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Study Objective: Our objective was to determine whether baseline polysomnography, cephalometry, and anthropometry data could predict uvulopalatopharyngoplasty (UPPP) success or failure., Design: We retrospectively reviewed polysomnography, cephalometry, and anthropometry data from patients who underwent UPPP for obstructive sleep apnea (OSA)., Setting: A university medical center., Patients: OSA was diagnosed by polysomnography in 46 patients who underwent UPPP surgery for their sleep disorder., Interventions: UPPP surgery with/or without tonsillectomy., Measurements and Results: The mean patient age was 43 years, and the mean body mass index was 32.5 kg/m(2). The mean presurgical apnea-hypopnea index (AHI) was 45, and the mean baseline nadir oxygen saturation was 81%. Successful surgery was defined as a reduction in AHI to < 10 or to < 20 with a 50% reduction from the patient's baseline AHI. Of the 46 patients, 16 were successfully treated and 30 did not respond to surgical treatment. A mandibular-hyoid distance (MP-H) > 20 mm was found to be significantly (p = 0.05) predictive of failure of UPPP. When stepwise regression analysis was performed utilizing postsurgical AHI as the dependent variable and presurgical AHI, age, body mass index, baseline nadir O(2) saturation, and five cephalometric measurements as independent variables, MP-H distance significantly (r = 0.524; p = 0.01) correlated positively with postsurgical AHI. The distance between the superior point of a line-constructed plane of the sphenoidale (parallel to Frankfort horizontal) and a point at the intersection of the palatal plane perpendicular to the hyoid correlated negatively with postsurgical AHI (r = 0.586; p = 0.05). By creating a logistic model of this data, an MP-H distance < 21 mm, an angle created by point A to the nasion to point B < 3 degrees, and the presence of a baseline AHI < 38 enhanced the predictability of UPPP success., Conclusions: The presence of a baseline AHI < 38 and an MP-H < or = 20 mm, and the absence of retrognathia are predictors of improvement after UPPP. Based on these findings, we would advocate the continued evaluation of cephalometric measurements and careful consideration of surgical treatment options for OSA.

Objective: To report the efficacy of maxillomandibular advancement (MMA) surgery, with a description of several innovations, as a site-specific treatment of obstructive sleep apnea syndrome (OSAS) in selected cases with disproportionate velo-orohypopharyngeal anatomy., Design: Clinical series of 50 consecutive cases., Setting: Surgery was performed in a hospital operating room, and perioperative management was provided in an intensive care environment. Except for polysomnography (PSG), which was performed and interpreted by independent sleep facilities/physicians, all pre- and postoperative evaluations were accomplished in a solo office private practice setting., Patients: Patients were referred for MMA evaluation when applicable conservative therapies such as nasal continuous positive airway pressure (nCPAP) were not tolerated, refused, or unsuccessful. Case selection was based primarily on the sites of disproportionate upper airway anatomy., Interventions: MMA consisted of a Lefort I osteotomy, bilateral sagittal split ramus osteotomies, and a new modified procedure called an anterior inferior mandibular osteotomy with indirect hyoid suspension. Some patients also received concomitant adjunctive nonpharyngeal procedures., Measurements and Results: Obtained at a mean of 5.2 months postoperatively, revealed significant improvement in all cases. Mean BPs (n = 50) were lowered, subjective symptoms were ameliorated, and mean body mass index (n = 50) was reduced. Cephalometric analysis (n = 50), with several new modifications including standardization for phases of respiration, quantified structural changes in soft-tissue and bony landmarks. Postoperative PSG results (n = 50) showed dramatic improvement over preoperative data (n = 50), with therapeutic values similar to nCPAP (n = 42). Mean values improved from preoperative to postoperative vs nCPAP for apnea index (34.5 to 1.0 vs 2.0, respectively), apnea-hypopnea index (59.2 to 4.7 vs 5.4, respectively), lowest arterial oxyhemoglobin desaturations (72.7% to 88.6% vs 88.6%, respectively), and number of desaturations < 90% (118.8 to 6.6 vs 2.4, respectively). The success rate was 100%., Conclusion: MMA is highly successful and safe and may be a definitive primary single-staged surgical treatment of selected OSAS cases with diffusely complex or multiple sites of disproportionate velo-orohypopharyngeal anatomy.

