Eur Arch Otorhinolaryngol DOI 10.1007/s00405-014-3033-3
Laryngology
Lingua–epiglottis position predicts glossopharyngeal obstruction in patients with obstructive sleep apnea hypopnea syndrome Shuhua Li · Dahai Wu · Qin Jie · Jimin Bao · Hongjin Shi
Received: 1 November 2013 / Accepted: 24 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective of the study was to investigate the relationship between lingua–epiglottis position and glossopharyngeal obstruction in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). One hundred and four patients with OSAHS diagnosed by polysomnography (PSG) were enrolled. Lingua–epiglottis position was visualized using endoscopy and classified into three types. Spiral CT imaging of the upper respiratory tract was performed to measure the cross-sectional area and inner diameter of the glossopharyngeal airway. The PSG was repeated after nasopharyngeal tube insertion (NPT-PSG). The NPTPSG results, CT-measured data and incidence of stenosis were compared among the different lingua–epiglottis position groups. Obstructive sleep apnea hypopnea syndrome patients with different lingua–epiglottis positions had similar demographics. As lingua–epiglottis position type varied from type I to type III, cross-sectional area and inner diameter of the glossopharyngeal area decreased, glossopharyngeal airway stenosis rate increased, and apnea hypopnea index measured by NPT-PSG increased. The lowest oxygen saturation decreased. Lingua–epiglottis position was significantly related to glossopharyngeal obstruction. Lingua– epiglottis position should be used in clinical practice for the preliminary assessment of glossopharyngeal obstruction.
S. Li (*) · D. Wu · Q. Jie · H. Shi Department of Otolaryngology‑Head and Neck Surgery, General Hospital of Shenyang Military Area Command, No.83, Wenhua Road, Shenhe District, Shenyang 110840, China e-mail: [email protected] J. Bao The Department of Otolaryngology‑Head and Neck Surgery, Liaoning Jinqiu Hospital, Shenyang, China
Keywords Obstructive sleep apnea hypopnea syndrome, OSAHS · Endoscopy · Lingua · Epiglottis · Computerized tomography, CT · Nasopharyngeal tube
Introduction Obstructive sleep apnea hypopnea syndrome (OSAHS) is associated with collapse or obstruction of the upper respiratory tract during sleep [1]. In theory, collapse or obstruction of any part of the upper respiratory tract can lead to OSAHS. The glossopharynx is the second most common location for respiratory tract obstruction, after the oropharynx [2, 3]. Accurate preoperative assessment of glossopharyngeal obstruction in OSAHS patients facilitates the choice of surgical method and improves surgical results [4]. Several methods have been used to diagnose glossopharyngeal respiratory tract obstruction. Airway examination during brief sedated sleep, continuous airway pressure measurement and use of the AG200 ApneaGraph system during natural overnight sleep have been shown to accurately determine whether glossopharyngeal respiratory tract obstruction exists [5–7]. These methods require special equipment and have a high demand on human and material resources. Hence, their application is limited. Methods that are widely used in clinical practice are routine physical examination, endoscopy, CT and MRI measurements in the awake state [4, 8–10]. Classification of the Friedman tongue position (FTP) and endoscopy are most commonly used as they are easy to apply. There are no reported objective parameters from endoscopic examination that predict pharyngeal obstruction. The assessment relies on the examiner’s subjective judgment. This is especially true in the glossopharynx, where different examiners often make different conclusions. Easy to use clinical criteria are needed
13
for endoscopic examination of the glossopharyngeal respiratory tract. Lingua hypertrophy and lingual tonsil hypertrophy are the main causes of glossopharyngeal obstruction [11]. Lingua hypertrophy or lingual tonsil hyperplasia are typically accompanied by changes in the distance between the tongue and the epiglottis. We investigated the relationship between different lingua–epiglottis positions and glossopharyngeal obstruction.
