An analysis of the evidence-practice continuum: is surgery for obstructive sleep apnoea contraindicated?

Rationale, aims and objectives Currently there are multiple surgical interventions utilized in the treatment of adult obstructive sleep apnoea (OSA). The role of these operations remains controversial, with perspectives on treatment efficacy varying considerably. Despite this, their use is proliferating. Objectives In this paper, we present the degree of variability that occurs in the application of these procedures, and examine the effectiveness of surgical intervention as a treatment for OSA. Method A multi-centre retrospective clinical audit of consecutive, unselected surgical cases presenting at the sleep disorder clinics of two teaching hospitals in a major Australian city. Patients acted as their own historical controls, undergoing polysomnography pre and post surgery to gauge effectiveness. Results On variability demonstrate 94 individuals in this cohort received 220 individual upper airway surgical procedures, 184 occurred in their first operation (mean 2.5 per person; range 1-7) and 36 occurred in a second operation (n = 18; cumulative mean of 4 per person; range 3-7). These 94 individuals received 41 varying combinations of surgery. Results on effectiveness demonstrate an overall physiological success rate of 13% (87% fail). One operation reduced OSA severity by 20% (patients still had severe OSA), and two operations by 35% (still moderate OSA). In contrast, conventional Continuous Positive Airway Pressure therapy controlled OSA (n = 64). Conclusions This case study demonstrates substantial procedural variability and limited effectiveness. This raises questions as to the quality of care, the treatment-derived health outcomes of this population and of efficient resource allocation. This issue requires greater policy attention.