Surgery for obstructive sleep apnoea in adults

Supriya Sundaram; Jerome Lim; Toby J Lasserson

doi:10.1002/14651858.CD001004.pub2

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Figure 1

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

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Analysis 1.1

Comparison 1 TCRFTA versus sham TCRFTA, Outcome 1 Change from baseline in AHI.

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Analysis 1.2

Comparison 1 TCRFTA versus sham TCRFTA, Outcome 2 Change from baseline in Epworth sleepiness score.

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Analysis 1.3

Comparison 1 TCRFTA versus sham TCRFTA, Outcome 3 Change from baseline in quality of life (Functional Outcome of Sleep Questionnaire).

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Analysis 1.4

Comparison 1 TCRFTA versus sham TCRFTA, Outcome 4 Pain @ 1 week (VAS score).

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Analysis 1.5

Comparison 1 TCRFTA versus sham TCRFTA, Outcome 5 Pain @ 3 weeks (VAS score).

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Analysis 2.1

Comparison 2 Laser assisted UP versus conservative management, Outcome 1 AHI.

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Analysis 2.2

Comparison 2 Laser assisted UP versus conservative management, Outcome 2 Epworth sleepiness score.

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Analysis 2.3

Comparison 2 Laser assisted UP versus conservative management, Outcome 3 Quality of life (sleep apnoea quality of life index).

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Analysis 2.4

Comparison 2 Laser assisted UP versus conservative management, Outcome 4 Snoring intensity (VAS).

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Analysis 2.5

Comparison 2 Laser assisted UP versus conservative management, Outcome 5 Snoring frequency score (VAS).

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Analysis 2.6

Comparison 2 Laser assisted UP versus conservative management, Outcome 6 Withdrawals.

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Analysis 2.7

Comparison 2 Laser assisted UP versus conservative management, Outcome 7 Dysphagia.

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Analysis 2.8

Comparison 2 Laser assisted UP versus conservative management, Outcome 8 Infection.

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Analysis 2.9

Comparison 2 Laser assisted UP versus conservative management, Outcome 9 Bleeding (mild‐severe).

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Analysis 2.10

Comparison 2 Laser assisted UP versus conservative management, Outcome 10 Pain.

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Analysis 2.11

Comparison 2 Laser assisted UP versus conservative management, Outcome 11 Nasal regurgitation.

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Analysis 3.1

Comparison 3 UPPP versus conservative management, Outcome 1 Excessive daytime sleepiness (VAS).

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Analysis 3.2

Comparison 3 UPPP versus conservative management, Outcome 2 Falling asleep when not in bed.

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Analysis 3.3

Comparison 3 UPPP versus conservative management, Outcome 3 ODI4.

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Analysis 3.4

Comparison 3 UPPP versus conservative management, Outcome 4 ODI10.

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Analysis 3.5

Comparison 3 UPPP versus conservative management, Outcome 5 Withdrawals.

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Analysis 3.6

Comparison 3 UPPP versus conservative management, Outcome 6 Dysphagia.

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Analysis 4.1

Comparison 4 Palatal implants versus placebo, Outcome 1 Mean change in AHI.

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Analysis 4.2

Comparison 4 Palatal implants versus placebo, Outcome 2 Mean change in Epworth sleepiness scores.

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Analysis 4.3

Comparison 4 Palatal implants versus placebo, Outcome 3 Change from baseline in quality of life (SF‐36).

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Analysis 4.4

Comparison 4 Palatal implants versus placebo, Outcome 4 Loss to follow‐up.

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Analysis 5.1

Comparison 5 UPPP versus oral appliance therapy, Outcome 1 Apnoea Hypopnea Index.

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Analysis 5.2

Comparison 5 UPPP versus oral appliance therapy, Outcome 2 Quality of life: Vitality.

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Analysis 5.3

Comparison 5 UPPP versus oral appliance therapy, Outcome 3 Quality of life: Contentment.

