Epiglottis collapse in adult obstructive sleep apnea: A systematic review

DISE with CPAP: a useful procedure to evaluate upper airway collapsibility

PURPOSE

Drug-induced sleep endoscopy (DISE) is commonly performed in patients suffering obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) intolerance. We aimed to evaluate the effects of adding CPAP to DISE to provide understanding of the reason of its failure and better guidance in future therapeutic decisions.

METHODS

A retrospective observational descriptive study was conducted on CPAP-intolerant patients with moderate-severe OSA. DISE was used to evaluate upper airway collapsibility, and CPAP was tested to better describe anatomical sites of obstruction and to measure the opening pharyngeal pressure.

RESULTS

Sample size consisted of 38 patients with a mean age of 49 ± 9 years. Mean BMI was 28.4 ± 2.4 kg/m2, mean apnea-hypopnea index (AHI) was 35.4 events per hour ± 20.1, and mean saturation under 90% (TSat90) was 14.5%. In DISE we found a collapse at Velum in 92% of patients, at Oropharyngeal level in 89%, at tongue in 42%, and at epiglottis in 36%. In the subgroup of patients with clinical failure with CPAP, we observed 100% of epiglottic collapse and 50% of tongue obstruction. In this specific population, we recommended personalized surgery and myofunctional therapy.

CONCLUSION

DISE-CPAP is a useful tool to select the treatment that better fits to each patient taking care all information available. It improves our ability to prescribe a multilevel treatment with an exhaustive topographic evaluation of upper airway collapsibility that complements CPAP classic titration, and it can be helpful to distinguish better candidates for surgery, myofunctional therapy or CPAP.

Advances in Pharyngeal Surgery Over the Past 10 Years: New Techniques and Technology

This article is a review of advances in pharyngeal surgery over the past 10 years regarding literature, surgical technique, assessment, collaboration, and future direction in the management of adult and pediatric obstructive sleep apnea.

Evaluation of modified coblation endoscopic lingual lightening in multilevel surgery for obstructive sleep apnea hypopnea syndrome: an open intervention study

PURPOSE

To evaluate the efficacy and safety of modified coblation endoscopic lingual lightening to address retrolingual obstruction in multilevel surgery for obstructive sleep apneae (OSA).

METHODS

Patients with OSA due to retropalatal and retrolingual obstructions were enrolled. Group 1 consisted of patients who underwent modified coblation endoscopic lingual lightening combined with H-uvulopalatopharyngoplasty, while group 2 comprised patients treated by H-uvulopalatopharyngoplasty alone. Objective parameters and subjective evaluations were recorded preoperatively and at 6 months postoperatively.

RESULTS

The mean (standard deviation) apnea-hypopnea index (AHI) declined from 51.5 (18.9) to 14.3 (7.2) in group 1, and from 51.7 (15.8) to 28.5 (16.9) in group 2. The mean (standard deviation) percentage change in AHI was higher in group 1 than in group 2 (73.2 [10.9] vs. 48.9 [22.4], P < 0.01). The surgical response rate differed significantly between groups 1 and 2 (88.5 [23/26] vs. 46.7 [14/30], P < 0.01). Other outcomes, including the lowest oxygen saturation, Epworth Sleepiness Scale score, snoring visual analog scale score, and subjective improvement rate, were also significantly better in group 1 than in group 2.

CONCLUSION

Without increasing complications, modified coblation endoscopic lingual lightening significantly improved surgical outcomes as part of multilevel surgery in patients with OSA due to multilevel obstruction.

Types of Epiglottic Collapse in Breathing Sleep Disorder and Their Impact in Clinical Practice

Introduction  Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB) that is strongly correlated with comorbidities, in which epiglottic collapse (EC) and other contributing factors are involved. Objectives  To evaluate the occurrence of EC in OSA patients through drug-induced sleep endoscopy (DISE) and to determine the factors contributing to EC. Methods  A retrospective study of 37 adult patients using medical history. Patients were assessed for laryngopharyngeal reflux (LPR) and lingual tonsil hypertrophy (LTH) using reflux symptom index and reflux finding score (RFS); for OSA using polysomnography, and for airway collapse through DISE. An independent t -test was performed to evaluate risk factors, including the involvement of three other airway structures. Results  Most EC patients exhibited trap door epiglottic collapse (TDEC) (56.8%) or pushed epiglottic collapse (PEC) (29.7%). Lingual tonsil hypertrophy, RFS, and respiratory effort-related arousal (RERA) were associated with epiglottic subtypes. Laryngopharyngeal reflux patients confirmed by RFS (t(25) = -1.32, p  = 0.197) tended to suffer PEC; LTH was significantly associated (X2(1) = 2.5, p  = 0.012) with PEC (odds ratio [OR] value = 44) in grades II and III LTH patients; 11 of 16 TDEC patients had grade I LTH. Pushed epiglottic collapse was more prevalent among multilevel airway obstruction patients. A single additional collapse site was found only in TDEC patients. Conclusion  Laryngopharyngeal reflux causes repetitive acid stress toward lingual tonsils causing LTH, resulting in PEC with grade II or III LTH. Trap door epiglottic collapse requires one additional structural collapse, while at least two additional collapse sites were necessary to develop PEC. Respiratory effort-related arousal values may indicate EC.

Adult Laryngomalacia: A Scoping Review

OBJECTIVE

This review sought to determine the characteristics of adults diagnosed with new onset laryngomalacia including airway symptoms, laryngoscopic findings, treatments, and outcomes. Moreover, we wanted to highlight suspected limitations in the literature.

DATA SOURCES

Studies were identified through CINAHL, Cochrane Review, PubMed, and Scopus published between 1966 and 2023.

REVIEW METHODS

The search was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews checklist by 2 independent investigators. A meta-analysis of proportions and continuous measures was conducted.

RESULTS

Of the 1121 abstracts identified, 33 articles pertaining to laryngomalacia in the adult population were included. The most common presenting symptoms were stridor at rest (78.3%, 65.1-88.3) and dyspnea with exertion (83.8%, 64.8-96.3). The most suspected etiology was exercise-induced (86.0%, 69.4-95.5), and the most common description of laryngomalacia on visualization was collapse of supraglottic structures during exercise (93.3%, 79.0-99.1). Nonsurgical options were attempted in 87.0% (54.0-99.1), which included oral appliances, respiratory retraining, breathing techniques, and working with a speech pathologist. Surgical options were ultimately performed in 84.2% (75.0-91.0). Complete resolution of symptoms following therapy was seen in 61.9% (48.0-74.6).

CONCLUSION

Adult onset laryngomalacia is difficult to characterize. It typically presents in patients during exercise, with neurological injury, or idiopathically. Surgical management can lead to improvement or complete resolution of symptoms. The need for a universal nomenclature is highlighted in this review, as it is inconsistently classified.

Treatment of a floppy epiglottis with upper airway stimulation therapy

PURPOSE

To evaluate the efficacy of upper airway stimulation therapy in patients with a floppy epiglottis who have experienced continuous positive airway pressure failure or intolerance.

METHODS

A retrospective single-center cohort study was conducted. Patients who received an Inspire Upper Airway Stimulation system and had a 1-year follow-up were included. Baseline and one-year in-laboratory polysomnography examinations were performed. Patient characteristics, Epworth Sleepiness Scale scores and upper airway stimulation device settings were collected.

RESULTS

A total of 75 patients were included, of whom 10 had a floppy epiglottis. Patients with a floppy epiglottis had a significant therapeutic response to upper airway stimulation therapy, similar to patients without a floppy epiglottis. According to the Sher's success criteria, 90% of patients with a floppy epiglottis and 68% of patients without a floppy epiglottis were responders to therapy (p = 0.149). In the floppy epiglottis group, the apnea-hypopnea index decreased from 35.1 ± 5.5 events/hour to 11.2 ± 11.3 events/hour (95% CI (15.0, 32.9), p < 0.001), similarly in the non-floppy epiglottis group, the decline was from 36.4 ± 8.3 events/hour to 14.4 ± 9.5 events/hour (95% CI (18.6, 25.2), p < 0.001, between groups p = 0.659). Comparable reductions were observed for the other respiratory parameters.

