Comparison of upper airway stimulation, tongue base surgeries, and continuous positive airway pressure for moderate-to-severe obstructive sleep apnea: a systematic review and network meta-analysis.

PURPOSE: To compare treatment outcomes of tongue base-targeting interventions-transoral robotic surgery (TORS), plasma ablation tongue base reduction (PATBR), implantable upper airway stimulation (UAS)-and continuous positive airway pressure (CPAP) in moderate-to-severe obstructive sleep apnea (OSA) patients.

METHODS

The PubMed, SCOPUS, Embase, Web of Science, and Cochrane databases were systematically searched through January 2026. A network meta-analysis was conducted to compare tongue-directed surgical procedures (TORS and PATBR), UAS, and CPAP. Outcomes included changes in the apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), lowest oxygen saturation, postoperative hospital stay, success rate (postoperative AHI < 20 with > 50% reduction), and cure rate (postoperative AHI < 5).

RESULTS

Ten studies comprising 758 patients were included. UAS demonstrated significantly greater AHI reduction than TORS (standardized mean difference [SMD] = 1.36 [0.27-2.46]) and significantly improved lowest oxygen saturation (SMD = 1.46 [0.30-2.62]). CPAP showed greater, though not statistically significant, AHI improvement compared with TORS (SMD = 1.17 [- 0.32-2.66]). ESS improvement did not differ significantly among treatments. Both PATBR (SMD = - 1.30 [- 1.80--0.79]) and UAS (SMD = - 5.49 [- 6.65--4.33]) were associated with significantly shorter hospital stays than TORS. Success rates were higher with CPAP (odds ratio [OR] = 3.73 [1.38-10.13]) and UAS (OR = 5.58 [1.97-15.84]) compared to TORS, whereas cure rates were significantly higher with UAS (OR = 12.13 [1.98-74.50]). Ranking analysis indicated overall superiority of UAS across objective outcomes.

CONCLUSIONS

UAS provides superior objective outcomes with shorter hospitalization and comparable subjective improvement, supporting its role as an effective treatment option for moderate-to-severe OSA.