Postoperative Radiologic Imaging in Secondary Alveolar Bone Grafting for Cleft Lip and Palate: A Systematic Review and Meta-Analysis.

INTRODUCTION: Radiographs (XRs), computed tomography (CT) scans, and cone-beam CT (CBCT) scans are utilized for assessment of secondary alveolar bone graft (SABG) in patients with cleft lip and palate (CLP). However, the optimal choice for imaging modality remains unclear. This study compares the image fidelity and safety profile for XR, CT, and CBCT in the assessment of patients with CLP who have undergone SABG. METHODS: Articles from MEDLINE and Elsevier Embase were screened. The primary outcome was graft success rate. Secondary outcomes were percent-by-volume of graft maintained and patient safety, defined by radiation exposure. A random effects model was used to calculate the pooled outcomes for each imaging modality. Chi-squared analysis was used to compare pooled outcomes between different imaging modalities. RESULTS: Of the 149 articles identified initially, 14 were included. Computed tomography exhibited a significantly higher image fidelity demonstrated by a lower graft success rate (62.0%) compared with both XR (72.6%, P<0.01) and CBCT (69.8%, P<0.01). Cone-beam CT had the lowest reported percent-by-volume of graft maintained (32.1%). Computed tomography had a higher mean radiation dosage (39.7 milligray) than what has been reported for both XR and CBCT. CONCLUSION: Computed tomography demonstrated lower graft success rates than both XR and CBCT, possibly indicating a higher image fidelity. However, compared with CBCT, CT may have a higher radiation exposure. Randomized trials and longitudinal studies are necessary to perform a direct comparison between CT and CBCT and to correlate the image fidelity of these modalities with clinical outcomes.

Patient-Reported Outcome Measures Including Nasal Breathing Improvement After Functional Rhinoplasty Using Endonasal Septal Extension Grafting.

Objective: To measure the change perceived by patients after endonasal rhinoplasty using a, septal extension graft (SEG), as measured by patient-reported outcome measures (PROMs). Methods: A retrospective review of patients with nasal obstruction underwent septoplasty, turbinoplasty, and SEG. PROMs were assessed to compare operative outcomes for breathing (Nose Obstruction Symptom Evaluation [NOSE], Sinonasal Outcome Test [SNOT]-22, Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]), and sleep quality (Epworth Sleepiness Scale [ESS]) Results: Of the 34 patients undergoing rhinoplasty with Endonasal SEG, the median patient age was 38.3 years (range 17-58) and mostly male (n = 18, 52.9%). Additional procedures performed on the patients included septoplasty (n = 34, 100%) and turbinate reduction (n = 34, 100%). Average follow-up was 126.6 days (range 28-573) for a majority of PROMs. There were no complications. The average change in NOSE score was 71.5 and -49.4 (standard deviation [SD] = 19.0, p < 0.001). SNOT-22 change was 35.4 and -24.2 (SD = 14.5, p < 0.001), and ESS scores averaged 6.7 and -3.4 (SD = 4.3, p < 0.001). The average SCHNOS total, functional, and cosmetic scores were 40.6, 67.9, and 22.4, respectively, and -28.0 (SD = 19.8), -44.5 (SD = 22.9), and 17.1 (SD = 24.6) (p < 0.001). Conclusion: In this pilot study, patients reported improvement in nasal breathing after correcting a deviated caudal septum and applying an Endonasal SEG.

Virtual Surgical Planning for Patients with Skeletal-Dental and Obstructive Sleep Apnea Syndrome.

The integration of virtual surgical planning (VSP) for the treatment of skeletal, dental, and facial abnormalities and obstructive sleep apnea (OSA) with maxillofacial surgery has catapulted surgical planning. Although reported for treating skeletal-dental abnormalities and dental implant surgery, a paucity of knowledge existed reporting the feasibility and resultant outcome measures when VSP was employed for planning maxillary and mandibular surgery for OSA patients. The surgery-first approach is at the forefront of advancing maxillofacial surgery. Case series reporting success with the surgery-first approach for patients with skeletal-dental and sleep apnea patients have been reported. In sleep apnea patients, clinically significant reductions in apnea-hypopnea index and improvement of low oxyhemoglobin saturation have been achieved. More so, significant improvement in the posterior airway space at the occlusal and mandibular planes were achieved, while preserving aesthetic norms as measured by tooth to lip measurements. VSP is a feasible tool used for predicting surgical outcome measures in maxillomandibular advancement surgery for patients with skeletal, dental, facial, and OSA derangements.