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Analysis 5.4

Comparison 5 UPPP versus oral appliance therapy, Outcome 4 Quality of life: Sleep.

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Analysis 5.5

Comparison 5 UPPP versus oral appliance therapy, Outcome 5 Oxygen desaturation index.

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Analysis 5.6

Comparison 5 UPPP versus oral appliance therapy, Outcome 6 Withdrawals.

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Analysis 5.7

Comparison 5 UPPP versus oral appliance therapy, Outcome 7 Dysphagia.

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Analysis 5.8

Comparison 5 UPPP versus oral appliance therapy, Outcome 8 Nasopharyngeal regurgitation.

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Analysis 5.9

Comparison 5 UPPP versus oral appliance therapy, Outcome 9 Repeated adjustment.

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Analysis 6.1

Comparison 6 TCRFTA versus CPAP, Outcome 1 Mean change from baseline in Apnoea Hypopnea Index.

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Analysis 6.2

Comparison 6 TCRFTA versus CPAP, Outcome 2 Mean change from baseline in Epworth Sleepiness Score.

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Analysis 6.3

Comparison 6 TCRFTA versus CPAP, Outcome 3 Quality of life (Functional Outcomes of Sleep Questionnaire).

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Analysis 6.4

Comparison 6 TCRFTA versus CPAP, Outcome 4 Withdrawals/loss to follow‐up.

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Analysis 7.1

Comparison 7 UPPP versus lateral PP, Outcome 1 AHI.

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Analysis 7.2

Comparison 7 UPPP versus lateral PP, Outcome 2 Change in AHI from baseline.

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Analysis 7.3

Comparison 7 UPPP versus lateral PP, Outcome 3 Nasal regurgitation.

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Analysis 7.4

Comparison 7 UPPP versus lateral PP, Outcome 4 Withdrawals.

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Analysis 8.1

Comparison 8 Tongue advancement + palatopharyngoplasty versus tongue suspension + palatopharyngoplasty, Outcome 1 Epworth sleepiness scores.

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Analysis 9.1

Comparison 9 RAUP versus submucosal channeling technique, Outcome 1 Reduction in AHI below 10.

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Analysis 9.2

Comparison 9 RAUP versus submucosal channeling technique, Outcome 2 Pain score.

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Analysis 9.3

Comparison 9 RAUP versus submucosal channeling technique, Outcome 3 Dysphagia.

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Analysis 10.1

Comparison 10 Expansion sphincter pharyngoplasty (ESP) versus UPPP, Outcome 1 AHI.

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Table 1. Search history

Search dates	References
Initial version of the review	A total of 594 articles were identified through electronic searching, 44 through correspondence and a further 28 through hand‐searching reference lists. Of these, 656 articles were excluded because of the following non‐inclusive reasons: did not focus on sleep apnoea (n=134); did not look at surgical interventions (n=328); obviously not an RCT (overviews, letters, case series etc.) (n=194). Ten articles, for which full text reports were obtained, were assessed for inclusion by both reviewers. All of these articles were excluded, five because they were descriptions of a surgical procedure, reviews or letters, four because they were not intervention studies and one was not about sleep apnoea. There was no disagreement on final inclusion/exclusion of studies.
Update ‐ July 2004	An update search was conducted in July 2004. 110 references identified; 15 retrieved for further scrutiny. Seven studies met the inclusion criteria (Lojander 1996; Tegelberg 1999; Ferguson 2003; Cahali 2003; Naya 2002; Woodson 2003, Thomas 2003). One non‐English language article is awaiting assessment. Seven studies failed to meet the inclusion criteria of the review
Update ‐ July 2005	An update search was conducted in July 2005. 20 references were identified and two studies were retrieved for additional scrutiny. Of these, one trial met the inclusion criteria (Larrosa 2004) and another pertains to an ongoing study (Tommi 2004). Both studies have a sham surgical procedure as a control arm.
Update ‐ July 2006	A total of 10 references were identified from electronic literature searches. Three of these were obtained as full‐text papers. Two studies failed to meet the entry criteria of the review, and a further study is awaiting assessment. One new trial of 150 participants met the entry criteria of the review (Atef 2005).
Update ‐ July 2007	A total of 11 references were identified from electronic literature searches. One was retrieved as full‐text and met the entry criteria of the review. This study added data from 40 participants (Bassiouny 2007).

