This systematic review aimed to evaluate patient awareness, acceptance, and preferences regarding available treatment modalities for obstructive sleep apnea (OSA). The primary research question was how behavioral, perceptual, and communication-related factors influence treatment selection, adherence, and satisfaction in adult patients with OSA. A comprehensive systematic search of PubMed/MEDLINE, Scopus, Embase, and Web of Science was conducted from database inception to December 2025. Eligible studies included adults diagnosed with OSA who reported outcomes related to patient awareness, acceptance, or preferences toward any therapeutic option. Study selection and data synthesis followed PRISMA 2020 guidelines. Given heterogeneity across studies, findings were synthesized narratively. Nine studies comprising 5,401 patients were included. Continuous positive airway pressure (CPAP) was the most widely recognized and initially preferred therapy; however, long-term adherence was inconsistent. Patient preferences were predominantly influenced by perceived therapeutic benefit, comfort, ease of use, and perceived disease severity rather than demographic or clinical variables. Less than half of patients demonstrated prior awareness of OSA or its treatment options, representing a substantial barrier to engagement. Educational interventions and shared decision-making approaches consistently improved treatment acceptance and adherence. While economic considerations played a secondary role overall, they disproportionately affected older adults and individuals with lower socioeconomic status. Alignment between patient preferences and selected therapies was associated with improved adherence and satisfaction. Patient-centered factors, particularly perceived benefit, practicality, and effective physician communication, are critical determinants of successful OSA management. Enhancing patient education and shared decision-making may significantly improve long-term adherence and real-world treatment outcomes.

OBJECTIVES:To identify endoscopic and rhinomanometric correlation of response to 30° head-of-bed elevation (HOBE) in patients with obstructive sleep apnea (OSA), and to explore whether upper airway (UA) collapse patterns and nasal resistance are associated with positional improvement. METHODS:We assessed the associations between drug-induced sleep endoscopy (DISE) findings and rhinomanometric parameters with response to HOBE in OSA patients. Polysomnography was performed overnight in standardized supine, 30° HOBE, and lateral positions. HOBE response was evaluated based on percent change in apnea-hypopnea index (AHI), and correlations with VOTE collapse patterns and nasal resistance were determined. RESULTS:HOBE significantly reduced AHI from 22.6 ± 5.7 to 16.4 ± 4.9 events/h (p < 0.001), with further lateral position reduction (11.7 ± 4.2, p < 0.001). OSA patients demonstrated greater AHI improvement with HOBE than controls (-31.0% vs. -14.0%, p < 0.001). Expiratory nasal resistance was significantly elevated in OSA patients (p < 0.001) and strongly correlated with percent AHI change during HOBE (r = 0.912, p < 0.001). VOTE analysis revealed more severe multilevel collapse in OSA patients; epiglottic (r = 0.903) and tongue base collapse scores (r = 0.714) were strongly associated with the HOBE response. After adjustment for BMI and sex, epiglottic and velar collapse scores remained significantly associated with HOBE response, whereas rhinomanometric associations were attenuated and no longer statistically significant. CONCLUSION:DISE findings and expiratory rhinomanometric resistance values may help characterize positional responsivity to HOBE including patterns of UA collapse as well as nasal airflow resistance. However, results should be considered hypothesis-generating and require confirmation in larger cohorts with prospective data collection, formal model development, and external validation. LEVEL OF EVIDENCE: 3:

To investigate the contribution of nasal surgery to multilevel OSA surgical success outcome. Systematic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to OSA, nasal resistance, pharyngeal volume/space, nasal surgery, multilevel surgery and its outcomes. All relevant studies published between January 2000 to December 2024 were included. Twelve studies were included in this systematic review with 11 articles illustrating that nasal surgery was pivotal, and improved outcomes in multilevel OSA surgery, whilst nasal surgery alone for OSA did not significantly affect polysomnographic results. Five articles utilizing CBCT, 3D measurements of nasal and pharyngeal airway area/volume, computational fluid dynamics and nasal resistance demonstrated that reducing nasal resistance with nasal surgery increased the pharyngeal airway space and volume; whilst 6 articles established through clinical case studies that multilevel OSA surgery combined with nasal surgery yielded better AHI, LSAT and ESS outcomes than multilevel surgery without nasal surgery. The landmark article that reviewed 24 years of nasal surgery alone for OSA treatment, showed poor outcomes and minimal AHI change with nasal surgery alone. As the upper airway is a continuous air conduit, reducing nasal resistance would reduce pharyngeal pressures leading to improvement of outcome parameters. Hence, including nose surgery in multilevel surgery improves surgical success.

