I was diagnosed with RERA (Resp. Event Related Arousal) over a year ago.  At that time I posted many questions here.  Since then I've tried and given up on CPAP.  Even though my titration study showed it to help I simply cannot fall asleep or stay asleep with it so I'm worse off with it than without.  So I decided to look into surgery.  My ENT recommends a septoplasty and turbinate reduction and UPPP (taking out the tonsils but not the adenoids).  I got a second opinion from my maxillofacial surgeon and he doesn't think any of the nose changes will help my sleeping problem at all, though he does agree I need some work on the turbinates (I have only about half the air flow on one nostril that I do on the other) and he didn't have any objections to the idea of the UPPP.

I'm not afraid of surgery itself at all but I AM afraid of permanent complications such as some horror stories I've heard about complications such as trouble swallowing and dry mouth.  But I've also read that the uvula, for example, is not really needed for anything and there isn't any problem with removing it.

Any words of wisdom?  Links to facts, figures, statistics?  I'm going to be searching on this forum and Googling all night probably trying to educate myself.

Sorry if this threads like this have been created a thousand times already.  But it helps me gather my thoughts to get this all out like this.

I had a UPPP and it didn't do me any good.  After UPPP I began choking on small pieces of food such as peas or corn; it can take quite a while to cough up a piece of food.

Hi there cowboy1964,

Yes, I think it's a good idea for you to search this forum for the topic.
I don't have any contributions because I've not had any of those surgeries.  But it's good to be comfortable with your decisions.  

You might also go back and read all of your previous posts (you can do that by viewing your profile and there's a place to click).  Sometimes looking back on what you've said about your condition, your efforts to use cpap, etc. might be interesting, give you a new or fresh perspective, and help you to consider other things.  It certainly can't hurt.

It always bothers me when I hear of an ENT recommending a long list of surgeries.  Surgeries is what they do.   Nasal surgery might make you breathe better, easier, and may help you adapt to cpap more easily.  Tonsil removal may or may not eliminate sleep apnea, but it could also help with cpap usage.  But I suppose there could be scar tissue there that makes the condition worse, I don't know.  Good idea to read other posts on this forum.  Yes, there's a lot to consider, so you are wise to be asking.


Linda

I had a UPPP with soft palate reduction with septoplasty on Nov 27, 2007. They graded my uvula as a 4+ which means that it touched my tongue. My ENT assured me that I was a "perfect candidate" for the UPPP and that he had done maybe 500 of these (an ENT did his). One of my nostrils was 90% blocked. ENT told me CPAP would be more difficult because of that. "While we're doing the septoplasty we may as well do the UPPP." BTW my BMI is 21.2, very low.

I've spent the last several days/weeks researching CPAP machines as I am still tired and my followup split night sleep study showed that my AHI went from 18.3 to 8.9. Still mild OSA! My ENT didn't think I needed a CPAP as he thought my sleep architecture was better without the CPAP even though my CPAP AHI was 3. I went to a pulmonologist board certified in sleep medicine which is why I'm researching CPAPs. I still snore but it sounds different. At my five month followup appointment my ENT finally saw that the base of my tongue was collapsing. This was my third camera check of my throat (whatever it is called)! Why didn't he see it before???

The septoplasty and removing tonsils may help in your CPAP use as you may be able to reduce your pressure. If I had it to do over again I would just do the septoplasty and make the CPAP work. I've had the UPPP now I've wasted about 10 months but will make the CPAP work.  I echo "Bearded One" I have choked on small bits of food or too big a gulp of liquid. Did your MD tell you about the sore throat?

Popeye, what about the sore throat?  You mean immediately after the surgery or permanent?

The sore throat starts a couple days after the surgery. The ENT told me it would be the worst sore throat of my life for about 10 days. Mine wasn't the worst but it did hurt for 10 days. No sore throat problems now. There is a frequent feeling of not being able to totally swallow the last bit of a liquid. Do a search for my posts and UPPP for my take on the post-op.

