Obstructive sleep apnea (OSA) is a disease that has been recognized for the last 40 years. With the recognition and evaluation of disease parameters, the medical literature began to recognize that an upper-airway obstruction was the mechanical cause of OSA. The fi rst treatment available was tracheostomy and there was a time in the late 1960s and early 1970s when a permanent tracheostomy was the only recommended treatment for patients with severe behavioral or cardiopulmonary consequences of OSA. Tracheostomy remains the only uniformly totally eff ective surgical option to permanently relieve OSA. A full understanding of the physiology of OSA led to mechanical techniques and devices to treat the disease and resulted in patients with little need for a tracheostomy. There remain occasional patients with severe OSA who because of their anatomy or surgical complications of treatment are unable to tolerate other mechanical choices such as continuous positive airway pressure (CPAP) or have failed sequential upperairway surgery, and these patients will benefi t from a tracheostomy .