Abstract

Obstructive sleep apnea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP. The main results achievable by the surgery are UA expansion, and/or stabilization, and/or removal of the obstructive tissue to different UA levels. The site and pattern of UA collapse identification is of upmost importance in selecting the customized surgical procedure to perform, as well as the identification of the relation between anatomical and non-anatomical factors in each patient. Medical history, sleep studies, clinical examination, UA endoscopy in awake and drug-induced sedation, and imaging help the otorhinolaryngologist in selecting the surgical candidate, identifying OSA patients with mild UA collapsibility or tissue UA obstruction, which allow achievement of the best surgical outcomes. Literature data reported that the latest palatal surgical procedures, such as expansion sphincter palatoplasty or barbed reposition palatoplasty, which achieve soft palatal and lateral pharyngeal wall remodeling and stiffening, improved the Apnea Hypopnea Index, but the outcome analyses are still limited by methodological bias and the limited number of patients’ in each study. Otherwise, the latest literature data have also demonstrated the role of UA surgery in the improvement of non-anatomical factors, confirming that a multidisciplinary and multimodality diagnostic and therapeutical approach to OSA patients could allow the best selection of customized treatment options and outcomes.

Highlights

  • With expanded treatment options, the question arises of how to select the best treatment option, especially when considering upper airway (UA) surgery, knowing that the best outcomes are achievable with Continuous positive airway pressure (CPAP) in Obstructive sleep apnea syndrome (OSA) patients with the highest pharyngeal collapsibility

  • UA surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP, and the main result achievable by the surgery is UA expansion, and/or stabilization, and/or tissue removal to different UA levels [8]

  • This paper aims to analyze the data collected from medical history, sleep studies, and clinical examination, which could help an otorhinolaryngologist in detecting the preponderance of anatomical factors in UA collapsibility and its role in apnea events

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Summary

Introduction

The pathophysiology of OSA is related to four major endotypes related to specific pathophysiological traits (PTs): the upper airway size/pharyngeal collapsibility, distributed under the terms and conditions of the Creative Commons. Continuous Positive Airway Pressure (CPAP) is recognized as the first-line standard treatment for OSA, but long-term acceptance or adherence to CPAP is reported by the literature to be from 50 to 70% [4,5]. For this reason, multiple alternative treatment options are being advocated. With expanded treatment options, the question arises of how to select the best treatment option, especially when considering UA surgery, knowing that the best outcomes are achievable with CPAP in OSA patients with the highest pharyngeal collapsibility

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