CONCLUSION

Treatment of patients with obstructive sleep apnea and a floppy epiglottis can be challenging. Continuous positive airway pressure may aggravate the epiglottis collapse. Upper airway stimulation therapy can be considered an effective alternative treatment option for patients with a floppy epiglottis who have encountered either continuous positive airway pressure failure or intolerance.

Swallowing evaluation in patients who underwent Partial CO2 LASER Epiglottectomy for Sleep Apnea treatment

OBJECTIVE

To evaluate swallowing in patients who underwent CO2 LASER Partial Epiglottectomy (CO2-LPE) for Obstructive Sleep Apnea Syndrome and to assess the risk of aspiration with this technique.

MATERIAL & METHODS

Chart review of adult patients who underwent CO2-LPE between 2016 and 2020, in a secondary care hospital. Patients underwent surgery for OSAS, in accordance to Drug Induced Sleep Endoscopy findings and an objective swallowing evaluation was done at least 6 months after surgery. Eating Assessment Tool (EAT-10) questionnaire was applied and Volume-Viscosity Swallow Test (V-VST) and Fiberoptic Endoscopic Evaluation of Swallowing (FEES) were performed. Dysphagia was classified according to Dysphagia Outcome Severity Scale (DOSS).

RESULTS

Eight patients were included in the study. The mean time between surgery and the swallowing evaluation was 50 (±13,2) months. Only 3 patients presented ≥ 3 points on EAT-10 questionnaire. Two patients presented signs of decreased efficacy of swallowing (piecemeal deglutition) but none had a decrease in safety, according to V-VST. Although 50% of the patients presented some pharyngeal residue on FEES, it was classified as trace to mild in most of the cases. No evidence of penetration or aspiration was identified (DOSS ≥ 6 in all patients).

CONCLUSION

The CO2-LPE is a potential treatment for OSAS patients with epiglottic collapse and no evidence of swallowing safety compromise was found.

Defining Epiglottic Collapses Patterns in Obstructive Sleep Apnea Patients: Francia-Lugo Classification

Obstructive Sleep Apnea (OSA) is characterized by repetitive collapse of the upper airway during sleep. Drug-Induced Sleep endoscopy (DISE) is used to identify the collapse site. Among the possible sites of collapse, the epiglottis occurs more frequently than previously described. In this study, we reviewed DISE findings and classified different epiglottic collapse patterns. We found 104 patients (16.4%) with epiglottis collapse (primary 12.5% and secondary 3.9%). We described the following patterns of epiglottis collapse: Anterior-Posterior (AP) collapse with rigid component "trapdoor type" (48%); AP collapse with lax component "floppy type" (13.5%); Lateral- Lateral (LL) collapse with omega shape component "book type" (14.5%); and secondary due to lateral pharyngeal wall or tongue base collapse (24%). The identification of the epiglottic collapse pattern is crucial in decision-making when attempting to ameliorate OSA. These findings in OSA phenotyping could influence the type of treatment chosen.

The relationship between bi-spectral index and VOTE score in evaluation of drug-induced sleep endoscopy: A systematic meta-analysis

OBJECTIVE

The aim of this study was to investigate both the presence and severity of collapse in anatomical regions defined by the VOTE score (velum, orofarinx, tongue, and epiglottis), during drug induced sleep endoscopy (DISE) in patients diagnosed with obstructive sleep apnea, based on the bi-spectral index (BIS) sedation level.

METHODS

In order to conduct a meta-analysis of articles examining the relationship between the VOTE score and BIS sedation level in determining the presence and severity of upper airway collapse during DISE, a literature review was performed.

RESULTS

As a result of the search made in the specified databases, a total of 1864 articles were reached. Five articles included in this review that had sufficient statistical data to be included in the meta-analysis were found. A statistically significant correlation was found between the BIS sedation level and the areas of obstruction in the VOTE score. The strongest association is at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively (CC: 0.639, CC: 0.53, CC: 0.49, and CC: 0.346, P < .001). In the subgroup analysis of publications with BIS sedation levels in the range of 60 to 65, the distribution in the epiglottis region was heterogeneous, and it was found to be statistically significant according to the random effect model (P < .001). The distribution in the tongue was homogeneous, and it was found to be statistically significant according to the fixed effect model (P < .001). When the publications in which the BIS sedation level is in the range of 65 to 75 are examined according to the areas of obstruction; the distribution in 4 anatomical regions was homogeneous and statistically significant according to the fixed effect model (P < .001).

CONCLUSION

It was found that BIS sedation levels during DISE application in obstructive sleep apnea patients were associated with obstruction of the anatomical regions of the upper airway. The strongest association was found at the epiglottis level, followed by the velum, oropharynx, and tongue, respectively. It is helpful to monitor the sedation level with BIS in order to better define the collapsed areas during DISE application. However, more studies are needed to better understand the relationship between BIS sedation values and sleep stages.

Development of a Deep Learning-Based Epiglottis Obstruction Ratio Calculation System

Surgeons determine the treatment method for patients with epiglottis obstruction based on its severity, often by estimating the obstruction severity (using three obstruction degrees) from the examination of drug-induced sleep endoscopy images. However, the use of obstruction degrees is inadequate and fails to correspond to changes in respiratory airflow. Current artificial intelligence image technologies can effectively address this issue. To enhance the accuracy of epiglottis obstruction assessment and replace obstruction degrees with obstruction ratios, this study developed a computer vision system with a deep learning-based method for calculating epiglottis obstruction ratios. The system employs a convolutional neural network, the YOLOv4 model, for epiglottis cartilage localization, a color quantization method to transform pixels into regions, and a region puzzle algorithm to calculate the range of a patient's epiglottis airway. This information is then utilized to compute the obstruction ratio of the patient's epiglottis site. Additionally, this system integrates web-based and PC-based programming technologies to realize its functionalities. Through experimental validation, this system was found to autonomously calculate obstruction ratios with a precision of 0.1% (ranging from 0% to 100%). It presents epiglottis obstruction levels as continuous data, providing crucial diagnostic insight for surgeons to assess the severity of epiglottis obstruction in patients.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Assessment of Leptin Levels and Their Correlation With the Severity of Obstructive Sleep Apnea Syndrome: A Case-Control Study

Background Obstructive sleep apnea (OSA) is characterized by a combination of structural issues in the upper airway and imbalances in the respiratory control system. While numerous studies have linked OSA with obesity, it remains uncertain whether leptin, a hormone associated with fat, plays a role in the functional and anatomical defects that lead to OSA. Therefore, the aim of this study was to investigate whether leptin levels could be used as a predictor of OSA syndrome (OSAS). Methodology A case-control observational study was conducted, enrolling study participants who reported obesity (BMI > 30) within the range of >30 to <35 kg/m2, along with a short neck and a history of snoring, excessive daytime drowsiness, fatigue, or insomnia. Leptin levels and fasting blood sugar (FBS) were measured in all individuals. Additionally, the study evaluated the severity of OSAS using indicators such as the STOP BANG scores, apnea-hypopnea index, uvula grade score, and Epworth Sleepiness Scale scores. Results A total of 80 participants (40 cases and 40 controls) were included in the study. The mean leptin and FBS levels were significantly higher in cases compared to controls. Moreover, leptin levels exhibited a significant correlation with the severity indices of OSAS. Conclusion The study findings indicate that individuals with higher leptin levels tend to exhibit more severe OSAS symptoms. Furthermore, these elevated leptin levels contribute to the worsening of various OSA symptoms. Larger controlled studies have suggested that pharmacologically restoring the altered leptin levels may serve as a beneficial adjunct to treatment for alleviating OSAS symptoms.

