Clinical reviewAirway evaluation in obstructive sleep apnea
Section snippets
Methods of airway evaluation
As the interest in sleep-disordered breathing (SDB) has increased, various attempts have been made to assess upper airway anatomy in patients with this relatively frequent disorder. From the very beginning, researchers and clinicians used a multitude of different techniques not only to reveal potential differences in upper airway anatomy to better understand the origin and the pathophysiology of the disease but also to improve patient management and treatment success. While the value of
Clinical examination and clinical scores
A clinical examination including an endoscopy of the upper airway during wakefulness still constitutes the basis of every airway evaluation in snorers and obstructive sleep apnea (OSA) patients. Given the early failures in the surgical treatment of these patients, anatomic and static findings were the first parameters to be evaluated in order to improve treatment success. The impact of enlarged palatine tonsils became evident in the surgical experiences with children. If performed
The Mueller maneuver
Snoring as well as apneas can be simulated by most people and a direct effect of the Mueller maneuver may be seen during wakefulness. Thus, snoring simulation and the effects of the Mueller maneuver have been used in upper airway evaluation before surgical intervention in patients to predict surgical outcome and to improve patient selection.20, 21, 22 In addition, the Mueller maneuver has been performed to assess and predict postoperative changes of the upper airway,23, 24, 25, 26 although the
X-ray cephalometry
Over the years, lateral X-ray cephalometry has become one of the standard diagnostic tools in patients with SDB, especially with regard to the evaluation of the skeletal craniofacial morphology. Not specifically developed for the field of SDB, imaging techniques and standards for data analysis have been incorporated from the field of maxillofacial surgery, where it has already been used for decades.
Being a standard tool for maxillofacial surgeons and orthopedic surgeons, one focus of X-ray
CT scanning
Compared to lateral X-ray cephalometry, CT scanning significantly improves soft tissue contrast and allows precise measurements of cross-sectional areas at different levels as well as three-dimensional reconstruction and volumetric assessment. Fast scanning times and relatively quiet scanning conditions even allow a dynamic assessment of the airway during a respiratory cycle as well as measurements during natural sleep. Nevertheless, ionized radiation remains problematic and the vast majority
MR imaging
Compared to lateral X-ray cephalometry or CT scanning MRI offers various advantages, such as excellent soft tissue contrast, three-dimensional assessments of tissue structures and lack of ionized radiation. The advantages with regard to the lack of ionized radiation have made MR imaging the imaging technique of choice in the assessment of children with SDB.
Videoendoscopy during spontaneous sleep
As early as 1978 the first report about videoendoscopic recording of the pharynx and larynx during sleep was published. Borowiecki et al.162 described a palatopharyngeal collapse at the end of expiration and directly before inspiration in patients with OSA. They described different degrees of airway obstruction, often associated with a medialization of the lateral pharyngeal walls. Snoring sounds during arousals were attributed to the soft palate and the lateral pharyngeal walls. As there was
Impact of videoendoscopy under sedation on sleep, breathing and snoring
Videoendoscopy under sedation also makes it possible to visualize the site and mechanism of snoring and pharyngeal obstruction in patients with SDB. Therefore, it is mandatory that snoring and airway obstruction can be provoked in affected patients and that neither the endoscope itself nor the drugs used for sedation disturb or influence breathing patterns, snoring or airway obstruction during sedation. At first videoendoscopy during sedated sleep was described in children and 1 year later in
Multi-channel pressure measurements
Changes in inspiratory pressure in the upper airway during obstructive events can be measured with catheters. To assess airway obstruction, different measuring points meaning different pressure transducers can be used from the nasopharynx through the oro- and hypopharynx down to the esophagus. Initially, pressure transducers were used mainly to investigate the mechanisms of airway obstruction in general; nowadays research is focused on the diagnostic potentials compared to standard
Critical closing pressure
The severity of SDB is usually described by the AHI, representing the number of upper airway obstructions during sleep. Nevertheless, it has to be kept in mind that the AHI simply describes the frequency of upper airway obstructions, not the severity of the pharyngeal collapse itself. Furthermore, measuring the severity of upper airway collapse is believed to be important when estimating the forces needed to overcome these obstructions or to maintain upper airway stability. Schwartz et al.211
Summary
The various techniques of airway evaluation presented in this review have significantly increased our insight into the pathophysiology of SDB. Nevertheless, potential benefits with regard to patient management or the superiority over simple clinical assessment remains under discussion.