Objectives: We used upper airway (UA) imaging in 20 patients to determine (1) whether an effective enlargement of the UA is obtained after uvulopalatopharyngoplasty (UPPP), and (2) whether UA modifications explain the results of such surgery., Methods: Cephalometric measurements were made to assess the posterior airway space, the length and width of the soft palate, and the distance between the hyoid bone and the mandibular plane. Pharyngeal CT measured the airway cross-sectional area (CSA) at each 10-mm slice from 10 mm above (-10) to 40 mm below (+40) the hard palate. Polysomnography was performed before and after surgery (10+/-10 [SD] months). Good responders were defined by an apnea-hypopnea index (AHI) of <10 postsurgery or, in patients in whom AHI was initially <10, a reduction of AHI >50% of the initial AHI., Results: Twenty patients (age=45+/-11 years) were studied. For the whole group, the mean body mass index (26+/-4 kg/m2) and AHI (14+/-13 vs 18+/-16/h) were unchanged after UPPP. The results of the surgery were mediocre with 7 good responders (35%) and 13 nonresponders (65%) defined by polysomnographic criteria. The only changes on UA imaging for the group as a whole after UPPP were decrease in length (40+/-6 vs 29+/-5 mm, p< or =0.0006) and increase in width of the soft palate (11.5+/-2.7 vs 13.6+/-3.5 mm, p< or =0.006). The increase or decrease in minimal CSA at the oropharyngeal (OP) level after UPPP was significantly correlated with the change in AHI (r=-0.54, p<0.02). Moreover, the changes in CSA obtained at the OP level were significant only in the patients who responded favorably to UPPP (7 vs 13 nonresponders)., Conclusions: Postoperative OP enlargement is associated with a good outcome of UPPP. Persistent narrowing in nonresponders could be due to the increase in soft palate width after surgery.

Study Objectives: To evaluate pain, swallowing, speech, edematous response, tissue shrinkage, sleep, snoring, and safety (energy limits and adverse effects) following radiofrequency (RF) treatment to the palate in 22 subjects with sleep-disordered breathing., Design: This investigation is a prospective nonrandomized study. Polysomnography, radiographic imaging, and infrared thermography, along with questionnaires and visual analog scales, were used to evaluate the effects of RF treatment to the palate., Setting: Treatments were delivered on an outpatient basis at Stanford University Medical Center., Patients: Twenty-two healthy patients (18 men), with a mean age of 45.3+/-9.1 years, were enrolled. All were snorers seeking treatment and met predetermined criteria: a respiratory disturbance index < or = 15, oxygen saturation > or = 85%, and a complaint of daytime sleepiness., Intervention: RF was delivered to the submucosa of the palate with a custom-fabricated electrode for a mean duration of 141+/-30 s with a mean of 3.6+/-1.2 treatments per patient. Reduction of their snoring scores determined the end point of the study., Results: Neither speech nor swallowing was adversely affected. Pain was of short duration (0 to 48 h) and was controlled with acetaminophen. There were no infections. Although there was documented edema at 24 to 48 h, there were no clinical airway compromises. Polysomnographic data showed improvement in esophageal pressure measurements of the mean nadir and the 95th percentile nadir (p=0.031, p=0.001) respectively, as well as the mean sleep efficiency index (p=0.002). Radiographic imaging showed a mean shrinkage of 5.5+/-3.7 mm (p< or =0.0001). Subjective snoring scores fell by a mean of 77% (8.3+/-1.8 to 1.9+/-1.7, p=0.0001) accompanied by improved mean Epworth sleepiness scores (8.5+/-4.4 to 5.2+/-3.3, p=0.0001)., Conclusion: The results of this investigation allowed the formulation of safety parameters for RF in this defined population with mild sleep-disordered breathing. There was a documented tissue reduction and improvement in symptoms in all subjects. However, given the small sample size and short-term follow-up, these results should be confirmed by further investigation.