Comparing Diagnostic Efficacy of Imaging During Muller's Maneuver Versus Drug Induced Sleep Endoscopy in Obstructive Sleep Apnoea

The aim of the study was to compare the diagnostic efficacy of quantitative computed tomography (CT) based upper airway analysis using the Muller's maneuver (MM) and compare the findings with drug induced sleep endoscopy (DISE). A prospective observational study was conducted on 50 adult patients with symptoms of OSA and having apnoea-hypopnea index more than 5. They further underwent CT during normal breathing and during MM; findings of which were compared with DISE. Collapse at velum had statistically significant correlation with collapse at retropalatal level in CT (in MM) (P value = 0.001; r = 0.536). Base of tongue in DISE correlates significantly with retroglossal collapse on CT (P value = 0.002; r = 0.423). Epiglottic and oropharyngeal collapse had no correlation with any CT parameter. Collapse in CT as measured during MM shows significant correlation with DISE findings at velum and tongue base but cannot solely predict all levels without the aid of DISE.

Epiglottopexy for refractory obstructive sleep apnea in children - A single-institution experience

BACKGROUND

Refractory obstructive sleep apnea (OSA) is a common condition in children with medical comorbidities, leading to a significant impact on quality of life. Drug-induced sleep endoscopy (DISE) has become the standard of care in identifying the levels of obstruction in children with refractory OSA. Epiglottopexy has been shown to improve OSA symptoms in adults and healthy children with epiglottic prolapse in a few studies, with minimal long-term complications. The objective of our study was to evaluate the role of epiglottopexy in children with refractory OSA.

METHODS

A retrospective chart review of children with refractory OSA who were found to have epiglottic prolapse on DISE, and underwent epiglottopexy between January 2018 and November 2021 at a pediatric tertiary care hospital.

RESULTS

42 patients (age 8.1 ± 5.1 years) met inclusion criteria. Thirty patients (71.4 %) suffered from neurodevelopmental disease or congenital syndrome, and 14 patients (33.3 %) were gastrostomy-tube dependent. All patients had at least one prior surgical procedure to address their OSA. Thirty-six patients (85.7 %) were diagnosed with refractory OSA by polysomnography prior to surgery, with an average apnea-hypopnea index (AHI) of 12.4 ± 9.7/h. Forty patients (95.2 %) required an additional procedure in conjunction with epiglottopexy including lingual tonsillectomy (n = 27, 64.3 %), supraglottoplasty (n = 14, 33.3 %), tonsillectomy with or without revision adenoidectomy (n = 9, 21.4 %) and tongue base suspension (n = 1, 2.4 %). Twenty-one patients had repeated polysomnography; 4 patients were found to have residual severe OSA post-operatively (average AHI 17.4 ± 11.4/h), while the remaining patients demonstrated clinical improvement and a significant reduction in OSA severity, with an average AHI of 1.5 ± 2.2/h. Regression analysis identified pre-operative oxygen nadir <75 % to be associated with residual OSA postoperatively. Following surgery, 7 patients were found to have new-onset or worsening dysphagia, 6 of whom were diagnosed with complex medical comorbidities.

CONCLUSIONS

Epiglottopexy, as part of multi-level airway surgery, is associated with a significant improvement in the severity of refractory OSA. Dysphagia may complicate the post-operative course, particularly in children with medical comorbidities.

Relationship between level CPAP titration, anthropometric variables, and drug-induced sleep endoscopy DISE

INTRODUCTION

Subjects with palatal obstruction alone vs. multilevel obstruction on DISE had better outcomes after palate surgery. We asked ourselves if the therapeutic level positive airway pressure (PAP) titration could predict the level of airway obstruction and its complexity.

PURPOSE

The aim of this study was to identify possible relationships between therapeutic level of positive airway pressure initial titration and levels of collapse in drug-induced sleep endoscopy (DISE). A secondary objective was to establish the relationship the other variables and DISE.

METHODS

We analyzed retrospective clinical histories between March 2020 to March 2022 of 37 patients with polysomnography or cardiorespiratory polygraphy studies and PAP initial titration who were taken to drug-induced sleep endoscopy. Sleep study data, anthropometric variables, and patterns of airway collapse during DISE were analyzed with PAP initial titration levels.

RESULTS

Most of the patients with complex collapse had concentric velum collapse (p < 0.006). A significant association was found between the apnea-hypopnea index (AHI) and oropharyngeal collapse; (p < 0.0030) and finally we demonstrated relationship between neck circumference and gender with epiglottis collapse (p < 0.046), (p < 0.037), respectively.

CONCLUSIONS

Our findings show a strong relationship between that complex collapses and concentric velum collapse; patients with greater oropharyngeal collapse have a higher mean AHI. Patients without epiglottic collapse have a higher mean neck circumference. An association between mean pressure initial titration and complex collapse could not be established.

Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning

BACKGROUND

Treatment of obstructive sleep apnea is crucial for long term health and reduced economic burden. For those considered for surgery, drug-induced sleep endoscopy (DISE) is a method to characterize location and pattern of sleep-related upper airway collapse. According to the VOTE classification system, four upper airway sites of collapse are characterized: velum (V), oropharynx (O), tongue (T), and epiglottis (E). The degree of obstruction per site is classified as 0 (no obstruction), 1 (partial obstruction), or 2 (complete obstruction). Here we propose a deep learning approach for automatic scoring of VOTE obstruction degrees from DISE videos.

METHODS

We included 281 DISE videos with varying durations (6 s-16 min) from two sleep clinics: Copenhagen University Hospital and Stanford University Hospital. Examinations were split into 5-s clips, each receiving annotations of 0, 1, 2, or X (site not visible) for each site (V, O, T, and E), which was used to train a deep learning model. Predicted VOTE obstruction degrees per examination was obtained by taking the highest predicted degree per site across 5-s clips, which was evaluated against VOTE degrees annotated by surgeons.

RESULTS

Mean F1 score of 70% was obtained across all DISE examinations (V: 85%, O: 72%, T: 57%, E: 65%). For each site, sensitivity was highest for degree 2 and lowest for degree 0. No bias in performance was observed between videos from different clinicians/hospitals.

CONCLUSIONS

This study demonstrates that automating scoring of DISE examinations show high validity and feasibility in degree of upper airway collapse.

Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea

STUDY OBJECTIVES

Information on obstructive sleep apnea (OSA) is often latently detected in diagnostic tests conducted for other purposes, providing opportunities for maximizing value. This study aimed to develop a convolutional neural network (CNN) to identify the risk of OSA using lateral cephalograms.

METHODS

The lateral cephalograms of 5,648 individuals (mean age, 49.0 ± 15.8 years; men, 62.3%) with or without OSA were collected and divided into training, validation, and internal test datasets in a 5:2:3 ratio. A separate external test dataset (n = 378) was used. A densely connected CNN was trained to diagnose OSA using a cephalogram. Model performance was evaluated using the area under the receiver operating characteristic curve (AUROC). Gradient-weighted class activation mapping (Grad-CAM) was used to evaluate the region of focus, and the relationships between the model outputs, anthropometric characteristics, and OSA severity were evaluated.

RESULTS

The AUROC of the model for the presence of OSA was 0.82 (95% confidence interval, 0.80-0.84) and 0.73 (95% confidence interval, 0.65-0.81) in the internal and external test datasets, respectively. Grad-CAM demonstrated that the model focused on the area of the tongue base and oropharynx in the cephalogram. Sigmoid output values were positively correlated with OSA severity, body mass index, and neck and waist circumference.

CONCLUSIONS

Deep learning may help develop a model that classifies OSA using a cephalogram, which may be clinically useful in the appropriate context. The definition of ground truth was the main limitation of this study.

CITATION

Jeong H-G, Kim T, Hong JE, et al. Automated deep neural network analysis of lateral cephalogram data can aid in detecting obstructive sleep apnea. J Clin Sleep Med. 2023;19(2):327-337.