A new classification system for upper airway resistance syndrome (UARS) with distinct patient profiles and treatment modalities. Systemic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to UARS and obstructive sleep apnea (OSA) between January 1993 to May 2025. Sixteen studies included in this 32-year systematic review with a total of 3852 patients. Proponents argue that UARS is a distinct entity, while others believe that it is a continuum, between snoring to OSA. Nine articles support the evidence that UARS is a distinct entity, while 7 articles describe UARS as a spectrum of OSA. Type I is the UARS-TMD association, these patients are usually female, underweight or normal BMI, excessively tired, edgy, normal or low blood pressure, with neckaches, headaches, and functional psycho-somatic symptoms; many have teeth grinding, temporomandibular issues, insomnia, long sleep latency, depression, elevated hyoid position and loss of cervical lordosis. Type II UARS-OSA spectrum, are mostly males, overweight, thick neck, hypertensive, excessively sleepy, short sleep latency, at higher risk of cardio-vascular issues; and an overlap Type III. Treatment differs, Type I UARS-TMD have neckaches, headaches and psycho-somatic issues, many of them cannot tolerate the CPAP, while Type II UARS-OSA patients tend to appreciate CPAP. Type I UARS-TMD patients do well with the oral appliance and nasal surgery. The 2 distinct groups of patients with UARS (Pang-Vicini classification), have different phenotype and treatment outcomes; sleep physicians should be aware and recognize this. Level of evidence: III.

Barbed Pharyngoplasty (BP), a minimally invasive, muscle-preserving surgical technique utilizing Barbed Sutures (BS) for palatal suspension and remodelling, has shown efficacy in younger cohorts but remains underexplored in older adults. The aim of this study was to show the effectiveness and safety of the BP technique as a standalone surgical treatment in selected elderly patients with moderate-severe OSA and concentric pharyngeal collapse non-compliant, intolerant, or refractory to CPAP. A retrospective study was conducted on 17 patients aged ≥ 65 years (older group) and 23 patients aged < 65 years (younger group) who underwent BP. Pre- and postoperative assessments included Apnea–Hypopnea Index (AHI), Oxygen Desaturation Index (ODI), Epworth Sleepiness Scale (ESS), and snoring severity via bed partner Visual Analog Scale (VAS). In the older group, the mean AHI significantly decreased from 39.9 ± 20.1 to 21.1 ± 14.4 events/hour (p = 0.0002), and ODI from 32.6 ± 21.8 to 17.8 ± 12.5 events/hour (p = 0.002). Postoperative ESS and VAS scores also demonstrated significant improvement (14 ± 6.4 to 6.0 ± 3.2, and 7.9 ± 2.9 to 3.4 ± 1.5, respectively; p < 0.05). Surgical success was achieved in 42

This Viewpoint examines the potential role of neoadjuvant and adjuvant glucagon-like peptide–1 (GLP-1) receptor agonist therapy in improving surgical outcomes for patients with obstructive sleep apnea and obesity.

OSA has been demonstrated to be significantly influenced by body position, and supine one making the disease severity worse. Head-of-bed elevation (HOBE) is advocated as an easily applicable positional therapy, yet its hemodynamic response is incompletely elucidated. This investigation assessed the influence of HOBE on polysomnographic (PSG) parameters and nasal resistance drives and the pattern of upper airway collapse, compared with healthy controls in OSA patients. In this prospective multicenter observational study, we enrolled 60 participants (30 OSA patients, 30 controls). All underwent full polysomnography in three positions (supine, 30° HOBE, lateral). We assessed Rhinomanometry and nasal valve outcomes while upper airway collapse was classified using the VOTE system. Primary outcome was change in apnea–hypopnea index (AHI); secondary outcomes included oxygen desaturation index (ODI), minimum oxygen saturation (MinSaO₂), sleep efficiency, and responder rate (≥ 50

