Tonsillectomy alternative to Modified uvulopalatopharyngoplasty for selective patients with OSA: TEAMUP Study

The first line of treatment is nonsurgical, with continuous positive airway pressure (CPAP) or a mandibular retaining device (MRD). These approaches are often effective, but adherence to treatment remains a challenge because many patients use them insufficiently or not at all. For these patients, pharyngeal surgery may be an option, as recommended in a recent review by the American Academy of Sleep Medicine (AASM).

A common surgical procedure for OSA is uvulopalatopharyngoplasty (UPPP). Although different definitions exist, UPPP usually includes a tonsillectomy (TE) and a uvulopalatoplasty: suturing the palatal pillars and reducing the size of the uvula. Some early UPPP techniques extensively reduced the palatal tissues and were associated with significant adverse effects.

In children, TE alone is the standard treatment for OSA and is often effective. However, in adults, TE alone has traditionally not been considered an alternative for sleep apnea surgery, probably as tonsil hypertrophy is unusual in adults. Because mUPPP is expected to widen the airways by suturing the palatal pillars and the palatopharyngeus muscle laterally and is performed in addition to a TE, authors Joar Sundman and team presumed it to be a more effective treatment than a TE alone. They carried a RCT that aimed to compare the effectiveness of mUPPP with that of TE among a population of selected patients with medium to large tonsils (sizes 2, 3, or 4, per the Friedman scale) and moderate to severe OSA—the hypothesis being that the results of mUPPP would be superior to those of TE alone.

This blinded randomized clinical trial compared the effectiveness of mUPPP with TE alone before surgery and 6 months postsurgery in adults with tonsillar hypertrophy (sizes 2, 3, or 4 according to the Friedman staging) and moderate to severe OSA in a university hospital in Stockholm, Sweden. Participants underwent surgery from January 2016 to February 2021; the last postsurgery follow-up was completed in September 2021. Data analyses were performed from January to September 2022.

The study cohort comprised 93 with a mean (SD) body mass index of 29.0 (2.8). Of these, 90 participants (97%) completed the protocol (mUPPP, n = 45; TE, n = 45). The mean (SD) AHI score (number of events per hour [events/h]) for the mUPPP group decreased by 43%, from 51.0 (22.6) to 28.0 (20.0) events/h; and for the TE group, 56%, from 56.9 (25.1) to 24.7 (22.6) events/h. 

The mean between-group difference in AHI score was 9.2 events/h (95% CI, 0.5 to 17.9), with a small effect size (Cohen d = 0.44) in favor of TE. For ESS scores, the between-group difference was also small, only 1.1 (95% CI, –1.3 to 3.4; Cohen d = 0.21). Neither difference was considered to be clinically relevant.

This RCT compared mUPPP with TE alone to treat moderate to severe OSA in patients with tonsillar hypertrophy, with the hypothesis that mUPPP is superior to TE alone in improving nocturnal respiration and daytime sleepiness. Although this study could not verify this hypothesis, the results showed a small difference in effect size in favor of TE. Because TE alone is also a more conservative procedure than mUPPP, TE could be considered an alternative to mUPPP in patients with tonsillar hypertrophy (sizes 2, 3, or 4).

This RCT did not confirm our hypothesis that mUPPP is more effective than TE alone in treating patients tonsillar hypertrophy and moderate to severe OSA to treat nocturnal respiration and daytime sleepiness. Instead, there was a small difference in favor of TE. Because TE alone is a less extensive procedure than mUPPP, TE could be considered an alternative for this selected group of patients with OSA; however, further studies, including long-term evaluations, are needed.

Source: Joar Sundman, MD, PhD; Pia Nerfeldt, MD, PhD; Johan Fehrm,; JAMA Otolaryngol Head Neck Surg. doi:10.1001/jamaoto.2022.3432