TABLE IX.E.1.

Evidence for surgery and improved daytime sleepiness and quality of life

Study	Year	LOE	Study design	Study groups	Clinical end-point	Conclusion
Farrar et al.2009	2008	1a	SR and MA	Isolated radiofrequency ablation of the palate, tongue base, or both	ESS, RDI, LSAT	Radiofrequency ablation reduces ESS and RDI levels. ESS decreased by 31%. RDI reduced by 31% in short-term and 45% in long-term.
Franklin et al.2017	2009	1a	SR	1. Surgery 2. Sham or no treatment	ESS, AHI, QOL	Laser-assisted uvulopalatoplasty or radiofrequency ablation has no effect on daytime sleepiness, apnea reduction, and QOL.
Gao et al.2010	2019	1a	SR and network MA	Minimally invasive treatments including surgery	AHI, ESS	Simple surgical procedures improve AHI and ESS insignificantly.
Ishii et al.545	2015	1a	SR and MA	Nasal surgery including endoscopic sinus surgery	AHI, RDI, ESS	Significant improvements in ESS and RDI after nasal surgery, but no significant improvements in AHI.
Kezirian and Goldberg1802	2006	1a	SR	Hypopharyngeal surgeries	PSG, ESS, QOL	Hypopharyngeal surgery has success rates of 35%–62%. Improved ESS and FOSQ were seen.
Stuck et al.1688	2018	1a	SR	UPPP ± tonsillectomy	PSG, ESS, sexual function, cardiac parameters morbidity and mortality	UPPP ± tonsillectomy reduced AHI and ESS, and improved sexual function. AHI change was 18.59. ESS change was 5.37.
Sundaram et al.1483	2005	1a	SR	1. Surgical intervention for OSA 2. Other surgical or nonsurgical interventions, or no intervention	PSG, sleepiness, QOL	Surgery has inconsistent effects. There is no convincing evidence to support surgical treatment of OSA.
Zaghi et al.2007	2016	1a	SR and MA	MMA	AHI, RDI, LSAT, ESS	MMA is an effective treatment for OSA. Success rate of 85.5%; cure rate of 38.5%. ESS decreased from 13.5 to 3.2.
Atef et al.2013	2005	1b	RCT	1. Bipolar radiofrequency volumetric tissue reduction of the palate 2. LAUP	AHI	Bipolar radiofrequency volumetric tissue reduction of the palate required more sessions to achieve a favorable outcome, but benefit was also maintained for longer.
Baba et al.1782	2015	1b	SR and MA	Isolated TCRFTA of the soft palate, base of tongue or both	ESS, RDI, LSAT, SF-36	TCRFTA can reduce RDI and sleepiness when directed at the base of tongue or as a multilevel procedure.
Browaldh et al.1666	2016	1b	RCT	1. Modified UPPP including tonsillectomy 2. No treatment	ESS, SF-36, vigilance	ESS, SF-36, vigilance improved after surgery.
Holmlund et al.1737	2014	1b	RCT	1. Radiofrequency of the soft palate 2. Sham surgery	AHI, ESS, snoring	Radiofrequency surgery of the soft palate has no effect on daytime sleepiness or apnea frequency.
Li et al.906	2011	1b	SR and MA	Nasal surgery including endoscopic sinus surgery	AHI, ESS	Nasal surgery can effectively reduce daytime sleepiness, but is limited in reducing OSA severity.
Mackay et al.1919	2020	1b	RCT	1. Combined modified UPPP and radiofrequency of the tongue 2. Ongoing medical management	ESS, PSG	Combined palatal and tongue surgery, compared with medical management, reduced AHI. and ESS at 6 months. Mean AHI and ESS baseline-adjusted between-group difference was −17.6 and −6.7, respectively.
Sharma et al.1961	2019	1b	SR and descriptive MA	1. Rhinological surgical intervention 2. Non-surgical and/or non-rhinological surgical intervention	AHI, RDI, ESS	Nasal surgery may have limited benefit on OSA, although improvements in sleep parameters and ESS are seen. ESS changed by 3.9.
Vicini et al.1503	2010	1b	RCT	1. MMA 2. Auto-titrating positive airway pressure	AHI, ESS	Both groups had similar improvement of mean AHI and ESS.
