. Author manuscript; available in PMC: 2024 Jan 1.

Published in final edited form as: Int Forum Allergy Rhinol. 2023 Mar 30;13(7):1061–1482. doi: 10.1002/alr.23079

TABLE IX.A.3.

Evidence for surgery as a primary treatment for OSA

Study	Year	LOE	Study design	Study groups	Clinical end-points	Conclusion
Sundaram et al.¹⁴⁸³	2005	1a	Cochrane systematic review	Surgical RCTs for treatment of OSA (n = 709 patients combined)	Effectiveness of surgery for OSA	There is insufficient evidence to support surgery being consistently effective for OSA management. More RCTs are necessary to specify subgroups that would benefit most from surgery.
Woodson et al.¹⁴⁹⁷	2003	1b	RCT	Patients with mild to moderate OSA randomized to 1. Sham-placebo (n = 30) 2. CPAP (n = 30) 3. Temperature controlled radiofrequency tissue ablation, TCRFTA (n = 30)	AHI, quality of life measures	Both CPAP and TCRFTA had significant improvement over sham-placebo. There was no significant difference in outcomes between CPAP and TCRFTA.
Vicini et al.¹⁵⁰³	2010	1b	RCT	Patients with severe OSA (AHI > 30) randomized to 1. APAP group (n = 25) 2. MMA group (n = 25)	Reduction in AHI and ESS	MMA is a viable alternative surgical therapy to CPAP, with a noninferior success rate.
Rotenberg et al.¹⁴⁹⁵	2016	2a	Systematic review	1. Systematic review of CPAP trials (n = 82 trials) 2. Systematic review of surgery trials (n = 69 trials) 3. Systematic review of CPAP vs. surgery trials (n = 3 trials)	Comparison of success between CPAP and surgery for OSA	Lack of long-term follow-up and low adherence in CPAP trials, along with evidence of surgical success, should change our thought that surgery cannot be a primary treatment in OSA.
Aurora et al.¹⁴⁸²	2010	2a	systematic review	Review of effectiveness surgical trials (n = 79 trials)	Publishing of practice parameters for surgical management of OSA	Due to lack of strong evidence favoring surgical management of OSA, CPAP should always be considered as the initial treatment for OSA.
Walker-Engstrom et al.¹⁵⁰⁷	2002	2b	RCT	Patients with mild to moderate OSA 1. Dental appliance group (n = 32) 2. UPPP group (n = 40)	PSG parameters at 1 and 4 years follow-up, surgical success determined as AHI < 10	Oral appliance had better success rate of 62% over UPPP, with success rate of 33%. Compliance with oral appliance was 62% at 4-year follow-up.
Lojander et al.¹⁵⁰⁸	1996	2b	RCT	1. Nasal CPAP vs. conservative treatment (n = 44) 2. UPPP with or without mandibular osteotomy vs. conservative treatment (n = 32)	ESS and posttreatment ODI	CPAP was successful but compliance was an issue. Surgery also showed significant improvement compared to control. No comparison can be made in this study between CPAP and surgery.
Weaver et al.¹⁴⁹⁸	2004	3b	Cohort	VA Patients with OSA 1. Using CPAP (no compliance data) (n = 18,754) 2. Underwent UPPP (n = 2072)	Posttreatment overall survival	Patients on CPAP had a 31% higher probability of mortality at any time relative to patients who underwent UPPP.
Senchak et al.¹⁵⁰⁰	2015	3b	Cohort	Cohort of military patients undergoing tonsillectomy for reasons other than OSA. Out of 156, n = 19 with OSA	Posttreatment AHI	Patients had 82% reduction in AHI. In population of young overweight men with large tonsils and moderate OSA, tonsillectomy alone can be effective treatment.
Ceylan et al.¹⁴⁹⁶	2009	3b	Case–control	Mild to moderate OSA 1. nasal CPAP group (n = 21) 2. Temperature controlled radiofrequency tissue volume reduction group (TCRTVR) (n = 26)	ESS and post treatment PSG	No significant difference between success in the multilevel minimally invasive surgery group (TCRTVR) and nasal CPAP group.
Rotenberg et al.¹⁴⁹⁹	2014	3b	Case–control	Patients with moderate to severe OSA who failed CPAP and had favorable anatomy for palate surgery	1. 1-year posttreatment AHI 2. 1-year posttreatment ESS 3. 1-year posttreatment sleep apnea quality of life index (SAQLI-E) 4. 1-year posttreatment BP	By AHI, 85.7% of patients achieved surgical success. SAQLI-E scores improved significantly after surgery. A subset of patients can be managed more effectively with surgery than CPAP.
Kent et al.¹⁵⁰⁶	2021	1a	Meta-analysis	Evaluation of two RCTs and 15 observational studies. For RCTs patients were randomized to surgery or no treatment	AHI/RDI, ESS, LSAT, sleep-related QOL, snoring, ODI, blood pressure, death, persistent side effects	Recommend PAP as initial therapy for adults with OSA and a major upper airway abnormality. Harm for initial trial of PAP therapy is low. Recommendation was conditional.