The role of routine clinical and endoscopic evaluation of the upper airway is unquestioned especially in terms of patient management and treatment selection. Although the subjectivity of the assessment and the
Acknowledgment
We want to thank Mr. J. Wich-Schwarz, Ph.D., for his editorial assistance.
References* (219)
- et al.
Clinical staging for sleep-disordered breathing
Otolaryngol Head Neck Surg
(2002) - et al.
Obstructive sleep apnea and maxillomandibular advancement: an assessment of airway changes using radiographic and nasopharyngoscopic examinations
J Oral Maxillofac Surg
(2002) - et al.
Preliminary findings from a prospective, randomized trial of two tongue-base surgeries for sleep-disordered breathing
Otolaryngol Head Neck Surg
(2003) - et al.
Dynamic pharyngoscopy in predicting outcome of uvulopalatopharyngoplasty for moderate and severe obstructive sleep apnea
Chest
(1995) Midline laser glossectomy with linguoplasty: a treatment of sleep apnea syndrome
OP Tech Otolaryngol HNS
(1991)- et al.
Endoscopic evaluation of dynamic narrowing of the pharynx by the Bernouilli effect producing maneuver in patients with obstructive sleep apnea syndrome
Auris Nasus Larynx
(2006) - et al.
The pharyngeal critical pressure. The whys and hows of using nasal continuous positive airway pressure diagnostically
Chest
(1996) - et al.
Acoustic parameters of snoring sound to assess the effectiveness of the Muller manoeuvre in predicting surgical outcome
Auris Nasus Larynx
(2006) - et al.
Cephalometric and computed tomographic predictors of obstructive sleep apnea severity
Am J Orthod Dentofacial Orthop
(1995) - et al.
Cephalometric analysis in obese and nonobese patients with obstructive sleep apnea syndrome
Chest
(2003)
Cephalometric assessment of craniofacial morphology in Chinese patients with obstructive sleep apnoea
Respir Med
Comparison between anatomy and resistance of upper airway in normal subjects, snorers and OSAS patients
Respir Physiol
Obstructive sleep apnoea: multiple comparisons of cephalometric variables of obese and non-obese patients
J Craniomaxillofac Surg
The relationship between obesity and craniofacial structure in obstructive sleep apnea
Chest
The relationship between severity of obstructive sleep apnoea/hypopnoea syndrome (OSAHS) and lateral cephalometric radiograph values: a clinical diagnostic tool
Surgeon
An investigation into the relationship between the severity of obstructive sleep apnoea/hypopnoea syndrome and the vertical position of the hyoid bone
Surgeon
Anatomic determinants of sleep-disordered breathing across the spectrum of clinical and nonclinical male subjects
Chest
Cephalometric and physiologic predictors of the efficacy of an adjustable oral appliance for treating obstructive sleep apnea
Am J Orthod Dentofacial Orthop
A comparison of responders and nonresponders to oral appliance therapy for the treatment of obstructive sleep apnea
Am J Orthod Dentofacial Orthop
Influence of mandibular protruding device on airway passages and dentofacial characteristics in obstructive sleep apnea and snoring
Am J Orthod Dentofacial Orthop
Predictors of long-term orthodontic side effects from mandibular advancement devices in patients with snoring and obstructive sleep apnea
Am J Orthod Dentofacial Orthop
The effects of oral appliance therapy on occlusal function in patients with obstructive sleep apnea: a short-term prospective study
Am J Orthod Dentofacial Orthop
Dental and skeletal changes after 4 years of obstructive sleep apnea treatment with a mandibular advancement device: a prospective, randomized study
Am J Orthod Dentofacial Orthop
Occlusal and skeletal effects of an oral appliance in the treatment of obstructive sleep apnea
Chest
Prediction of uvulopalatopharyngoplasty response using cephalometric radiographs
Am J Otolaryngol
Obstructive sleep apnea: a comparison of continuous positive airway pressure and surgical treatment
Otolaryngol Head Neck Surg
Long-term results of uvulopalatopharyngoplasty for obstructive sleep apnea syndrome