Upper airway (UA) surgery is commonly employed in the treatment of patients with obstructive sleep apnea (OSA). The intricate pathophysiology of OSA, variability in sites and patterns of UA collapse, and the interaction between anatomical and non-anatomical factors in individual patients may contribute to possible surgical failures. This clinical consensus statement aims to identify areas of agreement among a development group comprising international experts in OSA surgery, regarding the appropriate definition, predictive factors in patients, and management of surgical failure in OSA treatment. A clinical consensus statement (CCS) was developed using the Delphi method by a panel of 35 contributors from various countries. A systematic literature review adhering to PRISMA guidelines was conducted. A survey consisting of 60 statements was then formulated and presented to the experts. Following two rounds of the Delphi process, consensus or strong consensus was achieved on 36 items, while 24 items remained without consensus. Specifically, 5 out of 10 statements reached consensus regarding on the 'Definition of Surgical Success/Failure after OSA Surgery'. Regarding the 'Predictive Factors of Surgical Failure in OSA Surgery', consensus was reached on 10 out of 13 statements. In the context of the 'Diagnostic Workup in OSA Surgery', consensus was achieved on 9 out of 13 statements. Lastly, in 'Treatment in Surgical Failure Cases', consensus was reached on 12 out of 24 statements. The management of OSA after surgical failure presents a significant clinical challenge for sleep specialists. This CCS provides valuable guidance for defining, preventing, and addressing surgical failures in the treatment of OSA syndrome.

Objectives To systematically review long-term (> 5 years) outcomes of ESP surgery for OSA treatment over 17 years. Methods Systemic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to OSA and Expansion Pharyngoplasty and its variants. All relevant studies published between January 2007 and June 2023 were included. Results Twelve studies were included in this systematic review with a combined total of 1373 patients who had the ESP procedure were included. The clinical outcomes included encouraging long-term success rate, reductions in Epworth sleepiness scale, good mean disease alleviation, anatomical structural area and volume improvements, blood pressure reductions, biochemical improvements in acute phase reactants after ESP surgery, reductions in intra-ocular pressures, and post-operative reduction of sympathetic overdrive. Conclusions Seventeen years on, the expansion sphincter pharyngoplasty has demonstrated not only increase in anatomical area and volume but significant desired improvements in polysomnographic, clinical and biochemical parameters post-surgery.

Objective. A new critical complication risk analysis, the reasonable risk ratio (RRR or R3) for palate surgeries in obstructive sleep apnea patients. Methods. Analysis from published meta-analyses, systematic reviews on success rates, and complications encountered for 3 palate surgeries, expansion sphincter pharyngoplasty (ESP), barbed repositioning pharyngoplasty (BRP) and modified uvulopalatopharyngoplasty (mUPPP), over 20 years. The RRR is derived from a ratio of the percentage of each respective complication over the success rate of that particular surgical procedure. The benchmark RRR of tonsillectomy is set at 0.035 to 0.078. An RRR below this benchmark value is more favorable as tonsillectomy is a widely accepted ENT procedure with risks to benefit well accepted. Results. The RRR for foreign body (FB) sensation (BRP) ranged from 0.03 to 0.23 (mean RRR of 0.14), FB sensation (ESP) 0.01, FB sensation (mUPPP) ranged from 0.33 to 0.55 (mean RRR of 0.44). The RRR for swallowing difficulties (BRP) ranged from 0.04 to 0.23 (mean RRR of 0.11), mUPPP, was 0.37; no reported swallowing difficulties with the ESP. The RRR for velopharyngeal insufficiency (VPI) (BRP) ranged from 0.009 to 0.18 (mean RRR of 0.07), and RRR VPI (mUPPP) was 0.14. The RRR (BRP) for dry throat was 0.06 and the mUPPP was 0.35, with no reported VPI or dry throat for ESP. The overall RRR for the BRP was 0.09, ESP was 0.01 and mUPPP was 0.29. Conclusion. RRR provides a summarized data-driven, statistical guide to aid decision-making, and helps in patient counseling. BRP and ESP have been shown to have less complications compared to mUPPP. Level of evidence: IV.

ObjectiveA 15 year review of the outcomes and success rates of the Expansion Sphincter Pharyngoplasty (ESP) in the treatment of patients with obstructive sleep apnea (OSA).MethodsA systemic review with two independent searches of MEDLINE, Google Scholar, Cochrane Library and Evidence-Based Medicine Reviews to identify publications relevant to OSA and Expansion Pharyngoplasty. All relevant studies published before 31 December 2021 were included.ResultsSixteen studies were included in this strict systematic review with a total of 747 patients who had the ESP procedure were included. The mean age was 41.3 years, mean BMI 28.2, the mean pre-op AHI was 32.3 and post-op AHI was 10.0 (p < 0.05), the mean pre-op ESS was 11.4, had reduced to post-op 5.3 (p < 0.05), and the mean pre-op snore VAS decreased from 8.7 to 2.9 (p < 0.05), with a mean follow-up time of 9.5 months. The overall pooled success rate for all the 747 patients was 80.0%. There were no significant reported complications noted in these studies.ConclusionAfter 15 years of presence, the expansion sphincter pharyngoplasty has shown to be reliably effective in the management of patients with OSA.

BackgroundEvaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). MethodsUsing previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. ResultsThe ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. ConclusionThis review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

To conduct a comparative performance evaluation of GPT-3.5, GPT-4 and Google Bard in self-assessment questions at the level of the American Sleep Medicine Certification Board Exam. A total of 301 text-based single-best-answer multiple choice questions with four answer options each, across 10 categories, were included in the study and transcribed as inputs for GPT-3.5, GPT-4 and Google Bard. The first output responses generated were selected and matched for answer accuracy against the gold-standard answer provided by the American Academy of Sleep Medicine for each question. A global score of 80

It is well accepted that obstructive sleep apnea (OSA) is not merely a simplistic anatomical imbalance of a small box (jaw) versus the over-crowding of tissue contents (namely the tonsils, tongue, palate, and lateral pharyngeal walls) within this container. Most sleep specialists agree that there is a strong complex neuro-physiological interconnected web of neurological and proprioceptor mechanism ongoing in this sleep disorder, perhaps simplified phenotypically as the PALM scale (Pcrit, arousal threshold, loop gain, and muscle responsiveness). What determines which patient would sleep through a prolonged and profound apneic event with a high arousal threshold and low muscle responsiveness versus another patient who would be easily aroused (low arousal threshold) and have frequent sleep fragmentations, no one has the answer. It has been shown that there is a complex relationship and physiological feedback mechanisms in the pathophysiology of upper airway collapse, cortical arousals, and teeth clenching in order to maintain airway patency. We are fairly clear that upper airway resistance syndrome (UARS) is the non-hypoxic sleep-disordered breathing that is closely related to cortical arousals, sleep fragmentation, psycho-somatic issues, excessive daytime sleepiness, neckaches, headaches, bruxism, and almost invariably nasal congestion.

