What are the surgical and non-surgical treatment options for Upper Airway Resistance Syndrome (UARS)?

Treatment Options for Upper Airway Resistance Syndrome (UARS)

First-Line Treatment: Nasal CPAP

Nasal continuous positive airway pressure (CPAP) is the most efficacious therapy for UARS, though patient compliance remains a significant limitation. 1

• CPAP effectively reduces respiratory effort-related arousals and improves daytime somnolence in UARS patients 1, 2
• Treatment should include comprehensive optimization with mask refitting, pressure adjustments, and heated humidification before declaring failure 3
• Educational and behavioral interventions should accompany CPAP initiation to improve adherence 3

Non-Surgical Treatment Options

Oral Appliances (Mandibular Advancement Devices)

Oral appliances represent an effective alternative for UARS patients who cannot tolerate CPAP, with strong evidence supporting their use. 4

• Mandibular advancement devices significantly improve Epworth Sleepiness Scale scores (p<0.0001), arousal index (p<0.0001), and sleep efficiency (p<0.005) in UARS patients 4
• These devices also improve minimal oxygen saturation (p<0.005) and multiple sleep latency test results (p<0.0005) 4
• Oral appliances are recommended for mild to moderate sleep-disordered breathing when CPAP is not tolerated (Grade A recommendation) 5
• Contraindications include severe periodontal disease, severe temporomandibular disorders, inadequate dentition, and severe gag reflex 3

Positional Therapy

• Sleep position significantly affects respiratory parameters in UARS, with lateral positioning reducing AHI compared to supine position (p=0.0001) 6
• Positional therapy yields moderate reductions in respiratory disturbances but is clearly inferior to CPAP and has poor long-term compliance 5
• This approach should only be considered in carefully selected patients with documented position-dependent symptoms 5

Nasal Interventions

External nasal dilation provides modest benefits in UARS by reducing stage 1 sleep and desaturation time. 6

• External nasal dilators significantly increase nasal cross-sectional area (p<0.001) and reduce stage 1 sleep from 8.6% to 7.1% (p=0.034) 6
• Desaturation time decreases from 12.2% to 9.1% with nasal dilation (p=0.04) 6
• However, nasal dilators alone are not recommended as primary treatment for sleep-disordered breathing 5

Surgical Treatment Options

Nasal Surgery

Nasal surgery as a single intervention is not recommended for treatment of UARS, but may facilitate CPAP tolerance when anatomical nasal obstruction is present. 5

• Nasal surgery (septoplasty, turbinate reduction) is recommended specifically for reducing high therapeutic CPAP pressure due to nasal obstruction (Grade C) 5
• Among patients with anatomical nasal obstruction preventing PAP use, evaluation for nasal surgery is appropriate 7
• The primary goal is enabling CPAP tolerance by correcting obstruction, not curing sleep-disordered breathing with surgery alone 7

Tonsillectomy

• Tonsillectomy as single therapy can be recommended for treatment when tonsillar hypertrophy is present (Grade C) 5
• Tonsillar hypertrophy shows the highest correlation with disease severity among anatomical alterations 5
• Recent studies demonstrate consistent and significant improvements in respiratory parameters after tonsillectomy, though residual sleep-disordered breathing often persists 5

Radiofrequency Thermal Ablation

Radiofrequency ablation of palatal tissue shows promise but requires further validation before routine recommendation. 1, 2

• Radiofrequency surgery of the soft palate may only be considered in patients with mild disease refusing or not requiring CPAP, when individual anatomy appears suitable (Grade C) 5
• This approach cannot be recommended except in carefully selected patients due to insufficient evidence 5
• Do not pursue radiofrequency ablation of the lateral nasal wall, as it has insufficient evidence and is categorized as "unproven" 7

Procedures NOT Recommended

Laser-assisted uvulopalatoplasty has strong negative evidence and should not be performed for UARS. 5

• Laser-assisted uvulopalatoplasty demonstrates no significant effect on sleep-disordered breathing severity, symptoms, or quality of life (Grade B negative recommendation) 5
• Isolated uvulectomy should not be pursued due to lack of demonstrated efficacy 7
• Uvulopalatopharyngoplasty (UPPP) as single-level surgery is effective only in highly selected patients with obstruction limited to the oropharyngeal area, with frequent long-term side-effects including velopharyngeal insufficiency, dry throat, and abnormal swallowing (Grade C) 5

Advanced Surgical Options

• Internal jaw distraction osteogenesis represents a promising treatment option for UARS patients with intact local neurologic systems 8
• Hypoglossal nerve stimulation is reserved for obstructive sleep apnea with specific criteria (AHI 15-65, BMI <32 kg/m²) and is not typically indicated for UARS 3

Treatment Algorithm

1. Initial approach: Trial of nasal CPAP with comprehensive optimization including mask fitting, pressure titration, heated humidification, and behavioral interventions 3, 1

2. If CPAP intolerant: Consider oral appliance (mandibular advancement device) as primary alternative, particularly effective in UARS population 4

3. If anatomical nasal obstruction present: Evaluate for nasal surgery (septoplasty, turbinate reduction) to facilitate CPAP tolerance 5, 7

4. If tonsillar hypertrophy present: Consider tonsillectomy as adjunctive or primary surgical intervention 5

5. Adjunctive measures: Positional therapy for position-dependent symptoms, external nasal dilation for mild symptomatic improvement 6

Common Pitfalls to Avoid

• Do not declare CPAP failure without documented trials of multiple mask types, pressure adjustments, and heated humidification 3
• Do not pursue laser-assisted uvulopalatoplasty or isolated uvulectomy, as these have strong negative evidence 5, 7
• Do not assume nasal surgery alone will cure UARS; its role is facilitating CPAP tolerance 5, 7
• Do not overlook the presentation of UARS as functional somatic syndrome, as most patients are initially seen by psychiatrists rather than sleep specialists 8
• Ensure polysomnography includes esophageal manometry and pneumotachographic airflow measurements, which represent the gold standard for UARS diagnosis 1