TABLE IX.C.1.

Evidence for physical exam for surgical planning

Study	Year	LOE	Study design	Study groups	Clinical endpoint	Conclusion
Friedman et al.1485	2002	4	Retrospective cohort	Retrospective analysis without control group	Surgical success	The use of clinical staging system identifies potential for success or failure with UPPP.
Friedman et al.814	2004	4	Prospective cohort	Prospective analysis without control group	Surgical success	The use of clinical staging system identifies potential for success or failure with UPPP and those for whom tongue base intervention should be added to intervention.
Kim et al.208	2014	3a	Case–control	Obese non-apneic (control) and obese apneic patients (study)	Volume of tongue fat	Increase deposition of tongue fat in apneics compared to obese non-apneic controls.
Vroegop et al.1584	2014	4	Observational study	Patients undergoing DISE	Patterns of collapse identified during DISE	Overview of patterns of collapse in a large cohort of SDB patients who underwent DISE.
Denolf et al.1585	2016	3a	Meta-analysis	Review of available literature on cephalometry	Using cephalometry to predict outcomes of MAD	Cephalometric patterns cannot reliably predict treatment outcomes from MAD.
Hong et al.1586	2016	3a	Systematic review	Review of available literature on upper airway evaluation in patients with OSA	Use of multiple modalities for evaluation of OSA	Physical examination cannot reliably predict site and mechanism of obstruction.
Ishii et al.545	2015	3a	Meta-analysis	Ten studies included	AHI, RDI, ESS	Isolated nasal surgery offered improvement in ESS and RDI. No improvement in AHI.
Kim et al.1587	2004	4	Case series	Subjects undergoing nasal surgery Pre- and postoperative sleep study	RDI Apnea index (AI) Oxygen desaturation index (ODI)	Significant improvement in RDI, AI, and OSI with nasal surgery.
Osborn et al.1588	2013	5	Expert opinion			Discussion of various medical and surgical treatment options for nasal obstruction.
Nuckton et al.1590	2006	2b	Prospective case series	Patients evaluated at Sleep Center	Likelihood of Mallampati score to predict OSA	Increased Mallampati score associated with risk of OSA diagnosis and increased severity.
Holmlund et al.1589	2016	2b	Multicenter prospective interventional study	Adult patients with tonsillar hypertrophy and OSA undergoing tonsillectomy	Resolution of OSA and reduction in AHI	Significant improvement in AHI.
Jara and Weaver327	2018	2c	Retrospective cohort study	Patients undergoing tonsillectomy for OSA	Association between palatine tonsil (PT) grade and volume and OSA	PT grade associated with PT volume and AHI. PT volume not associated with AHI.
Friedman et al.814	2004	2b	Prospective cohort study	One cohort of patients evaluated preoperatively using Friedman staging system and one cohort not	Surgical success rates	Cohort evaluated preoperatively with Friedman staging system and managed accordingly had improved surgical outcomes.
Olszewska et al.1592	2019	5	Expert opinion			Review of palate anatomy.
Dündar et al.1593	1996	5	Case report	Patient with OSA and lingual tonsillar hypertrophy	Surgical outcome	Improvement in disease severity.
Tang and Friedman557	2018	2c	Retrospective cohort study	Patients with lingual tonsillar hypertrophy and OSA compared to those without OSA	Association of lingual tonsil size and OSA diagnosis	No significant correlation between lingual tonsil size and diagnosis of OSA.
Friedman et al.1594	2017	5	Expert opinion
Delakorda and Ovsenik1595	2019	2c	Retrospective cohort study	Evaluation of epiglottis shape in patients with OSA undergoing DISE	Epiglottic shape in those patients with tongue base and epiglottic obstruction seen on DISE	Many patients with tongue base and epiglottic obstruction on DISE had abnormal epiglottis shape (flat).
Hsu et al.1597	2004	2b	Prospective cohort study	Quantitative computer-assisted videoendoscopy performed in patients with OSA and compared to cohort without OSA	Retropalatal and retrolingual airway measurements and their association with OSA	Retropalatal and retrolingual measurements found predictive of OSA.
Fernández-Julián et al.1598	2014	2b	Prospective cohort study	Comparison of surgical recommendations based on clinical evaluation vs. DISE	Correlation of surgical recommendation and type of evaluation	DISE evaluation provided more information for surgical planning, particularly at the level of the hypopharynx and larynx.
Yegïn et al.1600	2017	2c	Retrospective cohort study	OSA patients undergoing evaluation with Muller’s maneuver and DISE	Difference in upper airway obstruction findings with Muller’s maneuver and DISE	DISE may have improved ability to diagnose site(s) and configuration of upper airway collapse when compared to Muller’s maneuver.
Soares et al.1599	2013	2c	Retrospective cohort study	Patients with OSA undergoing office evaluation with Muller’s maneuver and DISE	Location in airway obstruction	Significant difference in finding of severe retrolingual obstruction seen on DISE compared to Muller’s maneuver.