This is major surgery! Mine was done on an "outpatient" basis meaning I was in the hospital for 23 hours. If your AHI is above 10 I wouldn't even consider this. I read that you only get 50% improvement and thought mine would be better than that but my AHI went from 18 to 8.9, not worth the hassle and expense.

My BMI is about 24.  I really don't even have the classic risk factors for OSA.  But my diagnosis was probable UARS so it seems logical that this surgery may really help me.

Yes I know about the sore throat.  I can deal with that.

Here are my AHI numbers:

AHI, NREM  0 (non-supine)  1.5 (supine)
AHI, REM  10.1 (non-supine)  54.0 (supine)

Obviously supine REM is horrible but I never sleep on my back (they made me do it for the study).  Which means I really vary from 1.5 in NREM to 10.0 in REM.  Pretty mild IMO.

I had my UPPP surgery on the 16th and I am in day 5 of my recovery. Before the surgery my snoring was unbearable and sometimes my Uvula would swell so large that I couldnt swallow easily.

My RDI was 38 and I tried the CPAP machine but could not successfully use the machine due to the high pressure required.

I had the Septoplasty surgery about a month ago. So far the pain has been very controllable with the pain meds. The best thing that I have used for pain is the miracle mouthwash. I am eating OK with yogurts and puddings for breakfast and soups and mashed potatoes for lunch and dinner. The best food for easing the pain is cream of chicken soup.

Since the surgery I do not snore anymore and that is so nice to be able to sleep in the same bed with my wife again. Before my snoring was so bad that my wife and kids on the other side of the house could still hear me snoring.  

Another plus is my blood pressure has came down sincce the surgery. Before the surgery with BP meds my blood pressure would be a little high at the 135/100 range and now Im at 125/80 without taking the meds due to the surgery.

It is a shame that the original thread for recovery was closed beacuse there was alot of good information on this surgery for both sides. I ultimately decided that if the surgery only corrected my snoring, I would be totally happy since I would at least not keep my family awake all night, and if the apnea still exsists they pressure can now be lowered to a level that I can tolerate.

Cowboy, it's understandable that you're getting conflicting information. There's really no consensus in the ENT community as to the best way of managing this condition surgically. As an ENT surgeon myself, here's my take on your situation (and others considering UPPP surgery):

We know that CPAP works the best, but only if you use it regularly. Only after you've thoroughly exhausted all your CPAP options, should you consider surgical management. Whenever I see patients for surgical consultation, in most cases, there are a few more things to try with CPAP before considering sleep apnea surgery. One caveat is that a septoplasty, but improving nasal breathing, help with CPAP usefulness and compliance. I spend a lot of time counseling the patient regarding CPAP use, something that seems very lacking in my area (NYC). However, once you arrive at a point where you are considering definitive sleep apnea surgery, there are a number of issues to consider:

First of all, I look at all the sleep study numbers, but take it with a grain of salt. The mild/moderate/severe categories are confusing and since every sleep lab tests differently, you can't compare apples to oranges. Also, since an apnea or hypopnea is scored only if the breathing pause lasts for greater than 10 seconds, if you stop breathing 35 times every hour and wake up from deep sleep to light sleep, but none last for more than 10 seconds, then your official AHI is 0. This is why when you're younger and thinner, you'll have more of these "short" obstruction that don't show up in the final AHI. Some people call these RERAs (respiratory event related arousals). So whether your score is 6 or 66, I treat the patient and the underlying anatomic areas of narrowing, rather than treating the number.

Most ENTs and sleep docs tend to focus way too much on the palate, since that's where the snoring is coming from. But decades of research has shown over and over that you have to consider the entire upper airway, from the tip of the nose to your voice box. If you have 2 or 3 areas of obstruction (palate and tongue), then treating the palate alone will not help. This is why the classic UPPP procedure has only a 40% success rate. And yes, "success" means greater than 50% drop in the AHI and the final number has to be under 20. There are many other "success" definitions (which can make the success rates look higher), but this is the most common one. Based mainly on research at Stanford and man other centers, if you add tongue base surgery, the success rate can go up as high as 75 to 80%. If you add upper and lower jaw advancement surgery, then success is 90-95%. A tracheotomy is 100% successful (but not conducive to normal living). So in theory, a 50% drop in your numbers is better than not using your CPAP at all. A recent Veterans study showed that there was no difference in overall long-term survival between a group that underwent UPPP alone vs. CPAP alone. A 40% UPPP success rate is probably equivalent to only about 40% of people using CPAP long-term. Actually, UPPP patients were slightly more likely to be alive at the end of the study, but this was not statistically significant.