Materials and methods Inclusion criteria The records of OSAHS patients admitted to the department of otorhinolaryngology in our hospital from January 2012 to December 2012 were reviewed. Patient selection criteria were: (1) symptoms met OSAHS diagnostic criteria; (2) male gender; (3) no significant nasal or nasopharyngeal obstruction; (4) no micrognathia and other abnormalities in the craniofacial structure; (5) endoscopy of the upper respiratory tract was successfully completed; (6) CT imaging and measurement of the Fig. 1 Lingua–epiglottis types. Type I, the epiglottis is separate from the tongue base. The entire vallecula epiglottica and glottis can be easily seen (a); type II: the epiglottis is in contact with the tongue base, making it difficult to see the vallecula epiglottica. The entire or part of glottis is visible (b); type III: the hypertrophic tongue base or lingual tonsil is pressed against the epiglottis, making the glottis tough. The entire vallecula epiglottica and glottis could not be seen (c)
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Eur Arch Otorhinolaryngol
upper respiratory tract was successfully completed; (7) PSG after nasopharyngeal tube insertion (NPT-PSG) was successfully completed; (8) informed was consent signed. Endoscopy technique and tongue–epiglottis classification Patients underwent clinical examination and FTP classification [4]. One percentage tetracaine was applied to the nose, nasopharynx and pharynx for topical anesthesia. The patient assumed a supine position without a pillow. The head and neck were in a position midway between flexion and extension, facing straight upward, with no left or right deflection. The mouth was closed with the patient breathing quietly through the nose. An endoscope was inserted through one nostril. The endoscope was advanced to the hypopharynx, so that the tongue base and epiglottis could be clearly observed. The endoscope’s left–right and anterior–posterior angles were adjusted so that the free edge of the epiglottis was located in the center of view. The spacing between the tongue base and epiglottis was observed and photographs taken. Patients were divided into three groups based on lingua–epiglottis position. Criteria for
Eur Arch Otorhinolaryngol
classification were—type I: epiglottis was clearly separated from the tongue base and the entire epiglottic vallecula and glottis could be easily seen (Fig. 1a); type II: epiglottis was in contact with the tongue base, making it difficult to see the epiglottic vallecula, but the whole or part of glottis was observable (Fig. 1b); type III: the hypertrophic tongue base or lingual tonsil was pressed against the epiglottis, making it touch the glottis. The entire epiglottic vallecula and glottis could not be seen (Fig. 1c). CT imaging and upper respiratory tract measurements SIMENS 16-slice spiral CT imaging was performed. The patient was in the supine position with the head and neck
midway between flexion and extension. Continuous scans were performed from the top of the nasopharynx to the glottis. The patient was instructed to breathe calmly and not swallow during imaging. CT image workstation software was used to evaluate the glossopharyngeal airway. The tip of the epiglottis was used as a landmark. Cross-sectional area, anteroposterior diameter and transverse diameter of the glossopharyngeal airway 0.5 cm above the epiglottis tip (Fig. 2a–c) were measured. The measurement method has been previously described by our group [10]. We have previously reported the cross-sectional area of the glossopharyngeal region in normal subjects [10] to be above 181 mm2. Patients with smaller cross-sectional areas in this study were considered to have glossopharyngeal airway stenosis.
Fig. 2 CT images of the glossopharyngeal area in OSAHS patients with different lingua– epiglottis types. The cross-sectional area and inner diameter of the glossopharyngeal respiratory tract decreased from type I to type III (a–c)
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PSG after nasopharyngeal airway insertion The Polywin PSG system (Respironics, USA) was used to monitor all patients’ sleep according to American Sleep Association standards. Diagnostic criteria for OSAHS also met American Sleep Association standards [12]. After patients were diagnosed with OSAHS by the first PSG examination, a second PSG examination with a nasopharyngeal tube was arranged (NPT-PSG). Selection and insertion of the nasopharyngeal airway were performed as previously reported [13]. A 7 mm nasopharyngeal (Fig. 3a) airway was used in 75 patients and an 8 mm airway in 29. The nasopharyngeal tube was secured at the nostril to prevent movement (Fig. 3b). The tip of the nasopharyngeal airway was positioned just beyond the free edge of the soft palate (Fig. 3c). The second PSG examination (NPT-PSG) was then performed.
