Hold on to the headline: E-S-P took the A-H-I from about twenty-one to about thirteen, and the muscle-sparing UPPP's fall was not statistically significant. What this adds is independent support for the principle behind B-R-P: palate surgery should reposition muscle and address the lateral wall, not just remove tissue. But this paper did not study B-R-P, and it should not be quoted as B-R-P evidence. Nothing in it argues for moving from B-R-P to E-S-P. The Neruntarat meta-analysis points to similar A-H-I results with a shorter operation for B-R-P.

For counseling, the paper adds frank morbidity numbers. After E-S-P, nearly a third of patients had a minor secondary bleed, and the top step of pain medicine was needed more often. The Innsbruck patients stayed five days. In Dr. Nord's practice, airway-surgery patients like these are kept for twenty-three-hour observation, so the Innsbruck pain and bleeding figures come from a much longer stay. Patients should also hear that palate surgery usually lowers the A-H-I rather than normalizing it. In this series, the average after E-S-P was still about thirteen events an hour, and twelve weeks says nothing about durability.

Weight belongs in that conversation. In this paper, a body mass index over twenty-five was linked to a worse postoperative A-H-I, though the size of that effect was not reported. An easy figure to quote comes from the Kaki study. Those patients averaged a body mass index of about thirty-two. Fewer than half met surgical success after E-S-P, twenty-four of fifty-two. The caveat is that this is a different cohort, scored with its own version of the success criteria, and it compares cohorts rather than measuring the effect of weight directly. Dr. Nord treats weight loss, including glucagon-like peptide-1, or GLP-1, drugs, as part of multimodal treatment of O-S-A, often alongside Inspire rather than instead of it.

My confidence that lateral-wall operations beat tissue trimming is moderate. My confidence in the size of the E-S-P advantage here is low. What would move both is a randomized or matched comparison of B-R-P against E-S-P, with the same sleep test before and after, outcomes by DISE pattern, and follow-up past a year.

What's your one takeaway from this paper?

Paper: Steinbichler TB, Bender B, Hartl R, Strasser V, Sontheimer D, Buricic S, et al. Uvulopalatopharyngoplasty Versus Expansion Sphincter Pharyngoplasty: A Single Centre Experience. *Clocks & Sleep*. 2025;7(3):38. doi:10.3390/clockssleep7030038 https://doi.org/10.3390/clockssleep7030038

Dr. Nord is a high-volume Inspire implanter, so in Dr. Nord's practice the first decision this touches is consent. Tell candidates what this series showed: about one in six patients noticed a new sound when the device switched on, most often described as buzzing. For most, it was mild. Of the twelve who heard it, five said it had no effect on daily life, sleep or mood. None described a severe effect, and none stopped using the device. Then give the caveats plainly: one center, a telephone survey, an unvalidated questionnaire, no hearing tests, and an unknown response rate.

Preexisting tinnitus isn't a reason to exclude a patient. It isn't grounds for blanket reassurance either, because four against eight can't settle the question. Record tinnitus and hearing history before surgery, since this study had to rely on recall to decide that a sound was new.

The second decision comes at activation and titration. Ask directly: do you hear anything when the device turns on? Ask whether it's louder lying on the implant side. When a patient's use is slipping, ask whether noise is part of the reason. That link isn't proven here. But the registry data show that discomfort can cost hours of use, and without targeted questions this effect is easy to miss. If a sound is bothersome, reprogramming is a reasonable next step, though no one has shown it changes the sound.

The paper describes an approach that intentionally includes the C1 fibers to the geniohyoid. This study is no reason to drop them; the bone-conduction mechanism is a hypothesis.

The paper doesn't say which Inspire generation was implanted, and there are no published outcomes yet for Inspire V, so don't tie this figure to any one generation.

Confidence is moderate that these questions belong in follow-up, and low for the exact rate. What would move it is a multicenter prospective study that reports its response rate and includes audiometry, acoustic recordings, laterality, programming changes and longitudinal follow-up. If device sound turned out to drive nonuse or explantation, it would become a selection question, not just a counseling one.

The citation: Belilos, Adibi, Tucker, Saeedi, Calder, Lee, and Nord. Auditory Perceptions Associated With Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea. Laryngoscope Investigative Otolaryngology, twenty twenty-six, volume eleven, article e seven zero five five zero.