Sleep Endoscopy with Positive Airway Pressure: A Method for Better Compliance and Individualized Treatment of Patients with Obstructive Sleep Apnea

In this study, we aimed to observe the effects of positive airway pressure (PAP) on individual levels of obstruction during drug-induced sleep endoscopy (DISE) of the upper airways (UA), to evaluate at which pressures the obstruction disappeared or worsened, and to identify cases in which PAP was ineffective. This prospective study was conducted from June 2018 to June 2022. PAP testing was performed during DISE in patients with moderate and severe OSA. The pressure was gradually increased over the range from 6.0 to 18.0 hPa. Our findings were evaluated using the VOTE classification. The examination was performed in 56 patients, with a median apnea-hypopnea index (AHI) of 26.4. Complete obstruction of the soft palate was observed in 51/56 patients (91%), oropharyngeal obstruction in 15/56 patients (27%), tongue base obstruction in 23/56 patients (41%), and epiglottic collapse in 16/56 patients (29%). PAP was most effective in cases of complete oropharyngeal obstruction, and least effective in cases of epiglottic collapse, where it was ineffective in 11/16 patients. DISE with PAP is a simple diagnostic method that can be helpful for identifying anatomic and dynamic reasons for PAP intolerance. The main indication is ineffective PAP treatment.

Surgical Treatment Options for Epiglottic Collapse in Adult Obstructive Sleep Apnoea: A Systematic Review

The critical role of epiglottis in airway narrowing contributing to obstructive sleep apnoea (OSA) and continuous positive airway pressure (CPAP) intolerance has recently been revealed. This systematic review was conducted to evaluate available surgical treatment options for epiglottic collapse in adult patients with OSA. The Pubmed and Scopus databases were searched for relevant articles up to and including March 2022 and sixteen studies were selected. Overall, six different surgical techniques were described, including partial epiglottectomy, epiglottis stiffening operation, glossoepiglottopexy, supraglottoplasty, transoral robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. All surgical methods were reported to be safe and effective in managing selected OSA patients with airway narrowing at the level of epiglottis. The surgical management of epiglottic collapse can improve OSA severity or even cure OSA, but can also improve CPAP compliance. The selection of the appropriate surgical technique should be part of an individualised, patient-specific therapeutic approach. However, there are not enough data to make definitive conclusions and additional high-quality studies are required.

Patients with Epiglottic Collapse Are Less Adherent to Autotitrating Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Rationale: The anatomic orientation of the epiglottis is such that it points in the opposite direction to inspiratory flow, thereby potentially making positive airway pressure (PAP) treatment challenging in patients with epiglottic collapse. However, no previous studies have analyzed PAP adherence in these patients. Objectives: This study aimed to analyze adherence to autotitrating PAP (APAP) treatment in patients with epiglottic collapse. Methods: We performed an age- and sex-matched case-control study. On the basis of their overnight level-I polysomnogram, patients were prescribed APAP in a tertiary hospital between July 2018 and March 2019. The site of airway collapse was diagnosed with drug-induced sleep endoscopy. Demographic factors, sleep questionnaire, polysomnography, and APAP usage statistics were analyzed. Results: Eighteen patients with epiglottic collapse (epi-group) and 36 without epiglottic collapse (control group) were analyzed. We found that 22.8% of patients in the epi-group terminated APAP within 2 weeks, whereas only 2.8% of patients in the control group terminated APAP within 2 weeks (P = 0.048). The percentage of days with usage over 4 hours was significantly lower in the epi-group (64.6% vs. 75.6%; P = 0.008). In addition, the adherence failure rate was 66.7% in the epi-group and 33.3% in the control group (P = 0.039). Patients with epiglottic collapse were also found to have lower body mass index, which is an unfavorable predictor of APAP adherence. Conclusions: This study suggests that patients with epiglottic collapse have a higher APAP adherence failure rate than patients without epiglottic collapse. Thus, patients with epiglottic collapse should be followed closely during treatment, and alternative therapies should probably be considered for these patients.

Obstructive Sleep Apnea and Role of the Diaphragm

Obstructive sleep apnea (OSA) causes multiple local and systemic pathophysiological consequences, which lead to an increase in morbidity and mortality in patients suffering from this disorder. OSA presents with various nocturnal events of apnoeas or hypopneas and with sub-clinical airflow limitations during wakefulness. OSA involves a large percentage of the population, particularly men, but the estimate of OSA patients could be much broader than data from the literature. Most of the research carried out in the muscle field is to understand the causes of the presence of chronic nocturnal desaturation and focus on the genioglossus muscle and other muscles related to dilating the upper airways. Sparse research has been published regarding the diaphragm muscle, which is the main muscle structure to insufflate air into the airways. The article reviews the functional anatomy of the muscles used to open the upper respiratory tract and the non-physiological adaptation that follows in the presence of OSA, as well as the functional anatomy and pathological adaptive aspects of the diaphragm muscle. The intent of the text is to highlight the disparity of clinical interest between the dilator muscles and the diaphragm, trying to stimulate a broader approach to patient evaluation.

Epiglottopexy Is a Treatment of Choice for Obstructive Sleep Apnea Caused by a Collapsing Epiglottis

Drug-induced sleep endoscopy (DISE) reveals epiglottic collapse to be a frequent cause of obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP). These patients require different management. This prospective study aimed to compare transoral laser epiglottopexy outcomes in patients with OSA caused by epiglottic collapse with the patients’ previous PAP outcomes. Fifteen consecutive adult patients with OSA and epiglottic collapse during DISE were included; ten were analyzed. Before inclusion, PAP was indicated and ineffective in six patients, one of whom underwent unsuccessful uvulopalatopharyngoplasty. PAP was performed during DISE in all patients before epiglottopexy and was uniformly ineffective. ENT control was performed at 1 week and 1 month, and control limited polygraphy to 6 months after surgery. The apnea−hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) were significantly improved (p < 0.001 and p = 0.003, respectively) in all patients after epiglottopexy. Surgery was successful in 9/10 patients; the remaining patient had a significantly decreased AHI and could finally tolerate PAP. Transoral laser epiglottopexy is used to treat OSA in patients with epiglottic collapse. Unlike other methods, it significantly reduces both AHI and ESS and should be considered for these patients. An active search for OSA patients with epiglottic collapse is recommended to prevent treatment failure.

Treatment of primary epiglottis collapse in OSA in adults with glossoepiglottopexy: a 5-year experience

Objective

To review our 5-year experience with a modified version of glossoepiglottopexy for treatment of obstructive sleep apnoea syndrome (OSA) in two hospitals.

Methods

A retrospective analysis was carried out on a cohort of adult patients affected by OSA suffering from primary collapse of the epiglottis who underwent a modified glossoepiglottopexy. All patients underwent drug-induced sleep endoscopy, polysomnographic and swallowing evaluation, and assessment with the Epworth Sleepiness Scale (ESS).

Results

Forty-nine patients were retrospectively evaluated. Both the apnoea-hypopnoea index (AHI) (median AHI_post-AHI_pre = -22.4 events/h; p < 0.001) and oxygen desaturation index (ODI) showed a significant postoperative decrease (median ODI_post-ODI_pre = -18 events/h; p < 0.001), as did hypoxaemia index (median T_{90% post}-T_{90% pre} = -5%; p < 0.001). The ESS questionnaire revealed a significant decrease in postoperative scores (median ESS_post-ESS_pre =- 9; p < 0.001). None of the patients developed postoperative dysphagia.

Conclusions

Our 5-year experience demonstrates that modified glossoepiglottopexy is a safe and reliable surgical technique for treatment of primary epiglottic collapse in OSA patients.

