Videoendoscopic Assessment of Uncommon Sites of Upper Airway Obstruction during Sleep

 

 Buy Article Permissions and Reprints

ABSTRACT

Patients with sleep-disordered breathing (SDB) suffer from repetitive upper airway occlusion. Various techniques have been described to assess the site of upper airway collapse. In most cases the soft palate or the base of tongue, or both, are the major levels of obstruction; rarely, the larynx, including the epiglottis, are found to be involved. We present five cases in which sleep videoendoscopy finally revealed the true mechanism of the inspiratory airway behavior. Two patients were sent to our service because of inefficacy of nasal ventilation therapy. One had a floppy epiglottis that was being sucked into the glottis. The other had a normal larynx during videoendoscopy. Instead, common pharyngeal collapse could be detected. Increasing the pressure normalized sleep, breathing, and videoendoscopy. The third patient showed apneas due to the adduction of the lateral parts of his omega-shaped epiglottis. In another case, inspiratory fluttering of the vocal cords caused snoring and arousals. The last case came in for bilateral vocal cord palsy with heavy nocturnal desaturations suggesting airway closure. Yet, the pharynx and larynx remained open throughout the night. Sleep videoendoscopy is a convenient method to define the level and mechanism of occlusion in obstructive SDB, particularly if the larynx is involved. It is useful to rule out airway compromise in case of recurrent nocturnal hypoxemias. Thus the results of sleep videoendoscopy have a strong therapeutical impact.