Residents, what one question about sound will you add to your next activation visit?

Paper: Belilos A, Adibi I, Tucker A, Saeedi A, Calder A, Lee L, Nord R. "Auditory Perceptions Associated With Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea." *Laryngoscope Investigative Otolaryngology* 2026;11:e70550 (6 pages). DOI: 10.1002/lio2.70550 (as printed). PMID: not printed in PDF (42694569 per the weekly PubMed scan). Received 8 January 2026; revised 28 May 2026; accepted 21 August 2026. Open access (CC BY-NC-ND). All authors from the Department of Otolaryngology—Head and Neck Surgery, Virginia Commonwealth University Medical Center, Richmond; correspondence to Ryan Nord (ryan.nord@vcuhealth.org). This is the library owner's own series. https://doi.org/10.1002/lio2.70550

First, the paper sharpens counseling. In this series, the AHI was cut roughly in half, from about fifty to about twenty-three. Only about one in three was cured. Counsel with that residual AHI, not the nine-in-ten success figure, and plan with the patient for possible residual disease.

Second, it adds weight to treating large tonsils first, in line with Green and TEAMUP. Consider a patient with grade three or four tonsils who sits outside the Inspire window. For that patient, a tonsillectomy-based palate operation is a reasonable first step. This is one surgeon's uncontrolled series, so treat it as support, not proof.

Third, keep the Müller lateral wall finding as a hypothesis, not a selection rule.

Fourth, weight. Two figures are easy to share with patients. In the Green study, each one-point rise in body mass index meant about eight percent lower odds of responding to pharyngeal surgery. That is observational data across mixed palate techniques. For Inspire, the 2020 ADHERE registry analysis from Thaler in the Laryngoscope found that each one-point rise in body mass index meant about nine percent lower odds of success. It still calls a body mass index of thirty-two "a useful guide" for implant decisions. That is registry data, not a trial. In Dr. Nord's practice, weight loss, including glucagon-like peptide one drugs, is part of multimodal treatment of obstructive sleep apnea. It often runs alongside Inspire rather than instead of it. Many Inspire patients are already on these drugs or will become candidates for them. The South Carolina authors likewise suggest weight reduction alongside palate surgery when appropriate.

My confidence that the AHI roughly halves in patients like these is moderate. It is one surgeon, retrospective, uncontrolled, and six months long. What would raise it? A controlled comparison against tonsillectomy alone or against barbed reposition, and two-year results. For residents, the line to practice in clinic is simple: half the AHI, one in three cured.

Today's paper was Abdelwahab and colleagues, with Nguyen as senior author: "Preservation Palatopharyngoplasty for Obstructive Sleep Apnea: Predictors and Clinical Outcomes." It appeared in Otolaryngology–Head and Neck Surgery, 2026, volume one seventy-four, issue four, pages eleven-oh-two to eleven-oh-eight.

What's your one takeaway from this paper?

Paper: Abdelwahab M, Alhussien A, Kassir MF, Butehorn H, Munhall C, Nguyen SA. Preservation Palatopharyngoplasty for Obstructive Sleep Apnea: Predictors and Clinical Outcomes. *Otolaryngol.--head neck surg.*. 2026;174(4):1102-1108. doi:10.1002/ohn.70183 https://doi.org/10.1002/ohn.70183

Dr. Nord's practice is built on high-volume Inspire implantation and barbed reposition pharyngoplasty. This is Genio data from eleven patients, so its numbers stay with Genio. What it adds is to counseling and to imaging.

When a patient asks about the bilateral device, the meta-analyses are the place to start. There's no demonstrated efficacy advantage over unilateral stimulation, and the safety record is less mature. DREAM adds device-specific failure modes, including migration. When a patient with a Genio implant needs imaging of the floor of mouth or tongue base, we now know what to expect. Plain films show the hardware cleanly. CT will carry artifact, compounded by dental work, and the authors advise reformatting in at least two planes. This is an older population where head and neck cancer workup will come up, as the authors point out, so tell the radiologist up front.

What I teach residents in the operating room and clinic is this. A symmetric film is not a prediction of success, and an asymmetric one is not grounds for revision. The trigger for workup is failure to activate or failure to respond, not the picture.