There are ways of predicting whether or not a UPPP alone will work based on your tonsil size and tongue position (Friedman staging), but even this is just a rule of thumb. Here, if you have very large tonsils (3-4+) and a low sitting tongue, then your predicted success rate is about 80%. This is why children do much better after tonsillectomy.

Although I have my own way of performing surgery in every area (nose, palate, and tongue), my philosophy is that it doesn't matter what type of surgery you do, but where you do it and how definitively you do it, that matters most. If you're too concerned about velopharyngeal incompetence (leaking of air or food into your nose), then by being too conservative, you'll still have palatal narrowing, and by doing the more "minimally invasive" tongue procedures, you'll more likely get minimal results. There are caveats and exceptions to all the procedures, but my point is that the more appropriately you address the different levels of collapse, the better your results will be. Complications do occur to a small degree with any surgery, but statistically, you have a higher chance of being run over by a car crossing the street than dying in the operating room. This is were the surgeon's experience matters, not just the total number that's been done, but how well each procedure is performed with good results and minimal complications.

An in-office endoscopic exam by an experienced ENT can usually tell where the obstruction is occurring. He or she should be able to give an objective, quantifiable measure of where and how much narrowing you have in each of the three major areas. If you go to a surgeon that does not perform tongue base procedures routinely, then statistically, you have a 40% chance of success by addressing only the palate. Only by looking can you tell if you're in the small 80% success group.

Hope this helps.

sypark wrote:

Cowboy, it's understandable that you're getting conflicting information. There's really no consensus in the ENT community as to the best way of managing this condition surgically. As an ENT surgeon myself, here's my take on your situation (and others considering UPPP surgery):

We know that CPAP works the best, but only if you use it regularly. Only after you've thoroughly exhausted all your CPAP options, should you consider surgical management. Whenever I see patients for surgical consultation, in most cases, there are a few more things to try with CPAP before considering sleep apnea surgery. One caveat is that a septoplasty, but improving nasal breathing, help with CPAP usefulness and compliance. I spend a lot of time counseling the patient regarding CPAP use, something that seems very lacking in my area (NYC). However, once you arrive at a point where you are considering definitive sleep apnea surgery, there are a number of issues to consider:

First of all, I look at all the sleep study numbers, but take it with a grain of salt. The mild/moderate/severe categories are confusing and since every sleep lab tests differently, you can't compare apples to oranges. Also, since an apnea or hypopnea is scored only if the breathing pause lasts for greater than 10 seconds, if you stop breathing 35 times every hour and wake up from deep sleep to light sleep, but none last for more than 10 seconds, then your official AHI is 0. This is why when you're younger and thinner, you'll have more of these "short" obstruction that don't show up in the final AHI. Some people call these RERAs (respiratory event related arousals). So whether your score is 6 or 66, I treat the patient and the underlying anatomic areas of narrowing, rather than treating the number.

Most ENTs and sleep docs tend to focus way too much on the palate, since that's where the snoring is coming from. But decades of research has shown over and over that you have to consider the entire upper airway, from the tip of the nose to your voice box. If you have 2 or 3 areas of obstruction (palate and tongue), then treating the palate alone will not help. This is why the classic UPPP procedure has only a 40% success rate. And yes, "success" means greater than 50% drop in the AHI and the final number has to be under 20. There are many other "success" definitions (which can make the success rates look higher), but this is the most common one. Based mainly on research at Stanford and man other centers, if you add tongue base surgery, the success rate can go up as high as 75 to 80%. If you add upper and lower jaw advancement surgery, then success is 90-95%. A tracheotomy is 100% successful (but not conducive to normal living). So in theory, a 50% drop in your numbers is better than not using your CPAP at all. A recent Veterans study showed that there was no difference in overall long-term survival between a group that underwent UPPP alone vs. CPAP alone. A 40% UPPP success rate is probably equivalent to only about 40% of people using CPAP long-term. Actually, UPPP patients were slightly more likely to be alive at the end of the study, but this was not statistically significant.