Eur Arch Otorhinolaryngol
were compared. There was no significant difference in this information among the three groups (Table 1). CT imaging of the glossopharyngeal airway in OSAHS patients The cross-sectional area, transverse diameter and anteroposterior diameter of the glossopharyngeal airway were measured (Table 2). The cross-sectional area, transverse diameter and anteroposterior diameter were significantly different in each of the three groups. All three measurements decreased from type I to type III. Fourteen of the 104 (13.5 %) patients had glossopharyngeal airway stenosis (cross-sectional area
Laryngology
Lingua–epiglottis position predicts glossopharyngeal obstruction in patients with obstructive sleep apnea hypopnea syndrome Shuhua Li · Dahai Wu · Qin Jie · Jimin Bao · Hongjin Shi
Received: 1 November 2013 / Accepted: 24 March 2014 © Springer-Verlag Berlin Heidelberg 2014
Abstract The objective of the study was to investigate the relationship between lingua–epiglottis position and glossopharyngeal obstruction in patients with obstructive sleep apnea hypopnea syndrome (OSAHS). One hundred and four patients with OSAHS diagnosed by polysomnography (PSG) were enrolled. Lingua–epiglottis position was visualized using endoscopy and classified into three types. Spiral CT imaging of the upper respiratory tract was performed to measure the cross-sectional area and inner diameter of the glossopharyngeal airway. The PSG was repeated after nasopharyngeal tube insertion (NPT-PSG). The NPTPSG results, CT-measured data and incidence of stenosis were compared among the different lingua–epiglottis position groups. Obstructive sleep apnea hypopnea syndrome patients with different lingua–epiglottis positions had similar demographics. As lingua–epiglottis position type varied from type I to type III, cross-sectional area and inner diameter of the glossopharyngeal area decreased, glossopharyngeal airway stenosis rate increased, and apnea hypopnea index measured by NPT-PSG increased. The lowest oxygen saturation decreased. Lingua–epiglottis position was significantly related to glossopharyngeal obstruction. Lingua– epiglottis position should be used in clinical practice for the preliminary assessment of glossopharyngeal obstruction.
S. Li (*) · D. Wu · Q. Jie · H. Shi Department of Otolaryngology‑Head and Neck Surgery, General Hospital of Shenyang Military Area Command, No.83, Wenhua Road, Shenhe District, Shenyang 110840, China e-mail: [email protected] J. Bao The Department of Otolaryngology‑Head and Neck Surgery, Liaoning Jinqiu Hospital, Shenyang, China
Keywords Obstructive sleep apnea hypopnea syndrome, OSAHS · Endoscopy · Lingua · Epiglottis · Computerized tomography, CT · Nasopharyngeal tube
Introduction Obstructive sleep apnea hypopnea syndrome (OSAHS) is associated with collapse or obstruction of the upper respiratory tract during sleep [1]. In theory, collapse or obstruction of any part of the upper respiratory tract can lead to OSAHS. The glossopharynx is the second most common location for respiratory tract obstruction, after the oropharynx [2, 3]. Accurate preoperative assessment of glossopharyngeal obstruction in OSAHS patients facilitates the choice of surgical method and improves surgical results [4]. Several methods have been used to diagnose glossopharyngeal respiratory tract obstruction. Airway examination during brief sedated sleep, continuous airway pressure measurement and use of the AG200 ApneaGraph system during natural overnight sleep have been shown to accurately determine whether glossopharyngeal respiratory tract obstruction exists [5–7]. These methods require special equipment and have a high demand on human and material resources. Hence, their application is limited. Methods that are widely used in clinical practice are routine physical examination, endoscopy, CT and MRI measurements in the awake state [4, 8–10]. Classification of the Friedman tongue position (FTP) and endoscopy are most commonly used as they are easy to apply. There are no reported objective parameters from endoscopic examination that predict pharyngeal obstruction. The assessment relies on the examiner’s subjective judgment. This is especially true in the glossopharynx, where different examiners often make different conclusions. Easy to use clinical criteria are needed
13
for endoscopic examination of the glossopharyngeal respiratory tract. Lingua hypertrophy and lingual tonsil hypertrophy are the main causes of glossopharyngeal obstruction [11]. Lingua hypertrophy or lingual tonsil hyperplasia are typically accompanied by changes in the distance between the tongue and the epiglottis. We investigated the relationship between different lingua–epiglottis positions and glossopharyngeal obstruction.