Confidence is moderate on the imaging advice, because it rests on eight CT scans in patients who all had dental implants. It's low on anything linking position to function. What would move it is a repeat film over time. That would tell us when migration happens, in the first week or the first month. It would show how often only one side shifts, and whether day-one asymmetry gets worse. Tie those films to thresholds and twelve-month A-H-I, and the day-one baseline becomes actionable. That's what to watch.

The citation: Kilgue, Gehl, Abolmaali, Scholtz, Scherl and Todt. Post-operative radiological evaluation of a bilateral hypoglossal nerve stimulation system. Frontiers in Surgery, 2026, volume thirteen, article one eight one eight two four seven.

What's your one takeaway from this paper?

Paper: Kilgue A, Gehl H-B, Abolmaali N, Scholtz L-U, Scherl C, Todt I. "Post-operative radiological evaluation of a bilateral hypoglossal nerve stimulation system." *Front. Surg.* 2026;13:1818247. DOI: 10.3389/fsurg.2026.1818247. PMID: not printed in PDF (42712560 per the weekly PubMed scan). Received 26 February 2026; revised 30 June 2026; accepted 08 July 2026; published 25 August 2026. Klinikum Bielefeld / Bielefeld University, Germany. Open access (CC BY). https://doi.org/10.3389/fsurg.2026.1818247

The honest limit stays. The headline, about eighteen events an hour lower in the eighteen patients followed, is a real fall. But this uncontrolled series can't show that the DISE itself caused it, rather than the treatments that followed, time, or regression to the mean.

The paper doesn't alter who is offered an implant, since nothing at baseline predicted who would fail to couple. What it adds is to counselling the stuck patient. At this one hospital, about one implant in four needed this step, twenty-nine of one hundred and fourteen. A little over a quarter of those became responders, eight of twenty-nine. Quote that alongside eight of the eighteen followed, and don't call the higher figure a rescue rate.

Settings changes are the most hopeful branch, five of six. Dr. Nord performs barbed reposition pharyngoplasty, and after an implant, the honest expectation is that fewer than half respond: three of seven did. In Dr. Nord's practice, airway-surgery patients like these are kept for twenty-three-hour observation. None of the five who had an oral appliance or uvulectomy responded, though that group is tiny.

And Inspire V? The stimulation lead remains, so the configuration logic may carry over. That is untested; there are no published outcomes yet for Inspire V.

Dr. Nord's confidence in the size of the benefit is low to moderate. What would raise it is a comparison of DISE-guided management against repeated awake titration in matched non-responders, with every patient accounted for, follow-up to twelve months, and usage hours reported.

The paper is from Copper's group, in Sleep and Breathing, 2025, volume twenty-nine, article two eighty-five.

What's your one takeaway from this paper?

Paper: Kant E, Hardeman JA, Stokroos RJ, Copper MP. Exploring the role of drug-induced sleep endoscopy in optimizing upper airway stimulation therapy for non-responders. *Sleep Breath*. 2025;29(5). doi:10.1007/s11325-025-03468-z https://doi.org/10.1007/s11325-025-03468-z

The decision it touches is the conversation with a patient who carries excess weight and is considering Inspire or barbed reposition pharyngoplasty, BRP. In Dr. Nord's practice, weight loss, including GLP-1 drugs, is part of multimodal treatment of obstructive sleep apnea alongside Inspire, often both rather than either-or. Many Inspire patients are already on these drugs or will become candidates for them.

So quote the drug-specific headline, not the pooled ten: about twenty-two fewer events per hour than control with tirzepatide over a year, about six fewer with liraglutide.

Two more figures patients can hold onto. In the meta-regression from Bednarik's group, about a ten percent drop in body mass index matched about a thirty-six percent drop in the A-H-I. A twenty percent drop matched about fifty-seven percent. A thirty percent drop matched about sixty-nine. The gains shrink beyond twenty percent, these are averages across study arms rather than predictions for one patient, and Lilly funded the work.

In the ADHERE registry, from Mehra's group, in the European Respiratory Journal in 2019, with prior-generation Inspire II and Inspire IV devices, each one-point rise in body mass index meant about nine percent lower odds of success. Put the other way, a lower body mass index went with better odds, a fair reason to encourage weight loss, though the registry measured baseline weight, not weight lost.