There are ways of predicting whether or not a UPPP alone will work based on your tonsil size and tongue position (Friedman staging), but even this is just a rule of thumb. Here, if you have very large tonsils (3-4+) and a low sitting tongue, then your predicted success rate is about 80%. This is why children do much better after tonsillectomy.

Although I have my own way of performing surgery in every area (nose, palate, and tongue), my philosophy is that it doesn't matter what type of surgery you do, but where you do it and how definitively you do it, that matters most. If you're too concerned about velopharyngeal incompetence (leaking of air or food into your nose), then by being too conservative, you'll still have palatal narrowing, and by doing the more "minimally invasive" tongue procedures, you'll more likely get minimal results. There are caveats and exceptions to all the procedures, but my point is that the more appropriately you address the different levels of collapse, the better your results will be. Complications do occur to a small degree with any surgery, but statistically, you have a higher chance of being run over by a car crossing the street than dying in the operating room. This is were the surgeon's experience matters, not just the total number that's been done, but how well each procedure is performed with good results and minimal complications.

An in-office endoscopic exam by an experienced ENT can usually tell where the obstruction is occurring. He or she should be able to give an objective, quantifiable measure of where and how much narrowing you have in each of the three major areas. If you go to a surgeon that does not perform tongue base procedures routinely, then statistically, you have a 40% chance of success by addressing only the palate. Only by looking can you tell if you're in the small 80% success group.

Hope this helps.

Just a couple of questions/thoughts:

You do not put much weight in the AHI numbers pre surgery, but you do for success rates (50% drop in numbers was an example). I am not criticizing, but AHI (RDI ) may be the only true way to measure it, right?

Finally, a 50% drop in AHI is just not enough. There are mouth pieces out there that claim 50% reduction in AHI. Someone who is having 40+ events a night will still be in the moderate category. Yes it is a significant improvement, but does that improvement justify the cost, risk and recovery? It sounds like a tough sell.

Quote:

Cowboy, it's understandable that you're getting conflicting information. There's really no consensus in the ENT community as to the best way of managing this condition surgically. As an ENT surgeon myself, here's my take on your situation (and others considering UPPP surgery):

Welcome to the forum. I'm delighted to see this post, as it the first time we have seen a 'professionals' position on the UPPP.

Quote:

We know that CPAP works the best, but only if you use it regularly. Only after you've thoroughly exhausted all your CPAP options, should you consider surgical management. Whenever I see patients for surgical consultation, in most cases, there are a few more things to try with CPAP before considering sleep apnea surgery. One caveat is that a septoplasty, but improving nasal breathing, help with CPAP usefulness and compliance. I spend a lot of time counseling the patient regarding CPAP use, something that seems very lacking in my area (NYC). However, once you arrive at a point where you are considering definitive sleep apnea surgery, there are a number of issues to consider:

Terrific, unfortunately many professionals in sleep medicine don't seem interested in helping patients become compliant with cpap. This is a very positive statement. I don't believe that this lack of counselling is confined to your area. Historically we have had many members claiming great benefit from having a septoplasty to improve their compliance level with cpap.

Quote:

First of all, I look at all the sleep study numbers, but take it with a grain of salt. The mild/moderate/severe categories are confusing and since every sleep lab tests differently, you can't compare apples to oranges. Also, since an apnea or hypopnea is scored only if the breathing pause lasts for greater than 10 seconds, if you stop breathing 35 times every hour and wake up from deep sleep to light sleep, but none last for more than 10 seconds, then your official AHI is 0. This is why when you're younger and thinner, you'll have more of these "short" obstruction that don't show up in the final AHI. Some people call these RERAs (respiratory event related arousals). So whether your score is 6 or 66, I treat the patient and the underlying anatomic areas of narrowing, rather than treating the number.

