Sleep Medicine and Surgery: OSA Evaluation and Treatment
Sleep medicine questions center on obstructive sleep apnea (OSA) diagnosis, consequences, and treatment selection. Understand that OSA is caused by pharyngeal collapse during sleep and is associated with hypertension, cardiovascular disease, stroke, and metabolic dysfunction. Diagnosis is by polysomnography or home sleep apnea testing; the apnea-hypopnea index (AHI) defines severity (mild 5–15, moderate 15–30, severe >30).
Know the anatomic levels of obstruction: nasal, retropalatal, retroglossal, and hypopharyngeal. Drug-induced sleep endoscopy (DISE) can localize collapse. First-line therapy is positive airway pressure (PAP); alternatives include oral appliances (mandibular advancement), positional therapy, and weight loss. Surgical options include uvulopalatopharyngoplasty (UPPP), hypoglossal nerve stimulation (for PAP-intolerant patients with favorable anatomy), and maxillomandibular advancement for skeletal deficiency.
Traps: recommending surgery without documenting PAP failure or intolerance; missing central sleep apnea and obesity hypoventilation; and forgetting that pediatric OSA is often treated with adenotonsillectomy. Also know that bariatric surgery can improve OSA but does not guarantee cure.
Rule of thumb: "Diagnose with sleep testing, treat with PAP first, and reserve surgery for documented failure or anatomic targets."
Worked example: A 45-year-old with AHI 35, hypertension, and PAP intolerance has DISE showing retropalatal and retroglossal collapse. Consider hypoglossal nerve stimulation if criteria are met, or maxillomandibular advancement if skeletal deficiency is present.