The authors wish to express their thanks for the constructive criticisms and the opportunity to explain ourselves. The reasons for CPAP intolerance are manifold, and thanks to our longstanding experience with CPAP therapy we are fully aware of the measures to improve compliance. As we explained earlier, the patients had refused CPAP in spite of exhaustively trying out such measures. CPAP therapy in general and the options for improving compliance in particular were, however, not the subject of our study, and we therefore did not include a detailed discussion of the topic (1).
The authors agree that if CPAP works satisfactorily there will usually be no indication for surgery. It is well known that OSA is a multifactorial syndrome, and awareness of this fact can indeed make surgery more difficult. For this reason, we believe that it is even more important to conduct controlled studies of surgical methods.
A comparison of different therapeutic approaches for treating OSA cannot be based solely on the respiratory indices achieved in the sleep laboratory, but it also has to consider the aspects acceptance, adherence, and compliance. A reduction of the AHI by means of a surgical procedure can therefore be more effective in an individual case than CPAP therapy, which on polysomnography reduces the AHI more notably but which is insufficiently used in everyday life. The effort and expense of years of CPAP therapy and a once-only operation, such as TE-UPPP, have not been compared so far, but any comparison would probably come out in favor of surgery. The very few studies that have compared cardiovascular mortality associated with CPAP with that associated with TE-UPPP did not show superiority for CPAP (2, 3).
The observation that no similarly effective reduction of the AHI has been shown for any surgical procedure for OSA compared with CPAP therapy so far is not accurate and requires further comment. The most effective treatment for OSA is probably tracheotomy, although no comparative studies exist in this setting, and it is recommended only as a measure of last resort because of the associated morbidity. A prospective randomized study between CPAP therapy and maxillomandibular advancement (MMA) showed comparable efficacy for both procedures (4, 5).
The comment that the study did not show any advantage for TE-UPPP over tonsillectomy alone is correct, but such a comparison was not the subject of our study. The call for long term studies deserves support, but this cannot be implemented in the form of a controlled study design with an untreated control group.
Both methods, CPAP and surgery, have their specific indications, limitations, benefits and risks, which have to be weighed up in each individual case. Patients should be informed about the available procedures with the necessary objectivity, and patients’ own wishes should be considered in making the decision, in the same way as happens for other disorders and therapeutic approaches.
Footnotes
Conflict of interest statement
PD Dr. Sommer has received consultancy fees, reimbursement of conference fees and travel and accommodation expenses, fees for preparing scientific continuing professional development or other events, funding for research he himself initiated, and fees for conducting clinical studies on related subjects from Neuwirth Medical, ImThera Medical, Thorax Medical, Fisher & Paykel Healthcare, Heinen & Löwenstein, Medtronic, Revent Medical, MedEl, Philips, Meda Pharma, Inspire Medical, and Nyxoah.
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