On oxygen, be precise: the pooled desaturation index and lowest saturation were not statistically significant, while the tirzepatide trials did show a lower hypoxic burden. Don't promise a cardiovascular benefit, and don't call these drugs a substitute for CPAP; the authors don't either. If a patient loses substantial weight before surgery, get a new sleep study before deciding.

What would sharpen this? A randomized trial of a GLP-1 drug before Inspire or BRP, measuring candidacy and surgical response. Data beyond fifty-two weeks, including what happens after stopping. And repeat drug-induced sleep endoscopy after weight loss, to see whether the collapse pattern changes.

Again, that's Aljazeeri's group, "GLP-1 receptor agonists for obstructive sleep apnea: a meta-analysis of randomized controlled trials." Sleep and Breathing, 2026, volume thirty, article two seventy-nine.

Residents, what's your one takeaway from this paper?

Paper: Carvalhal G, Mora MMR, Peralta-Jiménez GA, Ayasa L, Barrera V, Advani K, et al. GLP-1 receptor agonists for obstructive sleep apnea: a meta-analysis of randomized controlled trials. *Sleep Breath*. 2026. doi:10.1007/s11325-026-03826-5 https://doi.org/10.1007/s11325-026-03826-5

The first decision it touches is technique choice. In Dr. Nord's practice, B-R-P remains the palate operation of choice. This paper offers an appealing muscle-sparing idea, but no head-to-head data. The evidence that would move that decision is a direct comparison with B-R-P under identical steroids and analgesia. It would need blinded pain scoring, visits through the first two weeks, and sleep testing well beyond six months.

The second decision is counseling. The paper adds a carefully measured early recovery curve. Those numbers belong to the stayed bridge technique, so they should be quoted only as stayed bridge data. For a patient having B-R-P, the counseling numbers still come from the B-R-P series. About one in five have transient swallowing difficulty that settles within a week. Thread extrusion happens in about one in eight across barbed techniques. This paper adds one useful line: sparing the muscle did not make extrusion go away.

The third decision is observation. These patients stayed two days by protocol. In Dr. Nord's practice, airway-surgery patients like these are kept for twenty-three-hour observation. The twelve-hour scores fall inside that window. The twenty-four- and forty-eight-hour scores come after it. The paper did not monitor breathing on the first night, so it can't inform how long that observation should be.

Finally, the Inspire conversation. Dr. Nord is a high-volume Inspire implanter. Patients with this profile, moderate disease, a body mass index under thirty and tonsils present, are the group where Inspire and palate surgery are both on the table. This paper is palate-surgery data. It gives no outcomes by collapse pattern and no post-operative DISE. It adds recovery information on the palate side of that discussion, not Inspire evidence.

What's your one takeaway from this paper?

Paper: Pace A, Iannella G, Maniaci A, Cocuzza S, Moffa A, Alunni Fegatelli D, et al. Edema and Subjective Discomfort After Barbed Stayed Bridge Pharyngoplasty (BSBP). *JCM*. 2025;14(20):7402. doi:10.3390/jcm14207402 https://doi.org/10.3390/jcm14207402

Keep the headline in mind. Whole-night hypoxic burden fell to about a third of baseline. The median went from ninety-seven point one to thirty-five percent-minutes per hour.

The decision it touches is how to read a sleep study labeled a Sher failure. An AHI-only label may undersell what happened to the patient's oxygen. So after palate surgery, it's reasonable to look at hypoxic burden alongside the AHI. If you do, use the same software and scoring rules before and after, or the comparison means little. And be honest with the patient. In this paper, some failures got worse, and supine burden did not significantly improve in that group.

Dr. Nord's practice performs barbed reposition pharyngoplasty, which is a different operation. Lateral pharyngoplasty cuts the superior constrictor and uses no barbed suture. These numbers shouldn't be carried over to BRP. The literature has no hypoxic burden data for BRP yet.

Dr. Nord's practice is also a high-volume Inspire practice. Dr. Nord has previously consulted for Inspire. For Inspire counseling, the burden data come from the first-generation STAR device and from Inspire IV, not from this palate series. There are no published outcomes yet for Inspire V.

On weight, this paper's signal is small. Successes had a lower body mass index, but in only eight patients per group. In Dr. Nord's practice, weight loss is part of multimodal treatment of obstructive sleep apnea alongside Inspire, often both rather than either-or. That includes glucagon-like peptide one drugs. Many Inspire patients are already on these drugs or will become candidates for them.

