A side note about success: One of the biggest frustrations is that people use different definitions of success. The most commonly used definition in our field is a greater than 50% drop in the AHI, and that final number has to be less than 20. Unfortunately, many studies vary significantly from this definition, and others use very unorthodox ways of defining success.

 

Over the years, researchers have discovered that in cases where a UPPP fails, the tongue is the main culprit. Once the tongue collapse is addressed as well, the "success" rate increases to ~75%. Many subsequent studies report success rates in the 70-80% range.

 

There are many variation of  UPPP, some more invasive and other less invasive. Most surgeons will agree that the most important factor is that the procedure is performed properly in the appropriately selected patient. If sleep apnea remains despite a properly performed UPPP, in most cases it means that there may be tongue base collapse. If there was any suspicion of tongue collapse before the operation, then this issue must be discussed beforehand, not afterwards.

 

A recent tool used to guide surgeons in predicting whether a UPPP alone has a high likelihood for surgical success (> 50% drop in the AHI and the AHI is less than 20) was described by Dr. Michael Friedman in Chicago. Basically, if you have large tonsils and you can see some or all of you uvula (the thing hanging down the middle of the back you your throat), then you have about an 80% chance of success. This does not apply if you are mobidly obese. The remainder have about a 40% chance of success, which is consistent with the overall success rates for UPPP in other studies.

 

I use this as a guide only and don’t take it literally. In general, if you still have you tonsils, and they are very large, and if your tongue does not cover up you uvula, then you are a good candidate for a UPPP. If not, then either you have to go try CPAP, or a MAD (in select patients), or address tongue collapse the same time as the palate.

 

There are some strong opinions on the UPPP procedure amongst physicians, as well as by the lay public. Some say that the UPPP should never be done, and others say that CPAP compliance is extremely poor, and surgery is the only option.

My approach to this issue is as follows: One has to individualize the treatment approach based on the patient’s situation. Obviously, non-surgical options have to be tried first, but to say surgery never works is not an accurate statement. The only reason I continue to offer surgical options to my patients is due to the numerous numbers of patients that have their lives changed completely from a surgical procedure after failing conservative options.

 

Of all the CPAP compliance studies performed to date, I vaguely remember one study that found CPAP compliance to be about 40% (they vary from  40-70%). If UPPP success rate is 40%, then I would say they are equal. With UPPP, you have 100% compliance and 40% success, but with CPAP, you have 100% success (in theory) with 40% compliance. An interesting discussion, indeed. If you add tongue procedures, surgery may seem the better option. But again, surgery is not for everyone.