**2. Presurgical evaluation**

Polysomnogram (PSG) and home sleep testing do not provide information about the location of the obstruction. Therefore, a complete history that include the chief complaint, other significant symptoms, past medical history and surgical history are helpful. Some symptoms can help identify potential surgical approaches.


#### **Table 1.**

*VOTE classification system [9].*

The history should also include the patient past experience with continuous positive airway pressure (CPAP), an oral appliance, and/or weight loss.

Thorough physical exam to evaluate the structures that impact the upper airway. The nasal airway is evaluated in detail, checking for external deformity, nasal valve collapse, septal position, turbinate size, and nasal polyps.

Oral cavity and oropharynx examination provide information into the protentional upper airway surgery. It provides insight of the tongue size and position, dental health, and palate position.

Trans-nasal flexible laryngoscopy provides adequate evaluation of the lower pharyngeal and laryngeal airway. It gives great view of the entire upper airway while the tongue in native position.

Drug induce sleep endoscopy (DISE) using mild sedation (midazolam or propofol) required in some upper airway procedures like upper airway stimulation therapy [6]. It has been shown to be a valid assessment of the upper airway, with moderateto-substantial test-retest reliability and moderate-to-substantial inter-rater reliability. It allows the evaluation of the airway in a situation as close to sleep as possible [7, 8].

VOTE (Velum, Oropharynx, Tongue base, and Epiglottis) system specifies grades for the degree of obstruction at the velum, oropharynx, tongue base, and epiglottis, as well as the type of collapse (**Table 1**).

Several other diagnostic modalities have showed some value to supplement a physical examination, including lateral cephalogram, 3-dimensional cone beam computed tomographic scan, sleep endoscopy, or cine-magnetic resonance imaging (MRI) [10, 11].

A comprehensive counseling should be undertaken prior to the surgery, discussing potential site of the obstruction and non-surgical treatments options.

#### **3. Surgery selection**

There are different surgical procedures used to treat OSA. American Academy of Sleep Medicine recommends that patient should be advised about potential surgical success rates and complications, the availability of alternative treatment options. The desired outcomes of treatment include resolution of the clinical signs and symptoms of obstructive sleep apnea and the normalization of sleep quality, the apnea-hypopnea index, and oxyhemoglobin saturation levels [12, 13].

**177**

(**Table 3**) [18].

*Surgical Treatment Options for Obstructive Sleep Apnea DOI: http://dx.doi.org/10.5772/intechopen.91883*

Nasal obstruction has identified as an important target in the treatment of OSA. The main goal is to relive the obstruction as an adjunctive measure to improve the outcomes of continuous positive airway pressure (CPAP) by reducing CPAP pressure requirements, an oral appliance, or other surgery. Although nasal surgery in isolation does not have a consistent effect on the apnea-hypopnea index in OSA patients, it does have strong evidence on improving snoring, subjective sleep quality, daytime sleepiness, sleep-related quality of life measures, and other important

• Turbinate reductions reduce the obstruction caused by inferior turbinate.

• Rhinoplasty corrects any anatomical deformities that compromise the nasal

The most common adverse outcomes for most of the intranasal procedures are postoperative temporary bleeding and temporary nasal congestions. More serious

The extent to which tonsillar hypertrophy contributes to OSA in adults remains

unclear. Tonsillectomy with adenectomy is the first line treatment in pediatric patients with severe OSA and adenotonsillar hypertrophy. It also showed substantial improvement in AHI severity, oxyhemoglobin saturation and sleep quality in obese patient with OSA [16]. Patients who undergo tonsillectomy often experience significant reduction in the CPAP pressure required [17]. The most common postoperative complains include postoperative hemorrhage. Other risks such as pain, fever, and

It represented as the first surgical procedure specifically designed to treat obstructive sleep apnea (OSA) and remains the most commonly performed surgical

There are multiple approaches have been introducing to address the narrowing or collapse of the retropalatal region (**Table 2**). It traditionally involved removal of the uvula, a portion of the soft palate, tonsils and closure of the tonsillar pillars. All the new techniques involve resection or repositioning of the palatal tissues and pharyngeal walls to increase the dimension of the pharyngeal

To determine the likelihood for successful resolution of OSA after UPPP, a staging system was developed based on tonsil size, tongue-palate position, and BMI

• Nasal valve surgery improves the airflow in patient with nasal valve

• Septoplasty straightening a deformity of the nasal septum.

adverse effects could also occur but rare like cerebrospinal fluid leak.

**3.1 Nasal procedures**

OSA outcome measures [14, 15].

**3.2 Upper pharyngeal procedures**

obstruction.

airway.

*3.2.1 Tonsillectomy*

infection could also occur.

procedure to treat OSA.

airway to reduce obstruction.

*3.2.2 Uvulopalatopharyngoplasty (UPPP)*
