Background: Evaluation 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). Methods: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidencebased 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. Results: The 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. Conclusion:This 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.

Objective: To determine if a modified tissue-preserving palatopharyngoplasty could convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug-induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation due to complete circumferential collapse at the velum. Methods: A prospective, nonconsecutive, single-blinded cohort study was performed by two sleep surgeons at a tertiary care center from 2015 to 2018. Inclusion criteria included adults > 18 years of age with a diagnosis of obstructive sleep apnea with an Apnea-Hypopnea Index (AHI) > 15, a body mass index (BMI) < 32, and < 25% central apneas on polysomnography. Twelve patients with complete circumferential collapse underwent a modified palatopharyngoplasty. Postoperatively, a repeat sleep study was performed. A repeat DISE was recommended for those with incomplete surgical response (clinically and/or AHI). Results: Twelve patients with complete circumferential collapse were eligible for the study. Mean BMI was 30.5. Mean preoperative AHI was 54.0 events per hour. Following a modified palatopharyngoplasty, the mean AHI was reduced to 33.1 events per hour, and 100% (12 of 12) of the patients converted from a pattern of complete circumferential collapse to either no collapse at the level of the velum (3) or an anteroposterior pattern of collapse (9). Conclusion: We demonstrate that a modified palatopharyngoplasty can successfully convert collapse patterns in patients with complete circumferential collapse. Further studies are required to determine the outcome of these patients following upper airway stimulation implantation.

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