# Western University Protocol for Obstructive Sleep Apnea

## TL;DR

This paper presents a surgical protocol for obstructive sleep apnea, using drug-induced sleep endoscopy and personalized interventions to improve outcomes for patients who cannot tolerate CPAP therapy.

## Contribution

A novel, evidence-based surgical protocol for OSA management is proposed, integrating anatomical phenotyping and drug-induced sleep endoscopy.

## Key findings

- A DISE-guided surgical approach includes uvulopalatoplasty, septoplasty, and maxillomandibular advancement.
- Preoperative assessments using BMI and STOP-BANG scale help guide patient selection and treatment planning.
- Regional experiences in Saudi Arabia and Canada support standardized evidence-based surgical care for OSA.

## Abstract

Background/Objectives: Obstructive sleep apnea (OSA) is a prevalent disorder in adults, characterized by recurrent upper airway obstruction during sleep, resulting in intermittent hypoxia, sympathetic activation, and sleep fragmentation. It is linked to significant cardiovascular, metabolic, neurocognitive, and psychosocial morbidity. There is increasing evidence that continuous positive airway pressure (CPAP) adherence remains suboptimal in many patients, and in those patients, surgery is often indicated. Methods: This protocol report presents an updated and protocol-driven surgical approach grounded in clinical evidence and experience, highlighting the role of drug-induced sleep endoscopy (DISE) and personalized multi-level interventions for adult patients with OSA. The integration of anatomical phenotyping and DISE-directed planning enables precise surgical targeting. The protocol emphasizes patient selection, individualized treatment based on obstruction patterns, and perioperative optimization. This surgical algorithm improves the success rates and long-term outcomes in patients who are intolerant of CPAP therapy. Results: A DISE-guided and multi-level surgical approach includes uvulopalatoplasty, septoplasty, tongue base reduction, palatoplasty, and maxillomandibular advancement (MMA). Preoperative assessments include BMI and the STOP-BANG and Epworth Sleepiness scales, while postoperative care emphasizes follow-up polysomnography and adjunctive therapies only when necessary. Regional experiences in Saudi Arabia and Canada underscore the importance of standardized evidence-based surgical care. Conclusions: The purpose of this article is to establish a clear protocol for managing patients diagnosed with OSA, drawing on a review of the existing literature and the insights of experienced surgeons in the field of sleep apnea, and to update current protocols with modern evidence.