Study Objective: To investigate, in an animal model, the feasibility of radiofrequency (RF) volumetric tongue reduction for the future purpose of determining its clinical applications in obstructive sleep apnea syndrome (OSAS)., Design: The study was performed in three stages, one in vitro bovine stage and two in vivo porcine stages. The last stage was a prospective investigation with histologic and volumetric analyses to establish outcomes., Setting: Laboratory and operating room of veterinary research center., Participants: A homogeneous population of porcine animal models, including seven in stage 2 and 12 in stage 3., Intervention: RF energy was delivered by a custom-fabricated needle electrode and RF generator to the tongue tissue of both the in vitro and in vivo models., Measurements and Results: Microultransonic crystals were used to measure three-dimensional changes (volumetric reduction). Lesion size correlated well with increasing RF energy delivery (Sperman correlation coefficient of 0.986; p = 0.0003). Histologic assessments done serially over time (1 h through 3 weeks) showed a well-circumscribed lesion with a normal healing progression and no peripheral damage to nerves. Volumetric analysis documented a very mild initial edematous response that promptly tapered at 24 h. At 10 days after RF, a 26.3% volume reduction was documented at the treatment site (circumscribed by the microultrasonic crystals)., Conclusion: RF, in a porcine animal model, can safely reduce tongue volume in a precise and controlled manner. Further studies will validate the use of RF in the treatment of OSAS.

Study Objective: To assess separately the effectiveness and safety of nasal-continuous positive airway pressure (N-CPAP) and that of surgery in comparison to conservative management in patients with obstructive sleep apnea syndrome (OSAS). DESIGN. A randomized study with 1-year follow-up., Setting: A university hospital acting as a referral center for OSAS., Patients: Symptomatic patients with OSAS (72 male and 4 female patients aged 18 to 65 years), who had oxygen desaturations in the overnight recording., Interventions: After the initial diagnostic workup, patients were considered to be candidates for either N-CPAP (44 patients) or surgical treatment (uvulopalatopharyngoplasty [UPPP] with or without mandibular osteotomy) (32 patients). Within the groups, the patients were then randomized to either the assigned treatment or conservative management., Main Outcome Measures: The number of nocturnal oxygen desaturation events of 4% or more per hour in bed (ODI4); daytime somnolence; side effects., Results: N-CPAP Group: Compliance with N-CPAP therapy at 1 year was 13 of 21. The most common reason for noncompliance was general intolerance of CPAP. All compliant patients had a normal ODI4 ( < 10), whereas 1 of 20 of their control subjects had a normal finding. Patients receiving active treatment were significantly less somnolent than their control subjects at 1 year (p < 0.05). SURGERY GROUP: At 1 year, 7 of 18 of the surgically treated and 1 of 14 of the conservatively treated patients had a normal ODI4 (p < 0.001). Daytime somnolence was significantly less severe in the surgically treated patients compared with their control subjects (p < 0.001) both at 3 and 12 months. The overall postoperative complication rate was 22%., Conclusions: N-CPAP is an effective therapy for OSAS, but compliance is a problem. Surgical therapy (UPPP with or without mandibular osteotomy) needs further evaluation.

Study Objective: We sought to determine whether preoperative fiberoptic pharyngoscopy (FOP) with Müller's maneuver (dynamic FOP) could be used to establish a subgroup of obstructive sleep apnea (OSA) patients with better outcome after uvulopalatopharyngoplasty (UPPP)., Design: Retrospective review of an observational cohort., Setting: Tertiary care referral center., Patients: Twenty-nine patients who underwent UPPP and nasopharyngeal surgery by one surgeon., Intervention: The patients were divided into two groups based on the findings of preoperative dynamic FOP: group 1 (11 patients) had collapse of the velopharynx and the base of the tongue-epiglottis-hypopharynx (TEH) complex and group 2 (18 patients) had velopharyngeal collapse only., Measurements and Results: Surgical success was defined using a conventional definition (> 50% reduction in the apnea-plus-hypopnea index [OAHI]), and a criterion for cure (> 90% reduction in OAHI and postoperative OAHI < 15). Both groups had a significant improvement in their OAHI. The success rate was significantly higher in patients with velopharyngeal collapse only compared with patients with additional collapse of the TEH complex (78 vs 36% with the conventional definition, and 50 vs 9% using the definition for cure, respectively). Predictive value of dynamic FOP in predicting cure failure when collapse of the TEH complex was present was 91%., Conclusions: Dynamic FOP may help establish a subgroup of OSA patients with greater likelihood of successful UPPP. The high negative predictive value of dynamic FOP when a criterion for cure is used suggests that this maneuver could best be used to exclude patients with TEH complex collapse from UPPP.