Your approach here conflicts with the AASM guides, also the accepted norms throughout the world. The categories of OSA are very clearly defined throughout the world. <5 = Normal, >5 <15 = Mild, >15 <30 = Moderate and >30 = Severe. I disagree that sleep labs give different diagnosis...........after all the diagnostic equipment from ResMed/Respironics/DeVilbiss etc, whether shipped to Korea or the US do report the same results. The category numbers are consistent also.............so, I can't see your analogy of 'apples and oranges'. Also, I believe that diagnostic equipment also reports on Hypopnoeas and RERAs..........as they are consistently posted here as part of sleep study reports.

Treating the anatomy only seems strange. We have reports here of sufferers who are not overweight, don't snore, don't have any 'clutter' in their airway......but have OSA.

Quote:

Most ENTs and sleep docs tend to focus way too much on the palate, since that's where the snoring is coming from. But decades of research has shown over and over that you have to consider the entire upper airway, from the tip of the nose to your voice box.

True, but medical research has consistently proven that upper airway surgery is unsuccessful in treating OSA. Particularly once the patient reaches the 2/5 year period post operatively.

Quote:

If you have 2 or 3 areas of obstruction (palate and tongue), then treating the palate alone will not help. This is why the classic UPPP procedure has only a 40% success rate. And yes, "success" means greater than 50% drop in the AHI and the final number has to be under 20. There are many other "success" definitions (which can make the success rates look higher), but this is the most common one.

I believe that a 40% success rate, after say, 3 years (post op) is on the generous side, bearing in mind that the bulk of these figures are coming from the major (non private) hospitals with quite a few of the private hospitals not making any reports..........in my own case, my UPPP was declared a success after 6/8 weeks, a month later my OSA was back, even more severe, than pre op. One must ask the question.......when is a UPPP truly a success ??

Quote:

Based mainly on research at Stanford and man other centers, if you add tongue base surgery, the success rate can go up as high as 75 to 80%. If you add upper and lower jaw advancement surgery, then success is 90-95%.

This figure is very questionable. Messrs Powell & Riley have been practicing multi level surgery for many years.........as soon as one procedure fails they move on to another............taking multi level surgery over a 5/6 year period on this basis something has to work...........but for how long ? IMHO there are no studies, with meaningful numbers of participants, to confirm or deny success/failure.

 

Quote:

A tracheotomy is 100% successful (but not conducive to normal living).

I would have agrred wholeheartedly with this a few years ago, but there are now two members here who have had the trach and are very happy with their progress.

Quote:

So in theory, a 50% drop in your numbers is better than not using your CPAP at all. A recent Veterans study showed that there was no difference in overall long-term survival between a group that underwent UPPP alone vs. CPAP alone. A 40% UPPP success rate is probably equivalent to only about 40% of people using CPAP long-term. Actually, UPPP patients were slightly more likely to be alive at the end of the study, but this was not statistically significant.

The 50% drop in AHI is not guaranteed with the UPPP..........it is a best case scenario.

I think you are twisting the figures here. You are saying that UPPP has a 40% long term success rate (tieing it in with the long term survival of Veterans), and that CPAP has a 40% long term compliance rate........European figures are stating long term compliance rates to CPAP at anywhere between the mid 60% and up to 80%, depending on which country and the level of compliance support given in the particular country.

Quote:

There are ways of predicting whether or not a UPPP alone will work based on your tonsil size and tongue position (Friedman staging), but even this is just a rule of thumb. Here, if you have very large tonsils (3-4+) and a low sitting tongue, then your predicted success rate is about 80%. This is why children do much better after tonsillectomy.

Although I have my own way of performing surgery in every area (nose, palate, and tongue), my philosophy is that it doesn't matter what type of surgery you do, but where you do it and how definitively you do it, that matters most. If you're too concerned about velopharyngeal incompetence (leaking of air or food into your nose), then by being too conservative, you'll still have palatal narrowing, and by doing the more "minimally invasive" tongue procedures, you'll more likely get minimal results. There are caveats and exceptions to all the procedures, but my point is that the more appropriately you address the different levels of collapse, the better your results will be. Complications do occur to a small degree with any surgery, but statistically, you have a higher chance of being run over by a car crossing the street than dying in the operating room. This is were the surgeon's experience matters, not just the total number that's been done, but how well each procedure is performed with good results and minimal complications.