Walker-Engstrom et al.2016	2000	1b	RCT	1. UPPP 2. MAD	PSG, Minor Symptoms Evaluation-Profile (MSE-P)	QOL improved in both groups 1 year after intervention. The dental group had superior PSG values, but lower contentment.
Woodson et al.1497	2003	1b	RCT	1. TCRFTA 2. CPAP 3. Sham-placebo	QOL, ESS, PSG, reaction time	TCRFTA improved reaction time, OSA-specific QOL and ESS compared to baseline. TCRFTA improved reaction time, while CPAP did not.
Wu et al.1660	2017	1b	MA	Isolated nasal surgery	AHI, ESS	AHI and ESS improve significantly after isolated nasal surgery, but AHI demonstrated only slight improvement.
Bostanci and Turhan1817	2016	2a	SR	Tongue base suspension (TBS) techniques ± UPPP	AHI, LSAT, ESS	Tongue base suspension has some efficacy, with or without UPPP. ESS improved with tongue base suspension.
Choi et al.1746	2013	2a	MA	Pillar implant for mild to moderate OSA	ESS, AHI, snoring	The Pillar implant reduced ESS and AHI significantly for mild to moderate OSA.
Holty and Guilleminault1867	2010	2a	SR and MA	MMA	PSG, ESS, QOL	MMA improved AHI, reduced daytime symptoms and improved QOL. Success and cure rates were 86.0% and 43.2%, respectively.
Wang et al.2008	2019	2a	SR and MA	Nasal surgery ± endoscopic sinus surgery	AHI, ODI, LSAT, ESS	Isolated nasal and sinus surgery can reduce daytime sleepiness in OSA. ESS change was 3.79. There was no significant improvement on objective parameters.
Conradt et al.2018	1998	2b	Cohort	Patients were treated with CPAP before undergoing MMA	PSG, vigilance	MMA has positive effects on sleep, respiration and vigilance which are comparable to CPAP.
Klonoff et al.2022	1987	2b	Cohort	1. UPPP 2. Coronary bypass surgery	Psychological assessment battery, PSG	Anxiety and depression are lower after both surgeries, possibly by virtue of the surgery resolving the disease.
Xiao et al.2024	2016	2b	Cohort	1. Nasal surgery for patients with nasal obstruction 2. No surgery for patients without nasal obstruction	PSG, PSQI, Symptom Check List-90	Nasal surgery reduced daytime dysfunction scores on PSQI, anxiety, and hostility scores.
Boyd et al.2005	2019	4	Case series	MMA	ESS, QOL, AHI, psychomotor vigilance testing	MMA improved all measures. AHI decreased by 81.3%. ESS change was 8.5. 66.7% had normal FOSQ after surgery compared to 10% before surgery.
Camacho et al.1980	2014	4	SR and MA	Tracheostomy	AI, AHI, ODI, sleepiness	Tracheostomy significantly decreases AI, AHI, and sleepiness. AI change was 83.47. Mean AHI and ODI was in the moderate range post tracheostomy.
Camacho et al.1868	2019	4	SR and MA	MMA	AHI, ESS, LSAT	Improvements in AHI, sleepiness, and lowest oxygen saturation were maintained in the long-term (4 to <8 years). Mean AHI increased to moderate OSA in the very long term (≥8 years).
Certal et al.1874	2015	4	SR and MA	Hypoglossal nerve stimulation therapy	AHI, ODI, ESS, QOL	Hypoglossal nerve stimulation improves AHI, ODI, and ESS fairly consistently over 12 months. There was improvement in QOL.
Costantino et al.1890	2020	4	SR and MA	Hypoglossal nerve stimulation therapy	AHI, ESS, ODI	Hypoglossal nerve stimulation achieves high surgical success rates of up to 76.9% (ImThera) at 12 months, and 75% (Inspire) at 60 months. ESS improved with all devices.
Dahlof et al.2021	2000	4	Case series	UPPP	Psychiatric symptoms, dexamethasone suppression test, PSG	Sleep disturbance and reduced daytime alertness may be at least one of the factors behind depressive symptoms in OSA. Relapse occurred at 6 months, but symptoms were still less than baseline.
Ishman et al.2014	2014	4	Case series	Any OSA surgery	ESS, Beck Depression Index, RDI	Surgery, especially multilevel surgery, significantly reduces depression, and sleepiness scores. 77.3% and 75.0% had resolution of sleepiness and depression, respectively.