Confidence is moderate that burden falls after this operation in selected patients. It is low that Sher failures meaningfully benefit. Four things would move it. A controlled study. Hypoxic burden data after BRP. An analysis showing burden adds information beyond the AHI. And symptom or cardiovascular outcomes.

For the residents: when you present a postoperative sleep study in clinic, bring the oxygen picture along with the AHI.

That was de Aquino's group in Campinas, writing in Sleep and Breathing in 2026.

What's your one takeaway from this paper?

Paper: Vieira ALP, Duarte BB, Almeida AR, Greters ME, Leandro-Merhi VA, de Aquino JLB. "Hypoxic burden reduction after lateral pharyngoplasty in patients with obstructive sleep apnea: Beyond the apnea-hypopnea index." *Sleep and Breathing* (2026) 30:267. DOI: 10.1007/s11325-026-03808-7. PMID: not printed in PDF (42771120 per the weekly PubMed scan). Received 25 May 2026; revised 6 September 2026; accepted 14 September 2026. Open access (CC BY 4.0). https://doi.org/10.1007/s11325-026-03808-7

The decision this paper touches is what to make of tongue motion after implantation. Three pieces.

First, counseling. I won't tell a patient that a strong forward tongue at activation predicts a great sleep study, or that a modest one predicts failure. This paper gives no basis for either, and the Emory data say the same.

Second, titration. There's no support here for using visible or ultrasound motion as a titration target, or for raising amplitude just to make the tongue move more. Motion wasn't related to voltage in their standard-configuration patients. The authors caution against increasing stimulation beyond comfort. That's sensible, but it's their recommendation, not something this study measured.

Third, the non-responder whose tongue moves well. This paper and the Penn work both point away from making the tongue move more, and toward the airway itself. In Dr. Nord's practice, once awake endoscopy and reprogramming have failed, DISE is a good tool for the Inspire non-responder, because it shows the lumen that ultrasound can't. The authors suggest residual palatal or lateral-wall obstruction as one explanation, a hypothesis they didn't test. That's where palate surgery, including barbed reposition pharyngoplasty, enters the discussion, but this paper isn't evidence for it.

What doesn't change? This study says nothing about retraction, or about which nerve branches the cuff captures at implantation. That question still rests on Steffen's group's small series. When I teach residents in the operating room, the point is narrower now: how far the tongue moves forward is not a demonstrated predictor of the sleep study.

Confidence: moderate that graded ultrasound magnitude and symmetry aren't useful predictors at this level of measurement. Low on buckling, where the interval is wide. What would move me is a prospective study with measured displacement, several amplitudes per patient, paired DISE, one standardized full-night study, and adjustment for baseline severity.

The citation: Tschopp, Janjic, Caversaccio, Borner and Tschopp. "Ultrasonographic Tongue Base Motion Does Not Correlate With Hypoglossal Nerve Stimulation Outcomes." Laryngoscope Investigative Otolaryngology, twenty twenty-six. Volume eleven, issue two.

Residents, what's your one takeaway?

Paper: Tschopp S, Janjic V, Caversaccio M, Borner U, Tschopp K. Ultrasonographic Tongue Base Motion Does Not Correlate With Hypoglossal Nerve Stimulation Outcomes. *Laryngoscope Investig Oto*. 2026;11(2). doi:10.1002/lio2.70376 https://doi.org/10.1002/lio2.70376

In terms of an explicit call: watch. There is no change to our implant candidacy gate, but we must maintain a close watch on emerging trials of concurrent pharyngeal reconstruction.

Let us break down the exact decisions affected in clinic and the operating room.

First, candidate counseling. When I perform drug-induced sleep endoscopy on an Inspire candidate and observe complete oropharyngeal lateral wall collapse, I do not deny them surgery. Complete concentric collapse at the soft palate remains our only absolute anatomical exclusion. However, I change the conversation.

I tell the patient directly: if your lateral walls remained open, your expected chance of surgical success would be roughly seventy-five to eighty-five percent. With complete side-wall collapse, your expected chance of success drops by about fifteen to twenty percentage points, down to roughly fifty-eight to sixty-seven percent. But two out of three patients with this pattern still achieve success, your nightly device usage is expected to be just as high, and your stimulation voltage requirements are identical.