Holistic care for obstructive sleep apnea (OSA) with an emphasis on restoring nasal breathing: A review and perspective

Obstructive sleep apnea (OSA) is characterized by partial or complete airway blockage during sleep. Nocturnal nasal obstruction usually leads to mouth breathing while sleeping, which worsens sleep apnea by aggravating tongue base and lateral pharyngeal wall collapse. The pathogenesis of OSA is multifactorial, and the precipitating factors vary significantly among individuals. Although continuous positive airway pressure (CPAP) is considered the first-line therapy for OSA, its adherence rate remains a challenge. Oral appliances are more suitable for simple snorers or patients with mild OSA. Maxillomandibular advancement (MMA) is highly effective for treating those with mandibular retrognathia and moderate-to-severe OSA. Intrapharyngeal surgeries yield favorable outcomes in patients with large tonsils and low tongue resting position (Friedman Stage I); however, their efficacy declines with time. Each therapy has its own strength and weakness; thus, the principle of multimodality treatment should be adopted. Nasal surgery plays an indispensable role in the holistic care for OSA. In addition to alleviating nasal congestion, nasal surgery significantly reduces snoring intensity and daytime sleepiness, which improves the quality of life of patients with OSA. Although it significantly reduces the respiratory disturbance index, its effect on the apnea-hypopnea index remains controversial. A combination of nasal surgery and multilevel pharyngeal surgery may result in better prognosis. Nasal surgery can significantly reduce the therapeutic pressure and improve the CPAP compliance of patients undergoing CPAP therapy. In conclusion, multimodality treatment and holistic care for OSA should involve nasal surgery for optimizing treatment outcomes.

Obstructive Sleep Apnea: characterization of the obstructive site and type of collapse

Obstructive Sleep Apnea is characterized by recurrent episodes of partial or complete collapse of the pharynx, followed by decreased oxyhemoglobin saturation and frequent arousals. It is regarded as a public health issue with important night and day symptoms that impact life quality. Its effects are associated with the areas of competence of Speech and Language Pathologists. To establish efficient diagnosis and treatment methods, professionals must know the pathogenesis of upper airway obstruction during sleep. This study seeks to enlarge the understanding of obstructive sleep apnea pathophysiology, eligibility of individualized therapeutic procedures and guidance for orofacial myofunctional therapy by describing and illustrating the locations and types of upper airway collapse during sleep. We analyzed original records of Drug Induced Sleep Endoscopy exams of a series of cases with polysomnographic diagnosis of obstructive sleep apnea following the proper ethical processes. The images of the exam recordings were analyzed by five professionals with expertise in the sleep area. Obstructive sites and types of collapse were presented according to the current classification. The videos were divided into screenshots, originating figures from each anatomical site: without collapse and collapsed. The results are visualized in the images of the cases showing a predominance of velopharyngeal collapse: anteroposterior, lateral, or concentric; oropharyngeal lateral collapse; tongue anteroposterior collapse and anteroposterior collapse of the epiglottis. Understanding the obstruction sites and types of collapse illustrated in this study may help to predict therapeutic responses and learn the limitations or direct individual proposals patient.

Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement

STUDY OBJECTIVES

(1) To investigate if drug-induced sleep endoscopy (DISE) findings are predictive of surgical response for patients undergoing maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) and (2) to investigate the predictive value of the jaw thrust maneuver during DISE in terms of surgical response to MMA.

METHODS

A retrospective cohort study was conducted in patients with OSA who underwent a baseline polysomnography (PSG) and DISE followed by MMA and a 3- to 6-month follow-up PSG between September 1, 2011, and September 30, 2020.

RESULTS

Sixty-four patients with OSA (50 males [78.1%]; mean ± SD age = 51.7 ± 9.5 years; mean ± SD apnea-hypopnea index = 49.0 ± 20.8 events/h) were included. Thirty-nine patients were responders, and 25 were nonresponders. Adjusting for baseline characteristics and surgical characteristics (eg, age, baseline apnea-hypopnea index, degree of maxillary advancement), patients with complete anteroposterior epiglottic collapse had 0.239 times lower odds for response to MMA (95% confidence interval, 0.059-0.979; P = .047). No significant relationship was found between complete concentric velum collapse and MMA response. There was no statistically significant association between effect of jaw thrust maneuver during DISE on upper airway patency and treatment outcome of MMA.

CONCLUSIONS

This study indicates that DISE is a promising tool to identify patients who will or will not respond to MMA for treating OSA. Patients with complete anteroposterior epiglottic collapse may be less suitable candidates for MMA.

CITATION

Zhou N, Ho J-PTF, de Vries N, Bosschieter PFN, Ravesloot MJL, de Lange J. Evaluation of drug-induced sleep endoscopy as a tool for selecting patients with obstructive sleep apnea for maxillomandibular advancement. J Clin Sleep Med. 2022;18(4):1073-1081.

Obstructive Sleep Apnoea in pycnodysostosis; a three-dimensional upper airway analysis

AIM

To assess the upper airway (UA) morphology in patients with pycnodysostosis with a 3D analysis, compare results with normative data and investigate correlation of the total volume (TV) to other UA morphology variables.

MATERIALS AND METHODS

Cone beam computed tomography (CBCT) images of eight Danish patients with pycnodysostosis (4 males, 4 females with a mean age of 31.8 years, SD:16.3 years), were analysed using Mimics® (Materialise®, Belgium) and compared with a sex- and age-matched control group (6 males, 8 females with a mean age of 33.6 years, SD:18.6 years).

RESULTS

The distance from the tip of the epiglottis (E) to the Frankfurt horizontal plane (Fp) was significantly shorter in the pycnodysostosis group (p < 0.042). Regarding the cross-sectional measurements, at the "maximum constriction" (p < 0.005), the "upper airway limit" (p < 0.001) and the "lower airway limit" (p < 0.035) cross-sections were significantly smaller in the pycnodysostosis group. The volumes "nasopharynx" (p < 0.002) and "total airway" (TV) (p < 0.01) were also significantly smaller.

CONCLUSION

Patients with pycnodysostosis have a reduced total airway as well as nasopharyngeal volume compared with matched controls. Additionally, they have a reduced cross-sectional area in the upper and lower borders of the UA, and the area of maximum constriction is also reduced. These factors might explain the high prevalence of obstructive sleep apnoea in pycnodysostosis. TV is positively correlated to total length and cross-sections at all levels including the maximum constriction area as well as the anteroposterior dimension at the upper and lower airway borders.

Robotic Modification of Epiglottis Trimming in the Treatment of Obstructive Sleep Apnea

OBJECTIVE

With the widespread use of drug-induced sleep endoscopy, it has been suggested that epiglottis pathologies are present at high rates in patients with sleep apnea. The aim of our study was to evaluate the efficacy of trimming the curled-inward epiglottis as an updated surgical technique in patients with omega epiglottis.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary hospital.

METHODS

Among the 283 patients with epiglottis pathology, 21 with isolated omega-shaped epiglottis (age, 33-53 years) fulfilled the inclusion criteria between May 2016 and April 2019. Drug-induced sleep endoscopy was used to detect epiglottic collapse compressed by the lateral parts during inspiration. An epiglottoplasty technique was applied as single-level sleep surgery in patients with an isolated omega-shaped epiglottis. The medical data were also reviewed.

RESULTS

The mean pre- and postoperative total apnea-hypopnea index (AHI) scores were 27.89 and 10.58, respectively, and this difference was statistically significant (P < .001). There was a statistically significant difference between the pre- and postoperative supine AHI scores (27.02 vs 10.48, P < .001). Surgical success, defined as AHI <20 and a decrease in AHI by 50%, was documented in 85.71% of patients (18/21), and 12 patients found complete relief from obstructive sleep apnea symptoms (AHI <5); the cure rate was 38.09% (8/21).

CONCLUSION

Trimming the curled-inward epiglottis may represent an excellent option for epiglottis surgery in patients with obstructive sleep apnea by being less invasive than techniques currently in use.

