OSA surgery is one of the fastest-growing areas for ENT in India. India has an estimated 100+ million OSA patients, mostly undiagnosed. Here are the clinical answers you need. Which OSA patients should you refer for surgery vs CPAP? Surgery is first-line only when there is an obvious anatomical obstruction (enlarged tonsils Grade 3–4, severe septal deviation, or adenoid obstruction in children). For most adults, CPAP is first-line. Surgery is appropriate when CPAP fails due to intolerance and the AHI is ≥15 with identified obstruction sites on DISE (Drug-Induced Sleep Endoscopy). What is DISE and when should you do it? Drug-Induced Sleep Endoscopy is flexible nasoendoscopy under propofol sedation (Bispectral Index target 50–70). It shows the exact level and pattern of airway collapse: palate, oropharynx, tongue base, or epiglottis. Do it before any OSA surgery in adults to avoid operating on the wrong level. It directly determines which procedure is appropriate. UPPP vs coblation tonsillotomy — which gives better results? UPPP (Uvulopalatopharyngoplasty) achieves surgical success (AHI reduction ≥50%) in 50–60% of carefully selected patients. Coblation tonsillotomy (partial removal) has less pain and bleeding than full tonsillectomy and is preferred for tonsil-predominant OSA. Both should be combined with tongue base reduction if DISE shows multilevel collapse. Is hypoglossal nerve stimulation available in India? The Inspire system (hypoglossal nerve stimulator) is now available at select centres in India. It is indicated for moderate-severe OSA (AHI 15–100), BMI ≤32, CPAP failure, and no complete concentric palatal collapse on DISE. It is implanted under general anaesthesia in 2–3 hours. Activation is 4 weeks post-op. Outcomes show 70–80% AHI reduction. What pre-op workup do you need before OSA surgery? Polysomnography (PSG) or validated home sleep test for AHI. DISE for adults. BMI assessment (surgery success drops significantly above BMI 35). Cardiovascular evaluation for severe OSA patients (AHI >30 with symptoms). Thyroid function test to rule out hypothyroidism as a cause. What is the commonest reason OSA surgery fails? Operating at the wrong level because DISE was not done. The second biggest reason is operating on obese patients (BMI >35) without weight management. Hypopharyngeal collapse — from large tongue base, lingual tonsil, or floppy epiglottis — is the most under-addressed failure cause. Always suspect it in revision cases.