In recent years, numerous smartphone applications (apps) have been developed that purport to diagnose and monitor sleep apnea. Physicians are often approached by patients self-diagnosing themselves with obstructive sleep apnea (OSA) based on a smartphone app recordings. With numerous sleep-related apps available between the App Store (Apple platform; Apple Inc., Cupertino, CA) and Google Play (Android platform; Google LLC, Menlo Park, CA), the array of data can become bewildering to navigate. Physicians must recognize that the validity and accuracy of the smartphone apps are unknown. We set out to examine five representative and sufficiently unique studies to determine the role of smartphone apps in the evaluation of sleep and sleep disorders. In 2016, Ong and Gillespie1 published the largest review to date focusing on the numerous smartphone applications available for sleep analysis. The study analyzed the apps available in the Apple (Apple Inc.) and Google Play (Google LLC) store that analyze and monitor sleep. The search terms used were sleep tracker, sleep apnea, and sleep cycle. There were 60 sleep apps found in the various app stores (33 from the Apple Store, Apple Inc.; 27 from the Google Play store, Google LLC), measuring a combination of sleep duration, time awake, time in light and deep sleep, and time in rapid eye movement. Each app provided data on sleep structure; however, the algorithms used were not validated by scientific studies, regulatory bodies, or against established sleep study methodology (polysomnogram (PSG) or ambulatory sleep studies). The lack of validation metrics were cited as a significant limitation of all existing apps marketed as relating to sleep apnea. The study did not show any one app as being superior or sufficiently accurate to merit being included as part of routine medical sleep analysis. In a study by Bhat et al.,2 the researchers examined a specific smartphone (Apple and Android) app (Sleep Time) marketed as the most popular and widely downloaded sleep assessment app. Twenty subjects with ages ranging from 22 to 57 with no previously diagnosed sleep disorders were recruited. After enrollment, subjects completed an anonymous questionnaire pertaining to sleep-related complaints. The subjects were asked to download the Sleep Time app and use it for five consecutive nights, after which all subjects underwent a PSG study while simultaneously using the app. The results showed that there was no correlation between PSG and the app ability to rate sleep efficiency. In comparison to the PSG, the app had high sensitivity for detecting sleep and was accurate in sleep–wake detection, but overall it performed poorly with low specificity for the diagnosis of OSA and had a poor correlation to PSG results (r = 0.127, P = .592). These results suggested that contrary to claims, this widely used app was unreliable in both diagnosing and monitoring OSA. In a study by Nakanoo et al.,3 the idea of monitoring sound to quantify snoring and sleep apnea using a smartphone was explored. The study consisted of 50 subjects (42 males; 8 females), with a mean age of 47.9 years old and a mean apnea hypopnea index (AHI) of 27.3, who underwent a PSG. Ten of the patients were delegated to develop the program, whereas the other 40 were used for validation. A smartphone was attached to the subjects' sternums, where it acquired snoring sound from the built-in microphone. In this instance, the snoring time measured by the smartphone highly correlated with the snoring time measured by the PSG. In addition, the snoring sounds recorded were able to be correlated with the AHI using proprietary software (r = 0.92). The study concluded that the use of a smartphone to monitor snoring sounds could be a valid way to quantify snoring and OSA, but the positive correlation diminished for subjects with an AHI less than 30. This study was performed in a quiet sleep lab, and no generalizations were made to whether it could apply in a noisier, home environment. Tal et al.4 performed a study in an attempt to validate a contact-free system to monitor sleep with high accuracy while still providing maximum comfort in comparison to the gold standard PSG. The EarlySense, Ramat Gan, Israel (ES) contact-free sensor is placed under the mattress where the patient's chest is estimated to lie and is connected through Bluetooth to a smartphone application. There were 63 subjects of varying ages who participated in the study. The variables tested include heart rate, respiratory rate, and sleep stage. There was a linear correlation between the total sleep time measured by the sensor and the PSG (r = 0.87), with a sleep detection accuracy of approximately 90%. The authors concluded that this system was highly accurate in detecting sleep and wake states in relation to the PSG. Furthermore, the ES contact-free sensor measured heart rate and respiratory rate throughout the night, with the values being highly correlated to those of the ES sensor currently used in hospitals. The authors intend to further explore whether it can record disturbed sleep as a measure of OSA. A unique study was conducted by Al-Mardini et al.5 by pairing smartphone sensor technology with a portable oximetry device. This is the only study conducted with equipment with ability to compare the two parameters in one system. The developed app consisted of an oximeter to measure the oxygen saturation, a microphone to record the respiratory effect, and an accelerometer to detect the body's movement. The results showed that the AHI values obtained from the app were close to the PSG. Further, the results demonstrated that 100% of patients were correctly identified as having the disease, and 85.7% of patients were correctly identified with not having the disease. These results supported the concept that in principle a properly configured smartphone app can mimic findings of PSG. A wide variety of smartphone applications exist that are either free or low-priced and purport to aid in the diagnosis of OSA or sleep-disordered breathing. Although for some sleep smartphone apps there is a linear correlation between a PSG and a smartphone application, this is far from replacing the gold standard data provided by hospital or ambulatory PSG testing. No current apps have been rigorously tested against PSG; most do not take oximetry into account; and some may obscure the clinical picture of OSA. Current smartphone apps therefore provide a weak indication of what patients are experiencing while they are sleeping, and the current landscape of sleep apps are not yet a substitute for either level 1 PSG or ambulatory. The technology landscape would seem to be ripe for development of a formally developed smartphone app designed with clinical sleep medicine in mind. One study was a level 2A review article; three studies were level 2C outcomes studies compared against existing standards; and one study was a level 5 basic science experiment.

Obstructive sleep apnea (OSA) is a systemic disease that is due to upper airway collapse and obstruction during sleep, resulting in frequent hypoxia, sympathetic overdrive, tachycardia, nocturnal hypertension, and oxidative metabolic stress. Daytime symptoms include unrefreshed sleep, daytime tiredness, loss of memory, irritability, lack of concentration, poor work productivity, poor quality of life (QOL), mood swings, and even depression; nighttime symptoms include loud snoring, choking at night, gasping for air, frequent arousals, witnessed apneas, and nocturia. OSA can lead to systemic diseases like hypertension, cardiovascular events, myocardial infarct, and fatal arrhythmias. The “gold” standard test for OSA is commonly assigned as the level I overnight polysomnography (PSG). However, sleep specialists are aware of its shortcomings and the inconsistencies of the single parameter AHI (apnea-hypopnea index). It is widely known that there is discordance between AHI (that is used to denote outcomes/success of therapy) and real actual clinical outcomes such as QOL, patient perception of disease, cardiovascular measures, and/or survival. Recent studies have shown that the use of a single parameter AHI is inaccurate, inadequate, and unrealistic; sleep medicine needs to be more holistic to assess actual clinical treatment outcomes. As OSA is a systemic disease that affects all the end organs, outcome parameters should be those related to these end organ effects; some of these more holistic parameters (SLEEP GOAL) include snoring level, sleep latency, execution time, Epworth sleepiness scale, blood pressure, gross weight (BMI), oxygen duration below 90%, AHI, and QOL scores.