Upper Airway Treatable Traits in Obstructive Sleep Apnea: Bridging Otolaryngology and Respiratory Medicine

Obstructive sleep apnea (OSA) is a heterogeneous disorder in which recurrent upper-airway obstruction reflects variable combinations of anatomical vulnerability and non-anatomical physiology. A treatable-traits framework may help move management beyond the apnea-hypopnea index by linking clinically relevant, modifiable characteristics to specific interventions. This narrative review focuses on upper-airway traits at the interface of otolaryngology, respiratory medicine, and sleep medicine. Nasal obstruction, tonsillar hypertrophy, palatal and lateral pharyngeal collapse, tongue-base obstruction, craniofacial restriction, epiglottic collapse, and position-dependent obstruction may be actionable, but the strength of evidence supporting treatment selection varies by trait. Drug-induced sleep endoscopy (DISE) can characterize dynamic collapse and may change management in selected patients, although visualization of a collapse pattern is not equivalent to validated prediction of treatment response. Positive airway pressure remains a cornerstone of therapy, while oral appliance therapy, positional therapy, site-directed surgery, maxillomandibular advancement, hypoglossal nerve stimulation, nasal treatment, and weight management may be appropriate for selected phenotypes. Anatomical findings should be integrated with physiological endotypes, comorbidity, treatment burden, and patient preference. We propose an evidence-informed, iterative pathway that distinguishes direct therapeutic targets from enabling traits and emerging treatment-selection markers, emphasizes selective rather than routine use of DISE, and incorporates clinical and objective reassessment tailored to treatment and clinical context. The goal of precision OSA care is not maximal phenotyping, but clinically useful phenotyping that changes management while acknowledging uncertainty.