Lesions of the brainstem have been associated with obstructive sleep apnea in previous reports. We now report a case in which retromastoid craniectomy with microvascular decompression of the medulla and ninth and tenth cranial nerves resulted in the complete resolution of severe obstructive sleep apnea. Possible mechanisms for this observation are discussed.

We prospectively studied nine patients with the obstructive sleep apnea (OSA) syndrome with polysomnography before and after combined (seven simultaneous and two sequential) uvulopalatopharyngoplasty and inferior sagittal mandibular osteotomy with genioglossus advancement as treatment for OSA. All patients had failed to tolerate nasal continuous positive airway pressure and had a respiratory disturbance index (RDI) > or = 20. All patients were found to have disproportionate pharyngeal anatomy with airway narrowing by cephalometrograms and/or fiberoptic nasopharyngoscopy. Following surgery there were significant reductions in the average numbers of respiratory events and significant improvements in average oxygen saturation measurements. When RDIs < or = 5 and < or = 10 are chosen as objective success benchmarks, the success rates are 67 percent (6/9) and 78 percent (7/9), respectively.

Patients with obstructive sleep apnea (OSA) have decreased long-term survival. Treatment of OSA with either nasal continuous positive airway pressure (CPAP) or tracheostomy improves survival, but the effect of uvulopalatopharyngoplasty (UPPP) on survival is unclear. We attempted to contact all patients with OSA treated with either UPPP or nasal CPAP over a 6-year period to compare long-term survival between these two treatments. One hundred fifty-four patients had a UPPP during this period. Five of these patients were later treated with nasal CPAP and were excluded from the analysis. Twelve of the remaining 149 were unavailable for follow-up but were included in the analysis. Follow-up polysomnography was performed on 140 (94 percent) of these patients; 114 (81 percent) had either a postoperative apnea index < 5/h or > 50 percent reduction in apnea index. Two hundred eight patients were started on a regimen of nasal CPAP during the same period. Eighty-two patients discontinued nasal CPAP therapy and were excluded from analysis. Nine of the remaining 126 were unavailable for follow-up but were included in the analysis. Six patients treated with UPPP died. Three of these six patients had a 3-month follow-up polysomnogram that revealed apnea indices of 1/h, 5/h, and 23/h. Three patients treated with nasal CPAP died. There was no difference in the long-term survival between the two treatment groups. We conclude that there may be no difference in the long-term survival of patients with OSA between those treated with UPPP and those treated with nasal CPAP. This study emphasizes the importance of follow-up polysomnography in all patients after UPPP.

Nasal continuous positive airway pressure (CPAP) is the primary therapy for obstructive sleep apnea syndrome (OSAS). Recent reports have indicated, however, that there is a small but significant number of failures related to patient compliance. Primary surgical treatment, which has been uvulopalatopharyngoplasty (UPPP), has declined because of poor results. A reviewed of UPPP failures has shown that while UPPP eliminated palatal obstruction, it failed to eliminate base of tongue obstruction. Maxillofacial surgery has been reported as treatment of OSAS by correcting base of tongue obstruction. Thirty patients with severe OSAS were evaluated to compare nasal CPAP and maxillofacial surgery. The goal was to determine if our surgical protocol was as effective as nasal CPAP. All patients initially underwent baseline diagnostic polysomnography to document OSAS. A nasal CPAP study was performed to determine the appropriate positive end-expiratory pressure. The patients in this study were using nasal CPAP, but they found it unacceptable as long-term treatment and elected surgery. Maxillofacial surgery consisted of maxillary, mandibular, and hyoid advancement. Polysomnography was performed six months following surgery and compared with the night 2 CPAP results. The parameters included in the investigation were the respiratory disturbance index (RDI), lowest SaO2, number of SaO2 falls below 90 percent, total sleep time (TST), REM sleep percent, stage 3-4 sleep percent, and wake after sleep onset. The mean RDI before treatment was 72.0 (SD 25.7). After completing therapy, the RDI from surgery and CPAP was 8.8 (SD 6.0) and 8.6 (SD 4.1), respectively. The mean low SaO2 prior to treatment was 61.0 (SD 13.5), and the CPAP results and postsurgical results were 86.2 (SD 5.5) and 86.1 (SD 4.2), respectively. An analysis of variance was used to examine the results, and there was no statistical difference between nasal CPAP and surgery for all respiratory variables.

