**4.1 Tongue reduction procedures**

Multiple techniques to improve lower pharyngeal airway by decreasing the volume of the tongue tissues:


#### **4.2 Tongue advancement**

Multiple procedures tend to improve lower pharyngeal airway by advance or stabilize the tongue base and pharyngeal muscular:


Multiple studies showed the effectiveness of lower pharyngeal and laryngeal procedures. It demonstrates improvements in respiratory physiology during sleep, daytime somnolence and quality of life. Successful sleep study outcomes defined as a reduction in AHI of 50% or more and an AHI of less than 20, was achieved in 35–62% of patients [24].

Adverse effects reported were based on the surgical techniques that been used. Pain, hemorrhage, tongue infection airway complications, taste change and dysphagia seen in partial glossectomy, lingualplasty and lingual tonsillectomy [25].

Postoperative pain and submandibular edema were the two most common complications followed radiofrequency tissue ablation [26].

#### **4.3 Maxillomandibular advancement**

The maxilla and the mandible are advanced together with both upper and lower teeth to widen the retrolingual and the retropalatal segments of the upper airway. It is beneficial mainly for patients with craniofacial issues, but it is not limited for patients with this problem. The maxilla is moved by a Le fort I osteotomy and the mandible by a sagittal split osteotomy. It is a major operation but showed a significant increase in the pharyngeal airway dimensions and decrease AHI score below the threshold of 20.

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

New treatment for OSA by Implantable neurostimulator device was approved

• Predominantly obstructive events (central and mixed apneas <= 25 percent of

• DISE shows no concentric velopharyngeal collapse or any other anatomical

Hypoglossal Nerve Stimulation showed 68% decrease in AHI score, oxygen desaturation index score decreased by 70%, and improved quality of life [27]. Most common reported adverse outcomes are infection, hemorrhage, and

The most immediate, effective and definitive treatment for OSA is placing a permanent cannula in the neck to bypassing the upper pharyngeal airway. Patient will be able to breath, speak and eat by capping the tube during waking time and open the cannula during sleep. Tracheostomy significantly decreases apnea index,

It requires a long-term care to reduce complications (e.g., pneumonia, mucus plugging, peristomal infections). Therefore, it is recommended primarily for patient with sever and life threating OSA who failed all the other treatment options

OSA is seen in about 45% of bariatric patients [28]. Surgically induced weight loss showed significantly improves obesity-related sleep apnea. It decreased the mean RDI to 15 ± 2 from 51 ± 4 (preoperatively). In addition, oxygen saturation, sleep efficiency, repaid eye movement latency and the requirement for continuous

Patient with OSA could have multiple locations of collapse in upper and lower pharyngeal tracts. Those patients would benefit from multilevel surgery. DISE is

tongue weakness. It is still unknown whether there are long term risks.

oxygen desaturation index, sleepiness, and mortality in OSA patients [28].

by US Food and Drug Administration in 2014. It keeps the lower pharyngeal airway open during sleep by activates the protrusion muscles of the tongue via the

• Moderate or severe OSA (AHI > 20 but less than 65 events per hour)

**4.4 Hypoglossal nerve stimulation**

Eligibility criteria include:

• Unable to tolerate CPAP

• Age > = 21 years old

hypoglossal nerve.

AHI).

findings.

**4.5 Tracheostomy**

and in morbid obese patients.

positive airway pressure [29].

**6. Multilevel surgery**

**5. Weight loss by bariatric surgery**

• BMI < 32 kg/m2
