the Division of Head and Neck Surgery at the David Geffen School Medicine at UCLA in Los Angeles. All patients were adults, up to 77 years old, and median body mass index was 27.1. Dr. Wang performed all the surgeries. Thirty-six patients did very well as outpatients. One patient was already an inpatient, hospitalized for other comorbidities related to obesity. Only three patients were admitted to the hospital overnight, and these were mainly for social reasons, such as not having a ride home or wanting a full night’s sleep undisturbed by young children, Dr. Wang said. No postoperative complications occurred in any of these patients-specifically, no bleeding, postoperative pulmonary edema, or respiratory difficulties.

Complications may occur with aggressive procedures. Dr. Wang explained that she favors a conservative technique, removing the tonsils and the uvula, and then placing sutures on the uvula and lateral walls. Scar tissue and fibrosis around the sutures mitigates the obstruction.

Dr. Wang emphasized that comorbidities are an important consideration in selecting patients for UPPP, as well as for inpatient or outpatient hospital stay. Morbid obesity, cardiac problems, and respiratory illness are contraindications to UPPP. Patients with these conditions are probably best treated with CPAP, she said. She believes that the decision about whether to hospitalize patients undergoing UPPP should be made jointly by the anesthesiologist and surgeon on a case-by-case basis.