Justin et al.2002	2016	4	SR and MA	TORS	AHI, LSAT, ESS	TORS appears to be a promising procedure as part of multilevel surgery. AHI decreased by 24.0. Success achieved in 48.2%. ESS decreased by 7.2.
Li et al.2023	2004	4	Case series	Extended uvulopalatal flap	RDI, LSAT, 5-Item Mental Health scale (MH-5), ESS	Extended uvulopalatal flap can mildly improve, but not normalize, mood. Success rate was 79.8%. The improvement is not purely due to changes in PSG or ESS.
Lin et al.1920	2008	4	SR and MA	Multilevel surgery involving at least two levels (nose, oropharynx, hypopharynx)	PSG, ESS, QOL	Multilevel surgery can improve outcomes. Success rate was 66.4%. ESS improved in 23/26 groups and changed by 43.0%.
Llewellyn et al.2011	2019	4	SR and MA	Cautery-assisted palatal stiffening operation	AHI, ODI, LSAT, ESS	Cautery-assisted palatal stiffening operation improved respiratory parameters. ESS improved from 11.8 to 5.1.
Meccariello et al.2003	2017	4	SR and MA	TORS	AHI, LSAT, ESS	TORS appears to be a promising procedure as part of multilevel surgery. Failure rate is 36.1%. ESS decreased significantly.
Murphey et al.2004	2015	4	SR and MA	Glossectomy	AHI, LSAT, ESS	Glossectomy significantly improves sleep outcomes and ESS as part of multilevel surgery. AHI decreased by 27.81. Success achieved in 59.56%. ESS decreased by 5.49.
Pang et al.1966	2018	4	MA	Palate surgeries	AHI, ESS, QOL	Palate surgery improved AHI and ESS. AHI change was 19.9. Success rate was 67.5%. ESS change was 5.8.
Santamaria et al.2019	1988	4	Case series cross-sectional study, then prospective cohort study	UPPP	Serum testosterone, interview on sexual function	Increased testosterone, and return of libido and sexual functioning to normal range was seen after UPPP.
Shin et al.2020	2013	4	Cohort	1. UPPP 2. CPAP 3. MAD	International Index of Erectile Function (KIIEF5), SAQLI, ESS, AHI, LSAT	Erectile dysfunction may improve after UPPP. ESS, AHI, LSAT improved significantly in the UPPP group.
Song et al.1804	2016	4	SR and MA	Hyoid surgery	AHI, ESS	Isolated hyoid surgery reduced OSA severity and improved sleepiness. Hyothyroidopexy achieved the largest AHI reduction.
Steward et al.2015	2004	4	Case series	TCRFTA of tongue and palate	ESS, FOSQ, reaction time	The addition of more sessions and levels of TCRFTA result in further improvement of ESS, QOL and reaction time.
Tsui et al.2006	2020	4	Cohort	1. Surgery (sagittal split ramus osteotomy/mandibular distraction osteogenesis) 2. Matched controls without OSA	ESS, QOL	ESS improved in the surgical arm. QOL scores in the surgical groups improved to the level of the control group. QOL was similar between the two surgical arms.
Veer et al.2012	2014	4	SR	Radiofrequency ablation	AHI, ESS	Radiofrequency ablation can improve AHI and ESS. Absolute reduction could not be calculated due to paucity of available data.

Abbreviations: AHI, apnea-hypopnea index; CPAP, continuous positive airway pressure; ESS, Epworth Sleepiness Scale; FOSQ, Functional Outcomes of Sleep Questionnaire; LAUP, laser-assisted uvulopalatoplasty; LSAT, lowest oxygen saturation; MA, meta-analysis; MAD, mandibular advancement device; MMA, maxillomandibular advancement; ODI, oxygen desaturation index; OSA, obstructive sleep apnea; PSG, polysomnography; PSQI, Pittsburgh Sleep Quality Index; QOL, quality of life; RCT, randomized controlled trial; RDI, respiratory disturbance index; SAQLI, Calgary Sleep Apnea Quality of Life Index; SF-36, 36-Item Short Form; SR, systematic review; TCRFTA, temperature-controlled radiofrequency tissue ablation; UPPP, uvulopalatopharyngoplasty.