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Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults

BMJ 2008; 336 doi: (Published 03 January 2008) Cite this as: BMJ 2008;336:44
  1. Adam G Elshaug, lecturer1,
  2. John R Moss, associate professor and head1,
  3. Janet E Hiller, professor of public health1,
  4. Guy J Maddern, director of surgery2
  1. 1Discipline of Public Health, University of Adelaide, SA 5005, Australia
  2. 2Queen Elizabeth Hospital, Woodville, SA 5011, Australia
  1. Correspondence to: A Elshaug adam.elshaug{at}

    Key points

    • Upper airway surgery for obstructive sleep apnoea in adults is resource intensive with low and inconsistent clinical effectiveness

    • Continuous positive airway pressure (CPAP) plus conservative weight and alcohol management should be first line treatment

    • When CPAP treatment fails, mandibular advancement devices may be considered (with conservative management) as second line treatment

    • Surgery for obstructive sleep apnoea should be done within controlled clinical trials; patients should be informed about the trial, as well as of the inconsistent results of surgery, its potential side effects, and the potential for relapse

    The clinical problem

    The prevalence of obstructive sleep apnoea in high income countries is estimated to be 20% for mild disease and 6-7% for moderate or severe disease. The condition is associated with multiple morbidities, motor vehicle crashes, and reduced health related quality of life.1 Clinical guidelines recommend continuous positive airway pressure (CPAP) with weight and alcohol management (if indicated) as first line treatment for symptomatic, moderate to severe obstructive sleep apnoea.2 3 Upper airway surgery (such as uvulopalatopharyngoplasty) may also be done, but evidence does not support its use.4 However, use of surgical procedures is widespread and increasing in Australia and elsewhere (such as the Nordic countries).5 6 We propose that upper airway surgery should not be first line treatment for obstructive …

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