Comparison of Drug-Induced Sleep Endoscopy and Natural Sleep Endoscopy in the Assessment of Upper Airway Pathophysiology During Sleep: Protocol and Study Design

Study Objectives: Obstructive sleep apnea (OSA) is increasingly recognized as a complex and heterogenous disorder. As a result, a "one-size-fits-all" management approach should be avoided. Therefore, evaluation of pathophysiological endotyping in OSA patients is emphasized, with upper airway collapse during sleep as one of the main features. To assess the site(s) and pattern(s) of upper airway collapse, natural sleep endoscopy (NSE) is defined as the gold standard. As NSE is labor-intensive and time-consuming, it is not feasible in routine practice. Instead, drug-induced sleep endoscopy (DISE) is the most frequently used technique and can be considered as the clinical standard. Flow shape and snoring analysis are non-invasive measurement techniques, yet are still evolving. Although DISE is used as the clinical alternative to assess upper airway collapse, associations between DISE and NSE observations, and associated flow and snoring signals, have not been quantified satisfactorily. In the current project we aim to compare upper airway collapse identified in patients with OSA using endoscopic techniques as well as flow shape analysis and analysis of tracheal snoring sounds between natural and drug-induced sleep. Methods: This study is a blinded prospective comparative multicenter cohort study. The study population will consist of adult patients with a recent diagnosis of OSA. Eligible patients will undergo a polysomnography (PSG) with NSE overnight and a DISE within 3 months. During DISE the upper airway is assessed under sedation by an experienced ear, nose, throat (ENT) surgeon using a flexible fiberoptic endoscope in the operating theater. In contrast to DISE, NSE is performed during natural sleep using a pediatric bronchoscope. During research DISE and NSE, the standard set-up is expanded with additional PSG measurements, including gold standard flow and analysis of tracheal snoring sounds. Conclusions: This project will be one of the first studies to formally compare collapse patterns during natural and drug-induced sleep. Moreover, this will be, to the authors' best knowledge, the first comparative research in airflow shape and tracheal snoring sounds analysis between DISE and NSE. These novel and non-invasive diagnostic methods studying upper airway mechanics during sleep will be simultaneously validated against DISE and NSE. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04729478.

Diagnosis of upper airways collapse in moderate-to-severe OSAHS patients: a comparison between drug-induced sleep endoscopy and the awake examination

PURPOSE

Compare awake evaluation (modified Mallampati score-MMs, Müller maneuver-MM) to drug-induced sleep endoscopy (DISE) findings according to NOHL (nose-oropharynx-hypopharynx-larynx) classification in moderate-to-severe OSAHS patients.

METHODS

43 moderate-to-severe OSAHS patients referred to our ENT department were enrolled over a 2-year period. In this observational prospective study, each patient was evaluated by the same ENT team both in wakefulness and during pharmacologically induced sleep. Level and severity of the obstruction were described.

RESULTS

The comparison of degree of collapsibility was statistically significative only at hypopharyngeal level: 41.8% of the patients showed a hypopharyngeal obstruction in wakefulness whereas 88.3% in DISE (p = 0.000). Laryngeal level was found in 18.6% patients during awake examination, conversely DISE demonstrated laryngeal obstruction in 4.6%. DISE identified significantly higher incidence of multilevel collapses (p = 0.001). However, the incidence of oropharyngeal obstruction in patients classified as MMs I and II was significantly higher in DISE compared to MM (p = 0.021).

CONCLUSION

DISE is the best predictor of hypopharyngeal obstruction, whereas MM underestimates the severity of the collapse at this level. DISE is more reliable than MM to identify the obstruction in patients with MMs score I and II.

Prediction of the obstruction sites in the upper airway in sleep-disordered breathing based on snoring sound parameters: a systematic review

BACKGROUND

Identification of the obstruction site in the upper airway may help in treatment selection for patients with sleep-disordered breathing. Because of limitations of existing techniques, there is a continuous search for more feasible methods. Snoring sound parameters were hypothesized to be potential predictors of the obstruction site. Therefore, this review aims to i) investigate the association between snoring sound parameters and the obstruction sites; and ii) analyze the methodology of reported prediction models of the obstruction sites.

METHODS

The literature search was conducted in PubMed, Embase.com, CENTRAL, Web of Science, and Scopus in collaboration with a medical librarian. Studies were eligible if they investigated the associations between snoring sound parameters and the obstruction sites, and/or reported prediction models of the obstruction sites based on snoring sound.

RESULTS

Of the 1016 retrieved references, 28 eligible studies were included. It was found that the characteristic frequency components generated from lower-level obstructions of the upper airway were higher than those generated from upper-level obstructions. Prediction models were built mainly based on snoring sound parameters in frequency domain. The reported accuracies ranged from 60.4% to 92.2%.

CONCLUSIONS

Available evidence points toward associations between the snoring sound parameters in the frequency domain and the obstruction sites in the upper airway. It is promising to build a prediction model of the obstruction sites based on snoring sound parameters and participant characteristics, but so far snoring sound analysis does not seem to be a viable diagnostic modality for treatment selection.

Natural sleep endoscopy in obstructive sleep apnea: A systematic review

This study's objective is to systematically review the literature on natural sleep endoscopy (NSE), including the set-up, different scoring systems, visualized collapse patterns during natural sleep, additional measurements, and comparison of upper airway collapse between NSE and drug-induced sleep endoscopy (DISE). A computerized search on Medline, Web of Science and the Cochrane library was conducted, obtaining 39 hits. Ten prospective studies were included in which NSE was performed in adults with obstructive sleep apnea (OSA). This study's findings suggest the soft palate to be the most frequent site of obstruction (58.8 %), followed by the tongue base (43.2 %), lateral walls (29.9 %), and epiglottis (22.4 %), which is in line with previous findings during DISE. Based on this literature review, the authors conclude that at this stage high quality, comparative research between DISE and NSE is missing. To adequately compare findings between OSA patients, endoscopic classification of upper airway collapse should be standardized. Non-invasive predictive tools to determine pharyngeal collapse are currently under investigation and may obviate the need for invasive endoscopy. This review highlights the contribution of NSE in validating such novel diagnostic methods and in studying upper airway mechanics in a research setting, yet larger and adequately powered studies are needed.

Physiological Traits and Adherence to Therapy of Sleep Apnea in Individuals with Coronary Artery Disease

RATIONALE

Untreated obstructive sleep apnea (OSA) is associated with adverse outcomes in patients with coronary artery disease (CAD). Continuous positive airway pressure (CPAP) is the most common treatment, but despite interventions addressing established adherence determinants, CPAP use remains poor.

OBJECTIVES

To determine whether physiological traits that cause OSA are associated with long-term CPAP adherence in patients with CAD.

METHODS

Participants in the RICCADSA trial with objective CPAP adherence (hours/night) over 2 years and analyzable raw polysomnography data were included (n=249). The physiological traits -loop gain, arousal threshold (ArTH), collapsibility and muscle compensation- were measured from polysomnography. Linear mixed models assessed the relationship between the traits and adherence. We also compared actual CPAP adherence between physiology-predicted "poor" (lowest quartile of predicted adherence) and "good" (all others) adherers.

MEASUREMENTS AND RESULTS

Median (IQR) CPAP use declined from 3.2 (1.0, 5.8) to 3.0 (0.0, 5.6) hours/night over 24-mo (p<0.001). In analyses adjusted for demographics, anthropometrics, OSA characteristics and clinical comorbidities, lower ArTH was associated with worse CPAP adherence (0.7 hours/SD ArTH, p=0.021). Both high and low muscle compensation were associated with lower adherence (p=0.008). Predicted "poor" adherers exhibited markedly lower CPAP use compared to "good" adherers for up to 2 years of follow-up (group differences: 2.0 to 3.2 hours/night, p<0.003 for all).

CONCLUSIONS

A low ArTH as well as a very low and high muscle compensation are associated with worse long-term CPAP adherence in patients with CAD and OSA. Physiological traits, alongside established determinants, may help predict and improve CPAP adherence.

Can drug-induced sleep endoscopy (DISE) predict compliance with positive airway pressure therapy? A pilot study

PURPOSE

Drug-induced sleep endoscopy (DISE) has been poorly explored as an examination to assess positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA). The present study aimed to identify by DISE possible characteristics related to low compliance with PAP therapy due to respiratory complaints.