Table 1. Search history

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Comparison 1. TCRFTA versus sham TCRFTA

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Change from baseline in AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Change from baseline in Epworth sleepiness score Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Change from baseline in quality of life (Functional Outcome of Sleep Questionnaire) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Pain @ 1 week (VAS score) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Pain @ 3 weeks (VAS score) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 1. TCRFTA versus sham TCRFTA

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Comparison 2. Laser assisted UP versus conservative management

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Epworth sleepiness score Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Quality of life (sleep apnoea quality of life index) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Snoring intensity (VAS) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Snoring frequency score (VAS) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

6 Withdrawals Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7 Dysphagia Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 Infection Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9 Bleeding (mild‐severe) Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

10 Pain Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

11 Nasal regurgitation Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 2. Laser assisted UP versus conservative management

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Comparison 3. UPPP versus conservative management

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Excessive daytime sleepiness (VAS) Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Falling asleep when not in bed Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

3 ODI4 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 ODI10 Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Withdrawals Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

6 Dysphagia Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 3. UPPP versus conservative management

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Comparison 4. Palatal implants versus placebo

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean change in AHI Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

2 Mean change in Epworth sleepiness scores Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

3 Change from baseline in quality of life (SF‐36) Show forest plot	1		Mean Difference (Fixed, 95% CI)	Totals not selected

4 Loss to follow‐up Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 4. Palatal implants versus placebo

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Comparison 5. UPPP versus oral appliance therapy

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Apnoea Hypopnea Index Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

1.1 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.2 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
1.3 4 years	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
2 Quality of life: Vitality Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Quality of life: Contentment Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

4 Quality of life: Sleep Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5 Oxygen desaturation index Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

5.1 6 months	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.2 1 year	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
5.3 4 years	1		Mean Difference (IV, Fixed, 95% CI)	0.0 [0.0, 0.0]
6 Withdrawals Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

7 Dysphagia Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

8 Nasopharyngeal regurgitation Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

9 Repeated adjustment Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 5. UPPP versus oral appliance therapy

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Comparison 6. TCRFTA versus CPAP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mean change from baseline in Apnoea Hypopnea Index Show forest plot	1		Events/hr (Fixed, 95% CI)	Totals not selected

2 Mean change from baseline in Epworth Sleepiness Score Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Quality of life (Functional Outcomes of Sleep Questionnaire) Show forest plot	1		QoL (Fixed, 95% CI)	Totals not selected

4 Withdrawals/loss to follow‐up Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 6. TCRFTA versus CPAP

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Comparison 7. UPPP versus lateral PP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

2 Change in AHI from baseline Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Nasal regurgitation Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

4 Withdrawals Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

Comparison 7. UPPP versus lateral PP

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Comparison 8. Tongue advancement + palatopharyngoplasty versus tongue suspension + palatopharyngoplasty

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Epworth sleepiness scores Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 8. Tongue advancement + palatopharyngoplasty versus tongue suspension + palatopharyngoplasty

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Comparison 9. RAUP versus submucosal channeling technique

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Reduction in AHI below 10 Show forest plot	1		Odds Ratio (M‐H, Fixed, 95% CI)	Totals not selected

2 Pain score Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

3 Dysphagia Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 9. RAUP versus submucosal channeling technique

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Comparison 10. Expansion sphincter pharyngoplasty (ESP) versus UPPP

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 AHI Show forest plot	1		Mean Difference (IV, Fixed, 95% CI)	Totals not selected

Comparison 10. Expansion sphincter pharyngoplasty (ESP) versus UPPP

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