**3.1 Nasal procedures**

*Updates in Sleep Neurology and Obstructive Sleep Apnea*

**Components Classification**

Degree of obstruction 0–No obstruction

Configuration of collapse Anteroposterior

The history should also include the patient past experience with continuous

Lateral Concentric

Structures V–velum, including soft palate, uvula or lateral pharyngeal wall

1–Partial obstruction 2–Complete obstruction X–Not visualized

wall tissue) T–tongue base E–epiglottis

O–oropharyngeal walls (including palatine tonsils and lateral

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

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

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

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

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, discuss-

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

ing potential site of the obstruction and non-surgical treatments options.

apnea-hypopnea index, and oxyhemoglobin saturation levels [12, 13].

positive airway pressure (CPAP), an oral appliance, and/or weight loss.

collapse, septal position, turbinate size, and nasal polyps.

epiglottis, as well as the type of collapse (**Table 1**).

dental health, and palate position.

*Adapted from Ref. [9].*

*VOTE classification system [9].*

**Table 1.**

while the tongue in native position.

**176**

**3. Surgery selection**

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 OSA outcome measures [14, 15].


The most common adverse outcomes for most of the intranasal procedures are postoperative temporary bleeding and temporary nasal congestions. More serious adverse effects could also occur but rare like cerebrospinal fluid leak.
