I. Clinical issues The prevalence of mild adult sleep apnea in high-income countries is estimated at 20%, and moderate to severe is estimated at 6-7%. The disease is strongly associated with the development of multiple diseases, motor vehicle crashes, and health-related quality of life decline. Clinical guidelines recommend continuous positive airway pressure (CPAP) and weight and alcohol control as first-line treatment for moderate to severe sleep apnea that presents with symptoms. Upper airway surgery (e.g., uvulopalatine C-pharyngoplasty) is also possible, but the morning evidence supports such use of surgery. Surgical approaches to sleep apnea are widely used in Australia and elsewhere (e.g. Nordic countries), and there is a progressive trend towards increasing use. We believe that upper airway surgery is not appropriate as a first-line treatment for obstructive sleep apnea in adults. II. Evidence for change A series of surgical procedures is either continuous or performed in steps with multiple operations. A recent multicenter retrospective statistic found a variety of basic surgical steps, with 41 different combined procedures performed in the population included in the study (n = 94). 2005 Cochrane systematic review of 7 randomized controlled studies with inconsistent surgical outcomes, with only 3 studies (225 total cases) showing significant improvement in polysomnography and only 4 studies (total cases 138) suggested an improved quality of life. The clinical significance of these 2 metrics was limited, and the review concluded that surgery did not reduce symptoms (except in 2 studies) and did not show a clear overall benefit. Although quality of life can be improved transiently after surgery, it rarely lasts longer than 12 to 24 months. A recent systematic evaluation of 48 studies (4 randomized controlled studies, 17 prospective studies of different designs, 23 retrospective studies, and 4 of uncertain design) found that more than 62% of the 21,346 patients who underwent surgery experienced persistent side effects such as persistent dry throat, bulbar palsy, dysphagia (including spontaneous nasal reflux), voice change, and taste and smell disturbances. As many as 22% of patients regretted undergoing the procedure. Another meta-analysis evaluated 18 surgical studies (n = 385, 17 levels in 4 levels, 1 randomized controlled study). Surgery was assessed as successful based on the number of patients with a postoperative apnea/hypopnea index ≤5 (a CPAP-corrected criterion for clinical significance), but this assessment method has limitations. the success rate for phase I surgery including uvulopalatine C pharyngoplasty was only 13% (14 studies, n = 347), and for phase II surgery including osteotomy 43% (4 studies, n = 38). III. Barriers to change Conservative treatment to control weight is recommended as an adjunctive therapy because it is the main risk factor for obstructive sleep apnea (based on 2 randomized studies, n = 91, and 2 non-randomized controlled studies, n = 41). However, weight reduction and other lifestyle modifications are difficult to implement successfully. CPAP is also dependent on patient tolerance and compliance, and the benefits of CPAP for mild to moderate obstructive sleep apnea seem uncertain, making the surgical “treatment” seem more attractive. In addition, these procedures are primarily done in private clinics in Australia, which have different incentives than the public health care system. Because there is no clear benefit to the procedure and the available evidence suggests that it may also be potentially harmful, relevant guidelines generally recommend CPAP as first-line treatment for obstructive sleep apnea. If CPAP treatment fails, pulling the mandible forward (conservative treatment) may be considered as second-line treatment (16 randomized controlled studies, n ＝ 745). IV. How has this changed outside of practice? CPAP is still recommended as the first-line treatment for obstructive sleep apnea in adults. Weight control (a major risk factor) as a conservative treatment is recommended as an adjunctive treatment. If CPAP therapy fails, pulling the mandible forward (conservative treatment) may be considered as second-line treatment. Surgical treatment of obstructive sleep apnea should be performed in a clinical in a controlled study. Patients should be informed at this time of the uncertainty of the outcome of the procedure, the pain associated with the procedure, the potential side effects, and the possibility of recurrence.