International Consensus Statement on Obstructive Sleep Apnea.

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 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. 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.

A comparison of an absorbable nasal implant versus functional rhinoplasty for nasal obstruction.

PURPOSE: An absorbable nasal implant for the treatment lateral nasal wall collapse was approved for use in patients with nasal obstruction. It remains to be seen whether this treatment is equivalent to open techniques for the treatment of nasal valve incompetence from collapsibility. MATERIALS AND METHODS: Two groups were analyzed for the study. One group had surgery which included the implant, septoplasty, and inferior turbinate submucous reduction and the other group had a variety of functional rhinoplasty techniques for lateral wall insufficiency in addition to septoplasty and inferior turbinate submucous reduction. NOSE and SNOT-22 were used to demonstrate pre and post-operative changes. RESULTS: Ninety total patients were identified. Fifty patients underwent insertion of an absorbable nasal implant and 40 underwent a traditional open technique to stabilize the LNW. For the implant group the mean NOSE score was 63.4 (SD 24) and post-operative was 22.9 (SD 19.9), in addition, the SNOT-22 score was 38.8 (SD 19.8) and post-operative was 18.5 (SD 15.2). For the open rhinoplasty group, the mean NOSE score was 57.9 (SD 23.2) and post-operative was 17.6 (SD 16.4). The SNOT-22 score was 33.6 (SD 14.9) and post-operative score was 11.5 (SD 15.2) The delta between pre and post-operative NOSE and SNOT-22 test were not different at an average of 3.95 months post-operatively between the groups (NOSE, P = 0.94 and SNOT-22, p = 0.53). CONCLUSION: In patients with multiple structural causes of nasal obstruction, including lateral wall insufficiency, insertion of an absorbable nasal implant, to support the LNW, seems to be equally effective as functional rhinoplasty techniques over a 4 month timeframe.

Mechanisms of Soft Tissue Injury and Repair from Ballistics.

Projectile injuries to the face deserve particular attention to evaluate for involvement of critical structures and functional elements and treat the devastating effects on facial aesthetics. Ballistic trauma to the maxillofacial region often has significant soft tissue and bony defects, creating a greater challenge to the reconstructive surgeon. The main goals of treatment of projectile injuries to the face are decreasing the amount of contaminants and nonviable tissue at the site, ensuring functionality, and restoring aesthetic appearance. There exists a lack of robust research on the subject. Soft tissue injuries from high-velocity projectiles have changed the perspective on treating acute injuries to the face and neck. Injuries encountered during both Operation Iraqi Freedom and Operation Enduring Freedom give the author pause to reflect upon a different wounding pattern than that encountered in stateside trauma centers. Given the dissemination of high-velocity weaponry by enemy combatants such as the improvised explosive device, mortar round, and high-velocity rifles, a higher incidence of facial wounds has been reported. The mechanism of injury and a stepwise approach for surgical repair are discussed incorporating advanced trauma life support principles and a reconstructive ladder of repair.

Recent advances in orthognathic surgery.

PURPOSE OF REVIEW: The aim of this article is to review the recent literature on orthognathic surgery for treatment of malocclusion and obstructive sleep apnea (OSA). The discussion outlines the refinements of the procedure and advances in technology. RECENT FINDINGS: Maxillomandibular advancement (MMA) may be performed for complex malocclusion and OSA. Although orthodontic management followed by MMA has been the gold standard in managing complex cases, the surgery first approach for treatment of malocclusion has increased in popularity because of decreased treatment time and improved patient quality of life. MMA continues to be the gold-standard for treatment of refractory sleep apnea. Technological advancements, including 3D printing and virtual surgical planning, have enhanced the patient experience and provided more efficiency to this surgery. SUMMARY: First introduced in the 19th century, orthognathic surgery has continuously been refined. Over the last few decades, there has been increasing support for a surgery first approach in the treatment of malocclusion. MMA has revolutionized the surgical treatment of OSA and provides the best opportunity for success or cure in patients with complex obstructive patterns. Technology has enhanced the surgical process and created more efficiency for the surgeon and patient. VIDEO ABSTRACT: http://links.lww.com/COOH/A40.

