title: The efficacy of multilevel surgery of the upper airway in adults with obstructive sleep apnea/hypopnea syndrome.
abstract: OBJECTIVE
  Many patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) are incapable of using continuous positive airway pressure. These patients therefore turn to surgical options as a salvage treatment. Early studies and reviews focused on the efficacy of uvulopalatopharyngoplasty, a single-level procedure for the treatment of OSAHS. Since OSAHS is usually caused by multilevel obstructions, the true focus on efficacy should be on multilevel surgical intervention. The purpose of this paper is to provide an overview of the literature on multilevel surgery for OSAHS patients.
  
  
  METHODS
  Systematic review of the literature and meta-analysis focusing on subjective and objective outcomes of patients with OSAHS treated with multilevel surgery of the upper airway.
  
  
  METHODS
  We searched PubMed, the Cochrane database, and MEDLINE bibliographic databases up to March 31, 2007, for studies dealing with multilevel surgical modification of the upper airway for the treatment of OSAHS. Additional studies were identified from their reference lists. Articles were included only if the surgical intervention involved at least two of the frequently involved anatomic sites: nose, oropharynx, and hypopharynx.
  
  
  RESULTS
  After applying specific inclusion criteria, 49 multilevel surgery articles (58 groups) were identified. There were 1,978 patients included in the study. The mean minimal follow-up time was 7.3 months (range, 1 to 100 months). A meta-analysis was performed to redefine the success rate to be consistent with the commonly agreed upon criteria, namely "a reduction in the apnea/ hypopnea index (AHI) of 50% or more and an AHI of less than 20." "Success" implies an improved condition and is not meant to imply cure. The recalculated success rate was 66.4%. The overall complication rate was 14.6%. The evidence-base medicine (EBM) level of these 49 studies revealed that only one study was EBM level 1, two papers were EBM level 3, and the other 46 papers were ranked as level 4 evidence.
  
  
  CONCLUSIONS
  Multilevel surgery for OSAHS is obviously associated with improved outcomes, although this benefit is supported largely by level 4 evidence. Future research should focus on prospective and controlled studies.
authors.affiliation: Department of Otolaryngology, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan.
authors.forename: Hsin-Ching
authors.initials: HC
authors.lastname: Lin
authors.forename: Michael
authors.initials: M
authors.lastname: Friedman
authors.forename: Hsueh-Wen
authors.initials: HW
authors.lastname: Chang
authors.forename: Berk
authors.initials: B
authors.lastname: Gurpinar
mesh_terms: D000328:Adult; D045422:Continuous Positive Airway Pressure / Q000379:methods; D005500:Follow-Up Studies; D006801:Humans; D008875:Middle Aged; D013517:Otorhinolaryngologic Surgical Procedures / Q000379:methods*; D020181:Sleep Apnea, Obstructive / Q000601:surgery* / Q000628:therapy; D016896:Treatment Outcome