We performed nocturnal diagnostic polysomnography (PSG 1), PSG early after UPPP on the second to the fifth postoperative night (PSG 2) and PSG late after UPPP (PSG 3) six or more weeks after surgery, on 15 male patients with obstructive sleep-disordered breathing. On PSG 1, the A + H/I for the group was 66.6 +/- 8.8 (mean +/- SE). During non-REM sleep the A + H/I on PSG 3 (29 +/- 10) was lower than it was on PSG 2 (54.3 +/- 11.3) (p = 0.004) and lower than that on PSG 1 (70.8 +/- 10.3) (p = 0.003). Similarly, during non-REM sleep, the AI on PSG 3 (16.1 +/- 7.4) was less than that on PSG 2 (39.1 +/- 10.4) (p = 0.003) and less than that on PSG 1 (41.7 +/- 9.6) (p = 0.015). In the eight patients in whom REM sleep was recorded on all three PSGs, there was no difference with respect to A + H/I or AI. The nadir of SaO2 during non-REM sleep was higher during PSG 3 than during PSG 1 (p = 0.002), but not different from that on PSG 2. There were no differences among the three studies with respect to REM-related nadirs of SaO2; however, there was a good deal of interindividual variability across the three PSGs. In general, individuals with satisfactory amelioration of sleep-disordered breathing on PSG 2 demonstrated similar improvement on PSG 3. Patients who did not have a substantial improvement in the early postoperative period often had improvement on PSG 3, but there was a good deal of interindividual variability in this regard. We conclude that PSG within a few days following UPPP is warranted in patients with obstructive sleep-disordered breathing to determine if there has been worsening of upper airway function or oxygenation (or both) during sleep in the early postoperative period. A satisfactory result early after UPPP suggests that a late postoperative PSG is unnecessary, with savings in cost and the convenience.

To evaluate the morbidity associated with obstructve sleep apnea syndrome (OSAS), we undertook a seven-year follow-up study of 198 OSAS patients seen between 1972 and 1980. The patients had been submitted to tracheostomy (71 patients) or had received a weight-loss recommendation (127 patients). Despite a lower mean apnea index (AI) (43 vs 69) and a lower mean body mass index (BMI) (31 vs 34 kg/m2) at entry, excessive daytime sleepiness (EDS) and vascular morbidity were significantly higher in the conservatively treated group. The relative risk (odds ratio) of finding EDS in the conservatively treated group, after adjustment for BMI at seven-year follow-up, was 3.7 (95 percent confidence interval [CI] = 2.6-5.3). The relative risk of developing new vascular problems in the same population, estimated by Cox models, was 2.3 (95 percent CI = 1.5-3.6). The effect of tracheostomy, independent of age, BMI, and AI at entry, was highly significant. At entry, 56 percent of the population already had a vascular problem, particularly hypertension, thus emphasizing the need for earlier treatment of the sleep-related abnormal breathing.

In an attempt to identify predictors of long-term compliance with nasal continuous positive airway pressure (CPAP), we reviewed the records of 125 patients with obstructive sleep apnea (OSA) referred to our center for nasal CPAP trials. Severity of sleep apnea, sleep staging, daytime hypersomnolence, effectiveness of nasal CPAP, previous palatal surgery, and adverse reactions were compared in compliant and noncompliant patients. Nineteen patients did not tolerate a nasal CPAP trial in the laboratory or refused home nasal CPAP therapy. Ten patients were unavailable for follow-up. Of the remaining 96 patients, 23 (24 percent) had discontinued therapy, while 73 (76 percent) were still using nasal CPAP at 14.5 +/- 10.7 months (mean +/- SD). There were no statistically significant differences between the compliant and noncompliant patients in baseline apnea plus hypopnea index (AHI), baseline sleep staging, AHI while receiving nasal CPAP, sleep staging while receiving nasal CPAP, or frequency of adverse reactions during therapy. Severe daytime sleepiness was present in 65 of the 73 compliant patients and in 12 of the 23 noncompliant patients (p less than 0.05). Ten of 43 in the compliant group had previous palatal surgery compared with ten of 23 noncompliant patients (p less than 0.05). Our data confirm earlier observations in smaller samples that compliant and noncompliant patients have equally severe sleep apnea and good initial responses to nasal CPAP. Long-term compliance with nasal CPAP may be associated with the severity of daytime hypersomnolence on presentation. Previous palatal surgery was more frequent in patients who did not tolerate long-term nasal CPAP therapy.