Unilateral and bilateral isokinetic knee strength indices in professional soccer players / Índices de fuerza isocinética unilateral y bilateral de rodilla en jugadores profesionales de futbol

INTRODUCTION: The maximum isokinetic torque is one of the most commonly applied methods to assess the muscle strength of the lower extremities in soccer. Knee force indices have been used extensively to identify possible risk factors for injuries such as torn hamstring muscles or rupture of the anterior cruciate ligament. There are previous studies that describe the isokinetic profile in different populations and there are few in Latin American population. The objective of this study is to describe the isokinetic profile and strength indices in a population of soccer players from a professional Mexican team. METHODOLOGY: This is an observational, retrospective, analytical study. The maximum torque was measured with an angular velocity of 60°/s in 375 professional soccer players from 1st, 2nd and 3rd division from 2010 to 2015 in the Department of Sports Medicine and Rehabilitation of the "Dr. José Eleuterio González" University Hospital, Monterrey Nuevo León, Mexico. RESULTS: The results obtained were general, clinimetry and isokinetic parameters. The maximum torque was cataloged by group in injured and non-injured players according to the division: 1st (n = 142), 2nd (n = 86) and 3rd (n = 147). From these, the isokinetic strength indices of each of the players were obtained, observing anthropometric differences, in the unilateral and bilateral knee indices, between each category, and even more so in players with injuries. It is important to have isokinetic parameters and identify at-risk players according to their category as this will provide reference data for future assessments of professional soccer players and they can be used to categorize muscle function as normal or at risk of injury

INTRODUCCIÓN: El torque máximo isocinético es uno de los métodos más comúnmente aplicados para evaluar la fuerza muscular de las extremidades inferiores en el futbol. Se han empleado índices de fuerza de la rodilla extensivamente para identificar posibles factores de riesgo para lesiones como desgarros de la musculatura isquiotibial o la ruptura del ligamento cruzado anterior. Hay estudios previos que describen el perfil isocinético en distintas poblaciones y hay pocas en población latinoamericana. El objetivo de este estudio es describir el perfil isocinético y los índices de fuerza en una población de jugadores de soccer de un equipo profesional mexicano. METODOLOGÍA: Es un estudio observacional, retrospectivo y analítico. Se midió el torque máximo con una velocidad angular de 60°/s en 375 futbolistas profesionales de 1°, 2° y 3° división del 2010 al 2015 en el Departamento de Medicina del Deporte y Rehabilitación del Hospital Universitario "Dr. José Eleuterio González", Monterrey Nuevo León, México. RESULTADOS: Los resultados recabados fueron generales, clinimetria y parámetros isocinéticos. Los torques máximos fueron catalogados por grupo en jugadores lesionados y no lesionados de acuerdo a la división: 1°(n = 142), 2° (n = 86) y 3° (n = 147). A partir de estos se obtuvieron los índices de fuerza isocinética de cada uno de los jugadores existiendo diferencias antropométricas, en los índices unilateral y bilateral de rodilla, entre cada categoría, y más aún en jugadores con lesiones. Es importante tener parámetros isocinéticos e identificar jugadores en riesgo según su categoría ya que esto aportar datos de referencia para futuras valoraciones en los jugadores profesionales de soccer y pueden ser utilizados para categorizar la función muscular como normal o con riesgo de lesión

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study.

OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort. METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression. RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m2 . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely). CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. LEVEL OF EVIDENCE: 2B Laryngoscope, 129:761-770, 2019.

Skeletal Surgery for Obstructive Sleep Apnea.

Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.

Anatomic measures of upper airway structures in obstructive sleep apnea.

OBJECTIVE: Determine if anatomic dimensions of airway structures are associated with airway obstruction in obstructive sleep apnea (OSA) patients. METHODS: Twenty-eight subjects with (n = 14) and without (n = 14) OSA as determined by clinical symptoms and sleep studies; volunteer sample. Skeletal and soft tissue dimensions were measured from radiocephalometry and magnetic resonance imaging. The soft palate thickness, mandibular plane-hyoid (MP-H) distance, posterior airway space (PAS) diameters and area, and tongue volume were calculated. RESULTS: Compared to controls, the OSA group demonstrated a significantly longer MP-H distance (P = 0.009) and shorter nasal PAS diameter (P = 0.02). The PAS area was smaller (P = 0.002) and tongue volume larger in the OSA group (P = 0.004). The MP-H distance, PAS measurements, and tongue volume are of clinical relevance in OSA patients. CONCLUSIONS: A long MP-H distance, and small PAS diameters and area are significant anatomic measures in OSA; however the most substantial parameter found was a large tongue volume.

