Surgery no quick fix for sleep problems

Surgery for obstructive sleep apnoea has no clear benefit and should not be offered as a first treatment, argue University of Adelaide researchers in the British Medical Journal.

Obstructive sleep apnoea is a common disorder caused by the collapse of the upper airways during sleep. This leads to loud snoring and sometimes breathing stops temporarily. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health-related quality of life. It mainly affects middle-aged, overweight men.

Guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management, if appropriate, as the first line treatment. But upper airway surgery is becoming increasingly popular in Australia and elsewhere.

Dr Adam Elshaug and researchers from the University of Adelaide’s Discipline of Public Health have analysed existing evidence for upper airway surgery and found the results of surgery are inconsistent.

One review of seven randomised trials concluded that surgery had a general lack of impact on symptoms and, even where improvements in quality of life have been shown immediately after surgery, these were rarely sustained beyond 12-24 months.

Another review of 48 studies found that up to 62% of patients who had surgery reported persistent adverse effects, such as a dry throat, difficulty in swallowing, voice changes, and disturbances of smell and taste. Up to 22% regretted having surgery.

Weight loss and other lifestyle modification is recommended as an adjunctive treatment to CPAP, but can be difficult to achieve, according to Dr Elshaug and his colleagues. CPAP therapy also depends on acceptance and adherence by patients and its benefits in mild to moderate sleep apnoea seem inconclusive, making surgery seem more attractive.

However, given the lack of clear benefit from surgery and the potential for harm indicated by currently available evidence, guidelines recommend CPAP as the first line treatment for obstructive sleep apnoea generally.

Surgery for obstructive sleep apnoea should be done within controlled clinical trials, Dr Elshaug says. Patients should be informed about the trial, as well as of the inconsistent results of surgery, the associated pain, the potential side effects, and the potential for relapse.

(Source: British Medical Journal: John Moss: University of Adelaide: January 2008)