Second, risk stratification by body mass index. When I see complete lateral wall collapse, I look immediately at the patient's body mass index. If their body mass index is twenty-eight or twenty-nine, I am very comfortable proceeding; data from Vena and Huyett show their response rate will likely stay near seventy percent. If their body mass index is thirty-two or thirty-three, or pushing into the newly expanded thirty-five to forty range, I have a much more sobering discussion. I explain that adiposity and lateral wall collapse act synergistically to cut response rates in half, and I make weight loss and lifestyle modification an active, mandatory part of our preoperative and postoperative plan.

Third, our surgical technique. Classic U-triple-P is historical context; that is not what we do. In our practice, when we need to reconstruct the pharynx, we perform barbed reposition pharyngoplasty, or B-R-P. As you have seen me do in the operating room, B-R-P suspends and repositions the lateral pharyngeal walls anteriorly and laterally to the pterygomandibular raphe using knotless barbed sutures.

When you see Huyett's combination tonsillectomy data showing an eighty-five percent A-H-I reduction but a six point seven percent return to the operating room for hemorrhage, that should give you pause. Traditional cold or electrocautery tonsillectomy leaves a raw, open granulating muscle bed in an adult sleep apnea patient. If we decide to address the lateral walls surgically alongside neurostimulation, B-R-P allows us to stabilize the lateral muscular sleeve and re-approximate mucosal pillars, which provides structural lateral wall tension while mitigating the catastrophic bleeding risks of exposed muscular beds. We do not routine-order concurrent tonsillectomy on every lateral wall patient today, but in patients with prominent tonsils and complete lateral collapse, concurrent B-R-P is the technique we are watching and evaluating.

Fourth, perioperative orders. Remember our owner ruling: patients admitted for a twenty-three-hour observation stay must always be managed and documented as a twenty-three-hour observation stay. Never refer to these patients as outpatient. If we perform an Inspire implant combined with pharyngeal surgery like B-R-P in a complete lateral wall patient, they are at higher risk for airway swelling and pain. They stay on our twenty-three-hour observation pathway, receive scheduled multimodal non-opioid analgesia, and are monitored closely overnight.

Fifth, postoperative management. When these patients return at three months, remember that a titration sleep study will paint an overly optimistic picture. If a complete lateral wall patient has a borderline titration study or reports lingering daytime fatigue, we do not declare victory; we order an entire-night home sleep apnea test. And as our twenty-twenty-four data demonstrated, we maintain a very low threshold for early awake flexible endoscopy in the clinic to visualize the palate and tongue base under active stimulation and optimize our electrode programming.

Our confidence in this approach is high, supported by low-certainty GRADE prognostic evidence that clearly refutes an absolute exclusion. What evidence would move my practice to a formal change? A randomized controlled trial comparing Inspire alone versus Inspire plus barbed reposition pharyngoplasty in patients with complete lateral wall collapse, measuring entire-night efficacy and long-term durability. Until such a trial is conducted, we counsel with nuance, we stratify by body mass index, and we offer therapy to candidates who still have a two-in-three chance of success.

The formal citation for this paper is: McBrinn S, Skan O, Iacovidou A. Oropharyngeal Lateral Wall Collapse on Drug-Induced Sleep Endoscopy as a Predictor of Hypoglossal Nerve Stimulation Response in Obstructive Sleep Apnea, A Systematic Review. Diagnostics twenty-twenty-six, volume sixteen, issue sixteen, article twenty-five twenty-nine.

Before we walk into morning clinic, let me leave you with this question: when you see complete lateral wall collapse on sleep endoscopy in a patient with a body mass index of thirty-two, what is your threshold for offering hypoglossal nerve stimulation alone versus recommending concurrent palate or lateral wall surgery?

Think about that, and I will see you in the OR or clinic.