METHODS

Patients using PAP for OSA underwent DISE in two conditions: (1) baseline (without PAP) and (2) PAP (with the same mask and airway pressure used at home). We compared patients reporting low compliance to PAP due to respiratory complaints to those well-adapted to therapy. VOTE classification (assessment of velopharynx, oropharynx, tongue base, and epiglottis) and TOTAL VOTE score (the sum of VOTE scores at each anatomical site) were assessed. ROC curve analyzed the accuracy of TOTAL VOTE to predict low compliance due to persistent pharyngeal obstruction in both conditions.

RESULTS

Of 19 patients enrolled, all presented multilevel pharyngeal obstruction at baseline condition, with no difference between groups at this study point. When PAP was added, the median VOTE value was higher in the epiglottis (P value=0.02) and tended to be higher at the velum and tongue base in the poorly adapted group; TOTAL VOTE score was also significantly increased in patients with low compliance (P value<0.001). ROC curve demonstrated that patients with TOTAL VOTE scored 2.5 or more during DISE with PAP presented a 4.6-fold higher risk for low compliance with PAP therapy due to pharyngeal obstruction (AUC: 0.88±0.07; P value<0.01; sensitivity: 77%; specificity: 83%).

CONCLUSIONS

Adding PAP during a DISE examination may help to predict persistent pharyngeal obstruction during PAP therapy.

Patients with epiglottic collapse showed less severe obstructive sleep apnea and good response to treatment other than continuous positive airway pressure: a case-control study of 224 patients

STUDY OBJECTIVES

The purpose of this study was to analyze patients with epiglottic collapse, especially their clinical characteristics related to obstructive sleep apnea and phenotype labeling using drug-induced sleep endoscopy.

METHODS

An age-sex matched case-control study was conducted to compare the clinical characteristics of patients with epiglottic collapse (Epi group) and patients without epiglottic collapse (non-Epi group). All patients underwent drug-induced sleep endoscopy January, 2015, to March, 2019, in a tertiary hospital for suspected sleep apnea symptoms. Demographic factors, underlying disease, overnight polysomnography, and their phenotype labeling using drug-induced sleep endoscopy were analyzed.

RESULTS

There was no difference in age, sex, the prevalence of hypertension, diabetes, cerebrovascular disease, and coronary artery disease. However, the body mass index was significantly lower in patients in the Epi group (P < .001). Additionally, the apnea-hypopnea index was lower (P = .001), and the lowest oxygen saturation was significantly higher in the Epi group (P = .042). The phenotype labeling on drug-induced sleep endoscopy showed that the prevalence of velum concentric collapse and oropharyngeal lateral wall collapse was lower, and that of tongue-base collapse was higher in the Epi group. Multilevel obstructions were more common in the Epi group. However, the Epi group showed a good response to mandibular advancement or positional therapy.

CONCLUSIONS

Although there was no difference in the underlying characteristics and self-reported symptom scores between the groups, the patients with epiglottic collapse showed significantly lower body mass index and obstructive sleep apnea severity. Additionally, patients with epiglottic collapse were expected to respond well to oral devices or positional therapy.

Prediction of Epiglottic Collapse in Obstructive Sleep Apnea Patients: Epiglottic Length

OBJECTIVE

This study aims to explore the factors that contribute to epiglottic collapse (EC) in patients with obstructive sleep apnea (OSA).

METHODS

This study enrolled 35 patients (34 males; median age, 39 years; median apnea-hypopnea index (AHI), 55.4 events/h; median body mass index (BMI), 26.9 kg/m²). EC (epiglottis attaching onto the posterior pharyngeal wall) was diagnosed by drug-induced sleep computed tomography (DI-SCT). Three dimensions were assessed for comparison between the EC and non-EC (NEC) groups that included anatomical measurement: epiglottic length and angle, endoscopic classification of epiglottis obstructing the glottis (Type I, none; Type II, partial; and Type III, total), and dynamic hyoid movement during DI-SCT (Δ hyoid = √(x² + y²), maximal displacement of hyoid in x and y axes during sleep breathing cycle).

RESULTS

EC was found in 12 patients (34%). No difference in age, gender, AHI, and BMI between the two groups was noted. The anatomical measurement revealed that epiglottis length was significantly different between the EC and NEC groups (21.2 vs 15.8 mm; p < 0.001), with a cutoff value of 16.6 mm (sensitivity, 100%; specificity, 65.2%). The EC group patients showed larger hyoid movement than the NEC group patients (Δ hyoid, 4.8 vs 3.0 mm; p = 0.027). By contrast, epiglottic angle and endoscopic classification revealed an insignificant difference between the two groups.

CONCLUSION

Epiglottis is a potential collapse site among multilevel obstruction in moderate to severe OSA patients. Epiglottic length is highly sensitive in predicting EC, with the cutoff value of 16.6 mm. Hyoid movement plays a role in contributing to EC in OSA patients.

Robot-assisted epiglottopexy as a method for managing adult obstructive sleep apnea

INTRODUCTION

Patients who do not tolerate continuous positive airway pressure (CPAP) for treatment of obstructive sleep apnea (OSA) often seek surgical management. A variety of procedures exist to address the nasal passages, oropharynx, hypopharynx, and larynx. Diagnostic studies including drug-induced sleep endoscopy (DISE) are helpful in identifying areas of obstruction. One potential site of obstruction is at the level of the epiglottis. We describe the use of robotic technology to assist with epiglottopexy to manage epiglottic retroflexion as a cause of two patients' OSA. This is the first reported robot-assisted epiglottopexy in the adult otolaryngology literature.

METHODS

This is a case series of two patients with OSA who demonstrated epiglottis collapse into the airway during DISE. They were evaluated by polysomnographic testing (PSG), Epworth Sleepiness Scale (ESS), and physical exam. Given their epiglottic collapse seen on DISE, they underwent robot-assisted epiglottopexy.

RESULTS

Both patients had moderate to severe OSA preoperatively. They successfully underwent robot-assisted epiglottopexy as a surgical intervention. They tolerated the procedure, and there have been no complications. Each reported improved symptoms, with patient one showing a decrease in total AHI and a substantial decrease in oxygen desaturations at night. The second patient reported a significant decrease in AHI and ESS.

CONCLUSION

There are many options for surgical intervention in patients with OSA. Epiglottopexy is one method for addressing collapse of the epiglottis and can be achieved successfully through robot-assisted epiglottopexy in adult patients with OSA.

LEVEL OF EVIDENCE

IV.

Therapeutic Positive Airway Pressure Level Predicts Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea

STUDY OBJECTIVES

To determine whether therapeutic positive airway pressure (PAP) level predicts response to hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea using the coprimary outcomes of apnea-hypopnea index (AHI) and 4% oxygen desaturation index.

METHODS

Combined cohort study from two US sleep otolaryngology training programs. Subjects were adults with AHI > 15 events/h who underwent HGNS. Eligible subjects had diagnostic preoperative sleep studies, full-night efficacy postoperative studies and therapeutic PAP levels available for analysis. Low and high PAP groups were compared using the t test for continuous variables and chi-square test for categorical variables.

RESULTS

Fifty-six patients met all inclusion criteria. On average, patients were male, Caucasian, middle-aged, and overweight. Thirteen patients were in the low PAP group (< 8 cm H₂O) and 43 patients in the high PAP group (≥ 8 cm H₂O). Although both groups experienced improvement of polysomnographic measures with HGNS, the low PAP group achieved a significantly larger mean AHI reduction (36.7 ± 22.7 versus 18.4 ± 23.4, P = .02). Additionally, the low PAP group had a greater response rate (defined as AHI < 20 events/h and > 50% reduction of AHI) than the high PAP group (92% versus 44%, P < .01).

CONCLUSIONS

Therapeutic PAP level may aid in the discernment of candidacy for HGNS, with a strong positive predictive value for PAP levels < 8 cm H₂O. A larger prospective study is needed to confirm these findings.