Skeletal Surgery for Obstructive Sleep Apnea.

Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.

Predicting Surgical Response Using Tensiometry in OSA Patients after Genioglossus Advancement with Uvulopalatopharyngoplasty.

OBJECTIVE: To evaluate the role of tension on the genioglossus muscle in the performance of genioglossus advancement on sleep-disordered breathing in patients undergoing multilevel obstructive sleep apnea (OSA) surgery. STUDY DESIGN: Prospective study. SETTING: Academic practice. SUBJECTS AND METHODS: Twenty-three subjects underwent genioglossus advancement with uvulopalatopharyngoplasty for OSA. Subjects underwent pre- and postoperative polysomnography, cephalometry, and subjective assessment questionnaires. Eighteen subjects completed the study. The tension force of the mandible and the bicortical width of the genial tubercle were measured and surgical response determined. RESULTS: Improvement in apnea-hypopnea index (AHI) was seen in 15 of 18 subjects (83.3%). Eleven subjects were classified as responders and 7 as nonresponders (61.1% success), with responders exhibiting a statistically significant reduction in mean delta AHI as compared with nonresponders: 28.3 ± 26.2 versus 2.0 ± 22.0 events per hour (95% confidence interval, 1.8-50.8; P = .037). The Epworth Sleepiness Scale improved from 13.2 ± 4.5 to 7.6 ± 3.4 (P = .002). There was no significant difference in body mass index, neck circumference, overall tension, or mandibular width between responders and nonresponders. However, there was a significant difference in the tension:width ratio between responders (53.9 ± 6.38 g/mm) and nonresponders (65.4 ± 11.2 g/mm; 95% confidence interval, 0.92-22.1; P = .036). CONCLUSION: This article describes a novel approach to determine the force applied to the genioglossus during advancement and its correlation to postoperative outcomes. The tension:width ratio may be an indicator for postoperative success and delta AHI improvement in OSA patients.

Quantifying Changes in Nasal Tip Support.

IMPORTANCE: Imparting surgical change to the nasal tip remains one of the most challenging aspects of rhinoplasty. The surgeon must assess the tip preoperatively and execute the necessary maneuvers to impart the desired change. OBJECTIVE: To assess nasal tip resistance to compression in a cadaveric model before and after specific rhinoplasty maneuvers using a novel method. DESIGN, SETTING, AND MATERIALS: Open rhinoplasty maneuvers were performed at an academic tertiary care center on 6 fresh-thawed cadaver heads. Assessment of tip support was performed with a motorized, computer-controlled test stand equipped with a digital load cell. Tip support was assessed by compression to a depth of 2.5 mm from contact both preoperatively and after each surgical maneuver. All force data were recorded in pound-force and converted to newtons (N) following analysis. MAIN OUTCOMES AND MEASURES: Nasal tip support, measured as resistance to compression, before and after various rhinoplasty maneuvers. RESULTS: Following the elevation of the skin-soft-tissue envelope with septoplasty, resistance to compression (1.82 N) was not significantly different from the preoperative assessment (1.60 N for all specimens). Tip support following placement of a caudal extension graft was significantly different from all other conditions (3.16 N; P < .01), showing support increased by more than 66% from preoperative assessment. Placement of columellar strut (1.28 N) did not show significant increase in tip support. Tip support was decreased slightly after placement of intradomal sutures, which was significant (1.22 N; P < .01). CONCLUSIONS AND RELEVANCE: This study demonstrates the use of materials testing equipment to assess and quantify change in tip support after several rhinoplasty maneuvers. Minor supporting maneuvers that rely on healing and scar do not significantly alter tip support in a cadaveric model. Caudal extension graft is an important maneuver imparting significant effect on nasal tip support. LEVEL OF EVIDENCE: NA.