Materials and methods Inclusion criteria The records of OSAHS patients admitted to the department of otorhinolaryngology in our hospital from January 2012 to December 2012 were reviewed. Patient selection criteria were: (1) symptoms met OSAHS diagnostic criteria; (2) male gender; (3) no significant nasal or nasopharyngeal obstruction; (4) no micrognathia and other abnormalities in the craniofacial structure; (5) endoscopy of the upper respiratory tract was successfully completed; (6) CT imaging and measurement of the Fig. 1 Lingua–epiglottis types. Type I, the epiglottis is separate from the tongue base. The entire vallecula epiglottica and glottis can be easily seen (a); type II: the epiglottis is in contact with the tongue base, making it difficult to see the vallecula epiglottica. The entire or part of glottis is visible (b); type III: the hypertrophic tongue base or lingual tonsil is pressed against the epiglottis, making the glottis tough. The entire vallecula epiglottica and glottis could not be seen (c)
13
Eur Arch Otorhinolaryngol
upper respiratory tract was successfully completed; (7) PSG after nasopharyngeal tube insertion (NPT-PSG) was successfully completed; (8) informed was consent signed. Endoscopy technique and tongue–epiglottis classification Patients underwent clinical examination and FTP classification [4]. One percentage tetracaine was applied to the nose, nasopharynx and pharynx for topical anesthesia. The patient assumed a supine position without a pillow. The head and neck were in a position midway between flexion and extension, facing straight upward, with no left or right deflection. The mouth was closed with the patient breathing quietly through the nose. An endoscope was inserted through one nostril. The endoscope was advanced to the hypopharynx, so that the tongue base and epiglottis could be clearly observed. The endoscope’s left–right and anterior–posterior angles were adjusted so that the free edge of the epiglottis was located in the center of view. The spacing between the tongue base and epiglottis was observed and photographs taken. Patients were divided into three groups based on lingua–epiglottis position. Criteria for
Eur Arch Otorhinolaryngol
classification were—type I: epiglottis was clearly separated from the tongue base and the entire epiglottic vallecula and glottis could be easily seen (Fig. 1a); type II: epiglottis was in contact with the tongue base, making it difficult to see the epiglottic vallecula, but the whole or part of glottis was observable (Fig. 1b); type III: the hypertrophic tongue base or lingual tonsil was pressed against the epiglottis, making it touch the glottis. The entire epiglottic vallecula and glottis could not be seen (Fig. 1c). CT imaging and upper respiratory tract measurements SIMENS 16-slice spiral CT imaging was performed. The patient was in the supine position with the head and neck
midway between flexion and extension. Continuous scans were performed from the top of the nasopharynx to the glottis. The patient was instructed to breathe calmly and not swallow during imaging. CT image workstation software was used to evaluate the glossopharyngeal airway. The tip of the epiglottis was used as a landmark. Cross-sectional area, anteroposterior diameter and transverse diameter of the glossopharyngeal airway 0.5 cm above the epiglottis tip (Fig. 2a–c) were measured. The measurement method has been previously described by our group [10]. We have previously reported the cross-sectional area of the glossopharyngeal region in normal subjects [10] to be above 181 mm2. Patients with smaller cross-sectional areas in this study were considered to have glossopharyngeal airway stenosis.
Fig. 2 CT images of the glossopharyngeal area in OSAHS patients with different lingua– epiglottis types. The cross-sectional area and inner diameter of the glossopharyngeal respiratory tract decreased from type I to type III (a–c)
13
PSG after nasopharyngeal airway insertion The Polywin PSG system (Respironics, USA) was used to monitor all patients’ sleep according to American Sleep Association standards. Diagnostic criteria for OSAHS also met American Sleep Association standards [12]. After patients were diagnosed with OSAHS by the first PSG examination, a second PSG examination with a nasopharyngeal tube was arranged (NPT-PSG). Selection and insertion of the nasopharyngeal airway were performed as previously reported [13]. A 7 mm nasopharyngeal (Fig. 3a) airway was used in 75 patients and an 8 mm airway in 29. The nasopharyngeal tube was secured at the nostril to prevent movement (Fig. 3b). The tip of the nasopharyngeal airway was positioned just beyond the free edge of the soft palate (Fig. 3c). The second PSG examination (NPT-PSG) was then performed.
Eur Arch Otorhinolaryngol
were compared. There was no significant difference in this information among the three groups (Table 1). CT imaging of the glossopharyngeal airway in OSAHS patients The cross-sectional area, transverse diameter and anteroposterior diameter of the glossopharyngeal airway were measured (Table 2). The cross-sectional area, transverse diameter and anteroposterior diameter were significantly different in each of the three groups. All three measurements decreased from type I to type III. Fourteen of the 104 (13.5 %) patients had glossopharyngeal airway stenosis (cross-sectional area