The purpose of this study was to evaluate the adequacy of speech following uvulopalatopharyngoplasty surgery. Twenty UPPP subjects, all of whom exhibited obstructive sleep apnea syndrome, and 15 non-UPPP control subjects participated in the study. Evaluation included measures of nasal airflow, speech recordings with listener judgments, and a questionnaire survey. Nasal resonance in the UPPP subjects was found not to be deviant by a panel of four experienced judges. The UPPP subjects were differentiated from their non-UPPP pairs on the basis of significant phonation (voice) problems, and to a lesser extent, their articulation problems. It is suggested that dryness problems that remained in many subjects postoperatively may be related to the observed voice problems.

The position of the hyoid bone, which anchors much of the tongue musculature, is often abnormally low in patients with obstructive sleep apnea syndrome (OSAS). Cephalometric measurements, frequently used to measure SNA and SNB angles, can also provide information on the posterior airway space (PAS), the mandibular plane, and the hyoid bone. This information is useful in determining the appropriate surgical treatment for OSAS patients.

We describe a patient with obstructive sleep apnea (OSA) who is unusual in two respects: 1) rapid development of severe OSA over a period of two to four months, and 2) direct temporal association between development of OSA and mediastinal surgery complicated by unilateral paralysis of the phrenic nerve and the recurrent laryngeal nerve.

The etiology of the SAS is unknown. To test whether endogenous opioids could be pathologically active in SAS, markers of opioid systems were measured in the CSF of 15 patients with SAS and in control subjects. Measured by receptor assay, the concentration of so-called fraction 1 opioid was higher in patients with SAS (3.0 +/- 1.5 pmol/ml; mean +/- SD) than in control subjects (1.1 +/- 0.5 pmol/ml) (p less than 0.01), whereas that of fraction 2 opioid was similar in the two groups. Beta-endorphin-like activity, measured by radioimmunoassay, was somewhat lower in patients with SAS (14.0 +/- 2.8 pmol/ml) than in control subjects (21.8 +/- 7.6 pmol/ml) (p less than 0.05). Six months after surgical treatment of the soft palate, new measurements were made in eight patients. Fraction 2 endorphin and beta-endorphin showed no consistent changes. A decrease in the level of fraction 1 from 4.1 +/- 1.5 pmol/ml to 2.3 +/- 1.0 pmol/ml (p less than 0.02) was noted in those six patients showing a successful clinical course. The data support the hypothesis that in SAS the opioid activity is increased.

Uvulopalatopharyngoplasty (UPPP), originally evaluated in 66 patients with objectively documented sleep apnea syndrome, was successful in 33 of the patients as indicated by clinical and polysomnographic improvements. One-year followup polysomnographic evaluations were obtained in 20 of these patients; the remaining 13 were lost to followup. After one year, the patients maintained the improvements seen at the six-week evaluation. Frequency and duration of apnea was significantly reduced from presurgery levels and similar to the six-week results. Oxygenation measures also did not differ from the six-week results, remaining better than presurgery values. Thus, respiration did not disrupt sleep to the degree it had before surgery. Sleep measures were improved compared to presurgery and similar to the six-week data. Body weight remained stable over the entire period.

As the actual mortality and morbidity of obstructive sleep apnea syndrome (OSAS) have been unknown heretofore, we undertook a follow-up study of 198 OSAS patients seen at the Stanford Sleep Disorders Clinic between 1972 and 1980, for whom either tracheostomy (71 patients) or weight loss (127 patients) had been recommended. At five-year follow-up, all of the deaths (14) had occurred among those conservatively treated with weight-loss (a mortality rate of 11 per 100 patients per five years). These patents also had a higher five-year crude vascular mortality rate: 6.3 per 100 patients per five years, with an age-standardized vascular mortality rate of 5.9 per 100 patients per five years (95 percent confidence interval [CI] 2.5-11.6) vs 0 per 100 for the surgically treated population; this despite a lower mean apnea index (43 versus 69) and a lower mean body mass index (31 versus 34 kg/m2) in the conservatively treated group. With the fictional adjunction of one possible death at five-year follow-up in the surgically treated group, the age-adjusted odds of vascular mortality at five years for the conservatively treated group was 4.7. Our data therefore encourage "aggressive" treatment for patients with OSAS.