Paper: McBrinn S, Skan O, Iacovidou A. "Oropharyngeal Lateral Wall Collapse on Drug-Induced Sleep Endoscopy as a Predictor of Hypoglossal Nerve Stimulation Response in Obstructive Sleep Apnoea—A Systematic Review." *Diagnostics* 2026;16:2529 (20 pages; issue number not printed). DOI: 10.3390/diagnostics16162529 (printed). PMID: not printed in PDF (42650932 per PubMed via the weekly scan). Received 18 June 2026; revised 9 July 2026; accepted 10 July 2026; published 11 August 2026. Imperial College NHS Foundation Trust and Chelsea and Westminster NHS Foundation Trust, London. Open access (CC BY). https://doi.org/10.3390/diagnostics16162529

This paper does not require an immediate change in operative technique because it represents expert consensus on diagnostic workup and decision-making rather than a comparative trial. However, it provides robust peer-reviewed support for four clinical decisions in our practice.

First, regarding Inspire hypoglossal nerve stimulation candidacy: this consensus strongly supports our staging algorithm. When an adult presents with severe tongue base collapse on sleep endoscopy but also carries grade three or four palatine tonsils, statement twenty-one provides unanimous consensus backing to perform tonsillectomy and palate expansion first. We do not implant a neurostimulator through obstructing palatine tonsils. During pre-implant sleep endoscopy, we must also evaluate the supraglottic phenotypes detailed here. If you identify primary trapdoor or floppy epiglottic collapse folding over the laryngeal inlet, unilateral hypoglossal nerve stimulation alone may fail to recruit the epiglottis if the lingual surface is not directly tethered to the advancing tongue base. Identifying that phenotype preoperatively allows you to counsel the patient on potential concurrent or staged epiglottopexy.

Second, regarding barbed reposition pharyngoplasty: this paper reinforces our sequencing principles. Ryan performs barbed reposition pharyngoplasty as his primary palatal procedure, providing anterolateral suspension of the lateral pharyngeal walls without tissue excision. Statement seventeen establishes unanimous agreement that when lower airway collapse is suspected to be secondary to upstream flow limitation, the palate and lateral walls should be treated first. Stabilizing the velum with barbed reposition pharyngoplasty frequently relieves downstream negative suction pressures, converting what appeared to be severe hypopharyngeal collapse into a stable airway.

Third, regarding perioperative care: statement nine in the history section highlights that a history of nocturnal choking, stridor, or continuous positive airway pressure intolerance specifically driven by choking sensations reached eighty-three to ninety-two percent consensus as an indicator of supraglottic obstruction. When a patient reports that history, we treat them as high risk for dynamic laryngeal collapse, communicating directly with anesthesia for post-extubation precautions and maintaining continuous overnight oximetry.

Fourth, regarding surgical failure and follow-up: when a patient presents with persistent moderate to severe obstructive sleep apnea after prior pharyngoplasty, statement five of the sleep endoscopy section gives us unanimous consensus backing to mandate a repeat drug-induced sleep endoscopy before offering secondary surgery. We do not guess at the failure mechanism from the clinic chair. A repeat sleep endoscopy is required to differentiate residual lateral wall collapse from persistent tongue base collapse, determining whether the patient needs hypoglossal nerve stimulation or skeletal surgery.

What evidence would move this call from watch to a definitive change in practice? We would need prospective cohort studies or clinical trials evaluating outcomes of staged versus synchronous palate and tongue surgery, along with validated reliability data demonstrating that classifying epiglottic collapse into trapdoor, floppy, or omega phenotypes improves surgical cure rates.

For your reference, the complete citation is: Olszewska, De Vito, Baptista, Delakorda, Heiser, Cheong, Plaza, Vanderveken, Perez-Martin, Kotecha, Maurer, and Vicini. Consensus Statements Among European Sleep Surgery Experts on Tongue, Hypopharynx, and Supraglottis Associated With Snoring and Obstructive Sleep Apnea: Part One: Evaluation and Decision Making, published in the Journal of Clinical Medicine, December 2025, volume 15, issue 1, page 80.

That wraps up today's teaching round on the lower upper airway consensus. Take these principles to clinic, evaluate your airways dynamically, and have a safe drive home.

Paper: Olszewska E, De Vito A, Baptista P, Delakorda M, Heiser C, Cheong RCT, et al. Consensus Statements Among European Sleep Surgery Experts on Tongue, Hypopharynx, and Supraglottis Associated with Snoring and Obstructive Sleep Apnea: Part 1: Evaluation and Decision Making. *JCM*. 2025;15(1):80. doi:10.3390/jcm15010080 https://doi.org/10.3390/jcm15010080