CITATION

Lee CH, Seay EG, Walters BK, Scalzitti NJ, Dedhia RC. Therapeutic positive airway pressure level predicts response to hypoglossal nerve stimulation for obstructive sleep apnea. J Clin Sleep Med. 2019;15(8):1165-1172.

Partial epiglottectomy improves residual apnea-hypopnea index in patients with epiglottis collapse

Continuous positive airway pressure treatment aggravates airway obstruction in patients with epiglottis collapse. In these patients, partial epiglottectomy can resolve epiglottis collapse by partial excision of the obstructed epiglottis. However, patients with epiglottic collapse usually have simultaneous obstructions on multiple levels, such as the soft palate, base of the tongue, etc. Therefore, sleep apnea cannot be controlled merely by resolving epiglottis collapse. The use of additional continuous positive airway pressure treatment after partial epiglottectomy is considered essential. However, no studies have yet evaluated the effect of partial epiglottectomy on continuous positive airway pressure treatment. In this study, we report on 2 patients with obstructive sleep apnea who underwent partial epiglottectomy. These 2 patients used autotitrating positive airway pressure treatment pre- and postoperatively. The present case report will provide insight into the effects of partial epiglottectomy on the use of positive-pressure devices.

Combined Surgical and Orthodontic Treatments in Children with OSA: A Systematic Review

Obstructive sleep apnea (OSA) is a sleeping breathing disorder. In children, adenotonsillar hypertrophy remains the main anatomical risk factor of OSA. The aim of this study was to assess the current scientific data and to systematically summarize the evidence for the efficiency of adenotonsillectomy (AT) and orthodontic treatment (i.e., rapid maxillary expansion (RME) and mandibular advancement (MA)) in the treatment of pediatric OSA. A literature search was conducted in several databases, including PubMed, Embase, Medline, Cochrane and LILACS up to 5th April 2020. The initial search yielded 509 articles, with 10 articles being identified as eligible after screening. AT and orthodontic treatment were more effective together than separately to cure OSA in pediatric patients. There was a greater decrease in apnea hypoapnea index (AHI) and respiratory disturbance index (RDI), and a major increase in the lowest oxygen saturation and the oxygen desaturation index (ODI) after undergoing both treatments. Nevertheless, the reappearance of OSA could occur several years after reporting adequate treatment. In order to avoid recurrence, myofunctional therapy (MT) could be recommended as a follow-up. However, further studies with good clinical evidence are required to confirm this finding.

Surgical treatment of epiglottis collapse in obstructive sleep apnoea syndrome: epiglottis stiffening operation

The epiglottis is an important structure that was largely ignored in early research on obstructive sleep apnoea/hypopnoea syndrome (OSAHS). Primary epiglottis collapse (EC) in patients with OSAHS is difficult to treat with conservative therapies, such as oral appliances and CPAP. Therefore, surgical treatment may represent a good option when dealing with EC, although up to now no standardised surgical procedures have been described. Herein, we describe a new surgical procedure that we called “epiglottis stiffening operation” (ESO); the technique is safe, devoid of complications, easy to perform and is effective in treatment of primary EC, which presents as a single or coexistent site of upper airway obstruction without altering fundamental functions of the epiglottis.

Floppy epiglottis together with extra-laryngeal mass causing an inducible laryngeal obstruction and hypoxemic event in an adult: A case report

Floppy epiglottis in an adult is rare and often pathological. Airway obstruction caused by floppy epiglottis in an adult is rarely reported. Neck mass, however, can affect the airway in many ways; however, inducible upper airway obstruction by extra-laryngeal neck mass is hardly been reported. In most of the instances of inducible laryngeal obstruction, the tumor is found in and around the laryngeal inlet. Herein, we report such an unusual incident happened to a 40-year-old gentleman, a case of oral carcinoma for 3 months and a rapidly increasing swelling (6 × 5 cm) over the right side of the neck for 8 days. He presented to us for emergency tracheostomy with the feature of acute upper airway obstruction, unable to lie down; and having difficulty in breathing, desaturation, and chocking even in propped up position. The case highlights the importance of clinical findings and difficulties faced for airway management in such patients.

How to manage continuous positive airway pressure (CPAP) failure -hybrid surgery and integrated treatment

Obstructive sleep apnea (OSA) is a prevalent disease, which influences social relations and quality of life with major health impact. The etiology of OSA is multi-factorial involving both anatomical obstruction and physiological collapse of the upper airway during sleep with different proportion in individual patients. Continuous positive airway pressure (CPAP) is the gold standard and first-line treatment for OSA patients. The mechanism of CPAP is acting as air splint to avoid principal pharyngeal collapse during sleep. Consequently, extrapharyngeal collapse and significant pharyngeal obstructions can lower its compliance and lead to its failure. Adequate mask and pressure with thorough survey to eliminate side effects of CPAP from nasal, mask and flow-related problems are the prerequisite to improve CPAP compliance. For CPAP failure patients, multi-dimensional surgery is an alternative and salvage treatment that involves soft tissue surgery, skeletal surgery, and bariatric surgery. OSA patients with craniofacial anomaly are suggested to skeletal surgery. By contrast, OSA patients with pathological obesity are referred to bariatric surgery. Soft tissue surgery targets at the nose, soft palate, lateral pharyngeal wall, tongue and epiglottis that can be implemented by multi-level surgery with hybrid technique (mucosa-preservation, fat-ablation, muscle-suspension, tonsil-excision, cartilage-reconstruction) to maximize surgical outcomes and minimize complications. Some evolution in surgical concept and technique are noteworthy that include mini-invasive septoturbinoplasty, palatal suspension instead of excision, whole tongue treatment, and two-dimensional supraglottoplasty. Postoperative integrated treatment including myofunctional, positional therapy and body weight control reduces relapse of OSA and improves long-term treatment outcomes.

Nasal Surgery May Improve Upper Airway Collapse in Patients With Obstructive Sleep Apnea: A Drug-Induced Sleep Endoscopy Study

OBJECTIVE

The aim of this study is to evaluate the effects of nasal surgery in the upper airway (UA) collapse using drug induced sleep endoscopy (DISE) in a group of patients with obstructive sleep apnea hypopnea syndrome (OSAHS).

METHODS

Prospective cohort of patients treated with nasal surgery between 2015 and 2016. All patients were diagnosed with mild to severe OSAHS. The inclusion criteria were age between 18 and 70 years, apnea-hypopnea index (AHI) higher than 15, and septal deviation. All patients had a DISE performed before surgery and 3 months after. The DISE findings were evaluated through the NOHL scale.

RESULTS

Thirty-four patients were included. Surgical success with subjective and objective improvement in nasal obstructions was achieved in all cases. The pattern of UA obstruction did change significantly following nasal surgery (P < 0.05). Before nasal surgery, 74% of the patients demonstrated multilevel obstruction. After nasal surgery, only 50% patients showed multilevel collapse (P < 0.05). Among patients with single-level collapse, the oropharynx was the most common location of obstruction. It became more frequent after nasal surgery was done (41% vs 21%, P < 0.05). Significant improvement was shown in hypopharyngeal collapse. Postoperative AHI decreased from a mean of 26.7 to 19 events/h, but this change was not significant.

CONCLUSION

Nasal surgery may improve hypopharyngeal collapses observed during DISE in patients with OSAHS. Thus, an improvement in nasal obstruction may also modify the surgical plan based on UA functional findings in OSAHS patients.

Base of Tongue Surgery for Obstructive Sleep Apnea in the Era of Neurostimulation

Retroglossal collapse is commonly seen in patients with obstructive sleep apnea. The role of upper airway stimulation surgery for these patients continues to evolve. However, base of tongue reduction surgery continues to have usefulness for appropriately selected patients with obstructive sleep apnea. Specific tongue base approaches may vary in response to patient and surgeon preferences and be used in multilevel surgery where appropriate. Key factors include patient age, willingness to undergo device implantation, and preferences for outpatient versus inpatient procedure, single procedure versus multiple, and tolerance for various procedure-specific postoperative restrictions and potential complications.