An in-office endoscopic exam by an experienced ENT can usually tell where the obstruction is occurring. He or she should be able to give an objective, quantifiable measure of where and how much narrowing you have in each of the three major areas. If you go to a surgeon that does not perform tongue base procedures routinely, then statistically, you have a 40% chance of success by addressing only the palate. Only by looking can you tell if you're in the small 80% success group.

I agree that the various 'levels of collapse' (sites of obstruction) are important, but you have consistently mentioned the upper airway in this context..........is it not possible to have collapse areas in the lower airway also ?

Finally, while I am not familar with all of the AASM guides........in European countries where clear clinical guidelines are published the use of a UPPP in 'treating' OSA is not recommended, and the basis of this is predominately its very poor success rates.

Once again, I thank you for your views and position on surgical procedures for OSA. It is good to hear from someone with a clear position on this subject.

Daniel.


_________________
The untreated Sleep Apnoea sufferer died quietly in his sleep.......
Unlike his three passengers who died screaming !!!!!!

(Anon)

RAM_SLEEP, all valid comments and criticism of how surgeons define success. Believe me, I as a surgeon want that number to drop as much as possible, since that's the most objective way of measuring success. It's truly gratifying after surgery to see someone go from the 50s or 60s to the single digits. In most cases, the patient feels significantly better, but in some cases, even when the number drops significantly, the patient feels no different. In some other cases, the number doesn't change or drops only a few points, but the patient feels great. What this implies is that there are variables other than the AHI that determines objective and subjective success.

The 50% decrease rule is in addition to the final number less than 20. So if you start at 76 and drop to 19, then most people will feel much better. But what if you start at 11? Dropping down to 5, will probably not give great results. The AHI is only one measure of breathing disturbances. There are less severe breathing pauses or diminished airflow that never get counted in the AHI (called RERAs, or respiratory event related arousals). Sometimes, the AHI remains the same, but the patient feels much better due to the fact that the many of the apneas have turned into hypopneas. There's even research suggesting that you can have subtle subcortical micro-arousals that fragment deep sleep, where the signal changes don't ever rise to the outer cortical areas of the brain.

As for your latter comments, as a surgeon, I never try to "sell" anyone surgery. It's a big decision that's made after a long, comprehensive process, reached only after exhausting CPAP to the  fullest. The vast majority of patients sent to me for surgical consultation by sleep doctors are not good candidates, not because of anatomic reasons, but there's always a few more things that they can try with CPAP or dental devices. Sometimes I offer a septoplasty to improve breathing and to make CPAP use easier. Most people need a lot of counseling to make major changes in their lifestyle, what they eat, when they eat, and exercise routines. I also integrate yoga-based breathing techniques to calm the over-stressed nervous system, and sometime incorporate acupuncture as well. Although the basic reasons for sleep apnea are similar (small jaws), every patient is unique and had different needs and expectations. The course of treatment should be individualized, rather than to use a published algorithm.

Regarding the cost, there are many studies showing that treating sleep apnea lowers the long-term economic cost. This assumes that you are treating effectively, whether it's CPAP, a dental device or surgery. I do agree with the literature that with good counseling and frequent follow-up, CPAP compliance can be good, but in practice, many people are unable to use CPAP, and even if they do use it, they'll stop using it after a period of time. Our health care system is not designed to provide this level of intensive counseling and follow-up. This may be a cynical statement, but I bet that most CPAP machines are stored in the closets or returned after a period of non-use. There's too much emphasis on the newest gadgets or features of the newest CPAP machines without focusing on good follow-up, proper counseling, and good customer service.

As for the risk and recovery, it seems like it's a given on these posts that everyone will undergo a horrendous, painful experience with multiple complications. If I were a patient reading these forums, I would probably go against surgery of any type. Believe me, when I first started learning these procedures as a resident, there was a lot of pain, bleeding and airway complications with low success rates. But once I understood that one has to address the entire airway from the tip of the nose to the voice-box, my success rates went up, and by constantly looking for lesser invasive and less traumatic ways of doing surgery, my patient's reactions to the surgery have been overall very positive. Since using the Coblator wand to perform UPPPs for the past few years, pain and discomfort has lessened as well.