Laryngoscope
Increase of the apnoea–hypopnoea index after uvulopalatopharyngoplasty: analysis of failure
Clin Otolaryngol Allied Sci
Previous tonsillectomy as prognostic indicator for success of uvulopalatopharyngoplasty
Laryngoscope
Predictive value of Muller maneuver, cephalometry and clinical features for the outcome of uvulopalatopharyngoplasty. Evaluation of predictive factors using discriminant analysis in 30 sleep apnea patients
Acta Otolaryngol
Effect of uvulopalatopharyngoplasty on upper airway collapsibility in obstructive sleep apnea
Am Rev Respir Dis
Prognostic significance of age and tonsillectomy in uvulopalatopharyngoplasty
Laryngoscope
Effects of uvulopalatopharyngoplasty on patients with obstructive sleep apnea—the severity of preoperative tonsillar hypertrophy
Nihon Kokyuki Gakkai Zasshi
Tonsil size and body mass index are important factors for efficacy of simple tonsillectomy in obstructive sleep apnoea syndrome
Clin Otolaryngol
Tonsillectomy as a treatment of obstructive sleep apnea in adults with tonsillar hypertrophy
Laryngoscope
Comparison of upper-airway evaluations during wakefulness and sleep
Laryngoscope
Staging of obstructive sleep apnea /hypopnea syndrome: a guide to appropriate treatment
Laryngoscope
Clinical predictors of obstructive sleep apnea
Laryngoscope
Does severity of obstructive sleep apnea /hypopnea syndrome predict uvulopalatopharyngoplasty outcome?
Laryngoscope
Prediction of uvulopalatopharyngoplasty outcome: anatomy-based staging system versus severity-based staging system
Sleep
Associated factors to predict outcomes of uvulopharyngopalatoplasty plus genioglossal advancement for obstructive sleep apnea
Laryngoscope
Interindividuelle Variabilität klinischer Befunde bei Patienten mit primärem Schnarchen und obstruktiver Schlafapnoe
HNO-Informationen
[Predictive value of the Muller maneuver in obstructive sleep apnea syndrome]
Acta Otorrinolaringol Esp
Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients
Otolaryngol Head Neck Surg
Was bringt die nasopharyngeale Video-Fiberendoskopie für die Diagnostik von Schnarchern und Patienten mit obstruktiver Apnoe
Laryngorhinootologie
Uvulopalatopharyngoplasty outcome assessment with quantitative computer-assisted videoendoscopic airway analysis
Acta Otolaryngol
The utility of cephalometry with the Muller maneuver in evaluating the upper airway and its surrounding structures in Chinese patients with sleep-disordered breathing
Laryngoscope
Snoring
The prognostic value of simulated snoring in awake patients with suspected sleep-disordered breathing: introduction of a new technique of examination
Sleep
Cited by (123)
Orthognathic Surgery for Obstructive Sleep Apnea
2023, Oral and Maxillofacial Surgery Clinics of North AmericaImpact of upper airway configuration on CPAP titration assessed by CT during Müller's maneuver in OSA patients
2021, Respiratory Physiology and NeurobiologyCitation Excerpt :Anatomic abnormalities and compliance of the upper airway constitute the main causes of OSA, by changing the size or caliber of the upper airway during sleep. Various methods including physical examination, flexible fiberoptic laryngoscopy, and imaging techniques have been used to assess the obstruction and collapse of the upper airway in OSA patients [(Liu et al., 2016; Stuck and Maurer, 2008; Tejan et al., 2019)]. Our previous study of 358 snoring patients also found that NP narrowing, UAL, and MPH seem to play important physiopathogenic roles in OSA [(Huang et al., 2016)].
Dynamic tongue base thickness measured by drug-induced sleep ultrasonography in patients with obstructive sleep apnea
2021, Journal of the Formosan Medical AssociationAnalysis and management of sleep data
2020, Biomedical Signal Processing and Artificial Intelligence in HealthcareTranscervical Epiglottopexy: A versatile technique for managing epiglottic prolapse
2024, Otolaryngology - Head and Neck Surgery (United States)
- *
The most important references are denoted by an asterisk.