Geniotubercle advancement with a uvulopalatal flap and its effect on swallow function in obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: Evaluate swallowing characteristics before and after geniotubercle advancement (GTA) with a uvulopalatal flap (UPF). STUDY DESIGN: Prospective case control series in an academic military practice. METHODS: Fourteen patients with apnea-hypopnea index (AHI) >10 scheduled for GTA were enrolled consecutively, eight of whom completed all aspects of the study for evaluation. Video fluoroscopic swallow study was performed preoperatively and 4 months postoperatively. National Institute of Health freeware ImageJ64 software was used to measure hyolaryngeal elevation and displacement. Video recordings assessed vallecular pooling, aspiration, and bolus movement. Studies were reviewed by a speech pathologist and an otolaryngologist. RESULTS: Preoperatively, the mean AHI was 48.3 ± 48.45 events per hour, with a median of 48.5 (range, 12.4-76). Postoperatively the mean AHI was 11.6 ± 10.7 events per hour, with a median of 10.75 (range, 3.8-29) (P = .003). There was no reported pre- or postoperative dysphagia or aspiration. No radiographic evidence of silent aspiration was seen. Hyolaryngeal movements were measured as a percentage of C2-C4 reference distance. The superior elevations were pre- and postoperatively 40% and 37% (P = .85), anterior displacement changes 18.9% and 18.8% (P = .23), and total motion 49% and 42% (P = .26), respectively. CONCLUSIONS: GTA with UPF surgery did not significantly affect the hyolaryngeal function of patients.

Virtual surgical planning improves surgical outcome measures in obstructive sleep apnea surgery.

OBJECTIVES/HYPOTHESIS: Determine the feasibility and accuracy of using virtual surgical planning (VSP) to direct the surgical and polysomnography (PSG) outcomes of patients with obstructive sleep apnea (OSA). STUDY DESIGN: Prospective case series. METHODS: Skeletal and soft tissue dimensions were measured from computed tomography (CT) to include posterior airway space (PAS) diameters at the occlusal (PAS-O) and mandibular (PAS-M) plane, position of the maxilla, and tooth-to-lip distance. All patients underwent an in-lab attended PSG whereby apnea-hypopnea index (AHI), respiratory disturbance index (RDI), and lowest oxyhemoglobin saturation percent (LSAT) were measured preoperatively and at least 9 months postoperatively. RESULTS: Four patients with OSA demonstrated a mean AHI and RDI of 60.1 and 69.5 events per hour, respectively. The mean preoperative LSAT was 76%. Mean CT-based measures for PAS-O and PAS-M were 3.08 mm and 9.03 mm, respectively. VSP was used to direct the amount of advancement and impaction in maxillomandibular advancement (MMA) surgery. The mean PAS-O and PAS-M postoperative measures significantly increased to 8.15 and 14 mm (P < .004), whereas the mean tooth-to-lip relationship stayed the same, 3.17 to 3.18, P = .98. The AHI and RDI significantly improved to 2.83 and 4.5 events per hour, respectively, P = .03, whereas the LSAT improved from 76% to 87%. CONCLUSIONS: VSP for MMA in OSA patients is feasible and safe while offering improvements in the predictability of airway change and tooth-to-lip measures.

Total airway reconstruction.

We present a case of obstructive sleep apnea (OSA) that required multilevel surgical correction of the airway and literature review and discuss the role supraglottic laryngeal collapse can have in OSA. A 34-year-old man presented to a tertiary otolaryngology clinic for treatment of OSA. He previously had nasal and palate surgeries and a Repose tongue suspension. His residual apnea hypopnea index (AHI) was 67. He had a dysphonia associated with a true vocal cord paralysis following resection of a benign neck mass in childhood. He also complained of inspiratory stridor with exercise and intolerance to continuous positive airway pressure. Physical examination revealed craniofacial hypoplasia, full base of tongue, and residual nasal airway obstruction. On laryngoscopy, the paretic aryepiglottic fold arytenoid complex prolapsed into the laryngeal inlet with each breath. This was more pronounced with greater respiratory effort. Surgical correction required a series of operations including awake tracheostomy, supraglottoplasty, midline glossectomy, genial tubercle advancement, maxillomandibular advancement, and reconstructive rhinoplasty. His final AHI was 1.9. Our patient's supraglottic laryngeal collapse constituted an area of obstruction not typically evaluated in OSA surgery. In conjunction with treating nasal, palatal, and hypopharyngeal subsites, our patient's supraglottoplasty represented a key component of his success. This case illustrates the need to evaluate the entire upper airway in a complicated case of OSA.