Hi sypark,

This question may not be related to this post, how long can velopharyngeal incompetence (leaking of air or food into your nose) last after sleep apnea surgery ?

My husband had the following done 20 days back - UPPP, tonsillectomy, septoplasty, turbinate reduction, genioglossus advancement. His main complaint now is that food goes up through the nose. Will this take a while to go away ?

Thanks in advance!

PS: he hasn't started using cpap after the surgery, he still has quite a bit of swelling left, but in spite of that he is sleeping a lot better. I can make that out from his mood :)

Daniel,

Thanks for your thoughtful comments. It's clear you are more knowledgeable about these issues more than most doctors (unless you are a doctor). I haven't learned you how to take snippets and comment like you did (can you tell me how you did that?), so here's an abbreviated response:

You are absolutely right about the criteria set for defining mild/moderate/severe OSA. But my point is that not everyone with an index of 70 will feel the same way. I've seen many people with a very high index that are otherwise completely healthy with no symptoms whatsoever, and many others with very mild numbers who are very symptomatic. Yes, we need to address the numbers from an objective standpoint, but it should be looked at in context of the entire person, not just as a number to be lowered.

In theory, all the labs have standardized equipment, so in theory all the numbers should be consistent, but in clinical practice, I see wide variations among a number the the local centers that I use, all which are AASM certified.

When I mean treating the anatomy, I mean addressing the appropriate levels of obstruction, and not just focusing on the soft palate. My belief is that ultimately the problem starts with smaller than normal jaws. Due to human's ability to talk, our airways are unprotected. We're the only animals that can choke and die, and the only mammals that get impacted molars. But due to gradual narrowing of our jaws in the last few hundred years, more people are susceptible to sleep breathing problems. This is thought to be due to a shift in our diets to more processed foods and refined sugars. Another interesting theory is that bottle-feeding prevents proper jaw widening during infanthood. This is also a modern phenomenon. Later on, these people are more susceptible to weight gain due to inefficient sleep, leading to the classic OSA patient. But more and more, these days, I'm seeing young, thin women that don't snore with upper airway resistance syndrome or mild OSA. These are the patients that respond best to surgery, without the obesity factor. Almost invariably, one or both parents will have OSA. Due to their hypersensitive nervous systems, many can't tolerate CPAP or dental devices.

Regarding CPAP compliance, I think that what we see in published reports is unrealistic. In my practice and in the real world, I think the numbers are much lower. Perhaps it's because I see all the people that can't use CPAP or dental devices. All the studies also enroll people who are willing to try CPAP, and they follow them rigorously. What I'm seeing in my area is that many patients refuse to even try CPAP. I get patients sent to me by sleep doctors for surgical evaluation even before trying CPAP. Usually I'll send them back to try CPAP first.

Powell and Reily and many other published studies report anywhere from 75 to 80% (surgical) success using one stage, multi-level (palate and tongue) surgery. It's not multi-stage. Of the ones that fail, they are offered maxillo-mandibular advancement, which has a well over 90% success rate. In my experience, people who undergo surgery successfully continue to stay well, as long as they don't gain weight.

Lastly, yes, there can be lower airway obstruction, but just below the vocal cords, there are cartilaginous rings, which are more difficult to collapse as opposed to the tongue falling back into the oropharynx.

I totally agree that UPPP alone is not a great solution for OSA. But my point is that in carefully selected patients who have exhausted or refused all their non-surgical options, multilevel surgery should be an option in the hands of an experienced surgeon.

Looking forward to all your further comments....

SK,

I've never seen permanent palatal leaking (also called velo-pharyngeal incompetence, or VPI), but temporary VPI is very common. In my experience, it goes away in a few weeks, and rarely a few months. Historically, there's only a 1-2% chance of permanent leakage.  The immediate results sound promising. Good luck.