Reasons for Refusal Were not Given

The present study included adults with obstructive sleep apnea (OSA) syndrome, tonsillar hypertrophy, and velopharyngeal obstruction. The patients had either refused nocturnal continuous positive airway pressure (CPAP) therapy or were CPAP intolerant (1).

In the methods section, the authors do not explain the study participants’ reasons for refusing CPAP treatment. In the discussion section they do not refer to the factors that affect long-term adherence to CPAP therapy. These include a well-fitting mask, the quality of professional support, and therapeutic effects such as improved sleep quality and reduced daytime sleepiness (2). Thus, treatment-associated problems may successfully be addressed by adequate patient education, mask training, and air humidification which may all help to avoid CPAP failure. Since these measures may not yield the desired success within the first two weeks of therapy it may happen all too early that CPAP treatment is considered a failure.

CPAP therapy is the gold standard in the treatment of OSA, and under sleep laboratory conditions it has been shown to lower the apnea-hypopnea index (AHI) to normal values. Unquestionably this cannot be achieved in many patients in their domestic environment, and achieving optimal adherence to treatment is an ongoing therapeutic task. But there is no reason to put up with a mere part-reduction of the AHI with regard to the effects of surgical treatment. An average postoperative AHI of 15.4/h (standard deviation up to 14.1/h!) and non-significant changes of both the desaturation index and t <90% (duration of desaturation) do not represent a therapeutic success that would justify the effort, costs, and risks of surgical intervention. Furthermore, if the residual AHI is 15/h or higher, the cardiovascular risk which is associated with OSA would probably not be substantially reduced.