Epiglottis shape as a predictor of obstruction level in patients with sleep apnea

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.

A Large Cohort Analysis of Epiglottic Phenotypes and Pharyngeal Residue

OBJECTIVE

To describe the phenotypic characteristics of the epiglottis at rest and their impact on vallecular residue.

METHODS

Videofluoroscopic studies (VFSS) were pooled from 2 Laryngology practices, and Image J was used to measure epiglottic anatomic features at rest. Studies were rated by the MBSImp and presence of vallecular residue following swallow of thin and puree boluses. A conditional inference tree analysis was performed to isolate which epiglottic parameters were risk factors for presence of vallecular reside followed by logistic regression.

RESULTS

The majority of patients had a normal shaped epiglottis, followed by omega shape. The mean angle of the epiglottis from the hyoid was approximately 90°. Only abnormal epiglottic movement was associated with increased risk of residue for thin boluses (OR 35.09, CI 10.93-158.66, P < .001). However, in those with normal epiglottic movement, age >70 years old was associated with increased risk of residue (OR 3.98, CI 1.73-9.23, P = .001). For puree boluses, a normal or omega shaped epiglottis was associated with residue (OR 5.19, CI 2.41-11.51, P < .001), and this relationship was further modulated by increased distance of the epiglottic tip from the posterior pharyngeal wall. No other anatomic features of the resting epiglottis were associated with residue. Comorbidities potentially affecting swallow were infrequent in the cohort and were not associated with residue.

CONCLUSION

Abnormal epiglottic movement is associated with aspiration, and in this study we find that abnormal epiglottic movement increases the risk of vallecular residue and that older age is a risk factor for residue. The resting properties of the epiglottis do not appear to be associated with abnormal epiglottic movement or residue.

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.

Obstructive Sleep Apnea in Adults and Ear, Nose, and Throat (ENT) Health: A Narrative Review

Obstructive sleep apnea (OSA), a form of sleep-disordered breathing, is a significant health concern that leads to substantial morbidity. The collapse or occlusion of the upper airway, which results in reduced or cessation of airflow, is the pathophysiology of sleep apnea. The condition has been attributed to numerous cardiovascular, metabolic, and neuropsychological issues and carries serious health concerns. The ensuing intermittent hypoxia and sleep disruption set off a chain of physiological reactions that aid in developing endothelial dysfunction, systemic inflammation, and oxidative stress. The following line of treatment depends on the appropriate diagnosis of sleep apnea and the underlying cause. The gold standard for diagnosis is polysomnography (PSG), which assesses different physiological parameters during sleep. However, because polysomnography is expensive, patients may use more friendly screening and diagnostic testing kits, like home sleep apnea testing. The clinical symptoms and head and neck history may reveal essential risk factors. The primary objectives of management treatments for sleep apnea are to lessen symptoms, enhance sleep quality, and reduce any health concerns that may be present. It is advised to start with lifestyle changes such as quitting alcohol and sedative use, losing weight, and exercising frequently. The primary treatment for moderate to severe sleep apnea is continuous positive airway pressure (CPAP) therapy, which includes administering pressurized air to keep the airway open while you sleep. Oral appliances, positional therapy, surgery, and complementary therapies are other treatment choices that can be adapted to each patient's needs and preferences. The goal of the review is to evaluate the morphological and functional aspects of the upper airway, including the nose and throat, that influence the onset and severity of OSA. With a focus on the interaction between otorhinolaryngologists, sleep medicine specialists, and other healthcare professionals, we aim to consider how OSA affects otorhinolaryngology-related medical issues, look at any potential reciprocal relationships, and provide a summary of the interdisciplinary management strategy for OSA. We tried to analyse the various surgical and non-surgical therapy options for OSA management available in the otorhinolaryngology field for improving OSA symptoms and results.

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.

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.

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.

Obstructive sleep apnoea after radiotherapy for head and neck cancer

Objective

The aim of this study is to focus attention on obstructive sleep apnoea hypopnoea syndrome (OSHAS) as a sequela of non-surgical treatments of selected head and neck cancer (HNca), sharing our experience in drug-induced sleep endoscopy (DISE). To the best of our knowledge, this is the first study that documents dynamic anatomical and functional alterations during sleep in irradiated OSAHS patients by DISE.

Methods

A retrospective study of patients affected by OSAHS referring to our department from January 2018 to December 2019 was carried out. Inclusion criteria were: patients who underwent radiation or chemo-radiation for HNca affecting upper airways that presented sleep-related breathing disorders after treatment.

Results

6 patients with moderate to severe OSAHS and a clinical story of previous non-surgical treatment for an HNca were enrolled. DISE showed in all patients typical anatomical alterations observed in irradiated individuals. Four patients were treated with continuous positive airway pressure, while 2 subjects were treated with tailored minimal invasive surgery without post-operative complications.

Conclusions

Our results suggest that minimal invasive surgical treatments can be a good therapeutic option in very selected patients with post-irradiation iatrogenic OSAHS.

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.

Awake endoscopic assessment of the upper airway during tidal breathing: Definition of anatomical features and comparison with drug-induced sleep endoscopy

OBJECTIVES

Awake nasopharyngoscopy is routinely performed in the assessment of patients who require treatment for sleep-disordered breathing (SDB). However, the applicability and accuracy of Müller's manoeuvre, the main evaluation method for this purpose, are disputable. The current study aimed to introduce an alternative method for awake nasopharyngoscopy in patients with SDB.

DESIGN

We defined qualitative anatomical features during tidal breathing at the levels of the soft palate, oropharynx, tongue base, epiglottis and hypopharynx, and compared these awake features to the sites and patterns of collapse as observed during drug-induced sleep endoscopy (DISE).

SETTING

Tertiary care academic centre.

PARTICIPANTS

Seventy-three patients diagnosed with SDB.

MAIN OUTCOME MEASURES

The primary outcome measure was the Kendall's tau correlation coefficient (τ) between observations during awake nasopharyngoscopy and DISE. Kappa-statistics (κ) were calculated to assess the agreement on awake endoscopic features with a second observer.

RESULTS

In contrast to epiglottis shape, the modified Cormack-Lehane scale was significantly associated with epiglottis collapse during DISE (P < .0001; τ = .45). Other upper airway features that were correlated with DISE collapse were the position of the soft palate (P = .007; τ = .29), crowding of the oropharynx (P = .026; τ = .32) and a posteriorly located tongue base (P = .046; τ = .32). Interobserver agreement of endoscopic features during tidal breathing was moderate (0.60 ≤ κ < 0.80).

CONCLUSION

The current study introduces a comprehensive and reliable assessment method for awake nasopharyngoscopy based on anatomical features that are compatible with DISE collapse patterns.

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.