REFERENCES

• 1 Goldberg A N, Schwab R J. Identifying the patient with sleep apnea: upper airway assessment and physical examination.  Otolaryngol Clin North Am . 1998;  31 919-930
  CrossrefPubMedGoogle Scholar
• 2 Isono S, Remmers J E, Tanaka A, Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects.  J Appl Physiol . 1997;  82 1319-1326
  PubMedGoogle Scholar
• 3 Ferguson K A, Love L L, Ryan C F. Effect of mandibular and tongue protrusion on upper airway size during wakefulness.  Am J Respir Crit Care Med . 1997;  155 1748-1754
  PubMedGoogle Scholar
• 4 Doghramji K, Jabourian Z H, Pilla M, Farole A, Lindholm R N. Predictors of outcome for uvulopalatopharyngoplasty.  Laryngoscope . 1995;  105 311-314
  CrossrefPubMedGoogle Scholar
• 5 Woodhead C J, Davies J E, Allen M B. Obstructive sleep apnoea in adults presenting with snoring.  Clin Otolaryngol . 1991;  16 401-405
  PubMedGoogle Scholar
• 6 Ritter C T, Trudo F J, Goldberg A N, Welch K C, Maislin G, Schwab R J. Quantitative evaluation of the upper airway during nasopharyngoscopy with the Muller maneuver.  Laryngoscope . 1999;  109 954-963
  PubMedGoogle Scholar
• 7 Woodson B T, Naganuma H. Comparison of methods of airway evaluation in obstructive sleep apnea syndrome.  Otolaryngol Head Neck Surg . 1999;  120 460-463
  PubMedGoogle Scholar
• 8 Woodson B T, Wooten M R. Comparison of upper-airway evaluations during wakefulness and sleep.  Laryngoscope . 1994;  104 821-828
  PubMedGoogle Scholar
• 9 Tvinnereim M, Cole P, Haight J S, Hoffstein V. Diagnostic airway pressure recording in sleep apnea syndrome.  Acta Otolaryngol . 1995;  115 449-454
  PubMedGoogle Scholar
• 10 Quinn S J, Huang L, Ellis P D, Williams J E. The differentiation of snoring mechanisms using sound analysis.  Clin Otolaryngol . 1996;  21 119-123
  PubMedGoogle Scholar
• 11 Schafer J, Pirsig W. Digital signal analysis of snoring sounds in children.  Int J Pediatr Otorhinolaryngol . 1990;  20 193-202
  CrossrefPubMedGoogle Scholar
• 12 Jager L, Gunther E, Gauger J, Reiser M. Fluoroscopic MR of the pharynx in patients with obstructive sleep apnea.  AJNR Am J Neuroradiol . 1998;  19 1205-1214
  PubMedGoogle Scholar
• 13 Chetty K G, Kadifa F, Berry R B, Mahutte C K. Acquired laryngomalacia as a cause of obstructive sleep apnea.  Chest . 1994;  106 1898-1899
  PubMedGoogle Scholar
• 14 Woo P. Acquired laryngomalacia: epiglottis prolapse as a cause of airway obstruction [see comments].  Ann Otol Rhinol Laryngol . 1992;  101 314-320
  PubMedGoogle Scholar
• 15 Brown L K. Abductor vocal fold palsy in the Shy-Drager syndrome presenting with snoring and sleep apnoea.  J Laryngol Otol . 1997;  111 689-690
  PubMedGoogle Scholar
• 16 McBrien F, Spraggs P D, Harcourt J P, Croft C B. Abductor vocal fold palsy in the Shy-Drager syndrome presenting with snoring and sleep apnoea.  J Laryngol Otol . 1996;  110 681-682
  PubMedGoogle Scholar
• 17 Pringle M B, Croft C B. A grading system for patients with obstructive sleep apnoea-based on sleep nasendoscopy.  Clin Otolaryngol . 1993;  18 480-484
  PubMedGoogle Scholar
• 18 Quinn S J, Daly N, Ellis P D. Observation of the mechanism of snoring using sleep nasendoscopy.  Clin Otolaryngol . 1995;  20 360-364
  PubMedGoogle Scholar
• 19 Pringle M B, Croft C B. A comparison of sleep nasendoscopy and the Muller manoeuvre.  Clin Otolaryngol . 1991;  16 559-562
  PubMedGoogle Scholar
• 20 Verse T, Pirsig W. Age-related changes in the epiglottis causing failure of nasal continuous positive airway pressure therapy.  J Laryngol Otol . 1999;  113 1022-1025
  PubMedGoogle Scholar
• 21 Marais J. The value of sedation nasendoscopy: a comparison between snoring and non-snoring patients.  Clin Otolaryngol . 1998;  23 74-76
  CrossrefPubMedGoogle Scholar
• 22 Sadaoka T, Kakitsuba N, Fujiwara Y, Kanai R, Takahashi H. The value of sleep nasendoscopy in the evaluation of patients with suspected sleep-related breathing disorders.  Clin Otolaryngol . 1996;  21 485-489
  PubMedGoogle Scholar
• 23 Skatvedt O. Localization of site of obstruction in snorers and patients with obstructive sleep apnea syndrome: a comparison of fiberoptic nasopharyngoscopy and pressure measurements.  Acta Otolaryngol . 1993;  113 206-209
  PubMedGoogle Scholar
• 24 Woodson B T, Wooten M R. A multisensor solid-state pressure manometer to identify the level of collapse in obstructive sleep apnea.  Otolaryngol Head Neck Surg . 1992;  107 651-656
  PubMedGoogle Scholar
• 25 Verse T, Pirsig W, Haase S. Value of routine use of multitransducer tubes in diagnosing obstructive sleep apnea: Radiokephalometric measurements.  Somnology . 1998;  2 58-62
  PubMedGoogle Scholar
• 26 Gao X M, Zeng X L, Fu M K, Huang X Z. Magnetic resonance imaging of the upper airway in obstructive sleep apnea before and after oral appliance therapy.  Chin J Dent Res . 1999;  2 27-35
  PubMedGoogle Scholar
• 27 Yoshida K, Fukatsu H, Ando Y, Ishigaki T, Okada T. Evaluation of sleep apnea syndrome with low-field magnetic resonance fluoroscopy.  Eur Radiol . 1999;  9 1197-1202
  CrossrefPubMedGoogle Scholar
• 28 Zohar Y, Sabo R, Strauss M, Schwartz A, Gal R, Oksenberg A. Oropharyngeal fatty infiltration in obstructive sleep apnea patients: A histologic study.  Ann Otol Rhinol Laryngol . 1998;  107 170-174
  PubMedGoogle Scholar
• 29 Hamans E P, Van Marck A E, De Backer A W, Creten W, de Heyning H P. Morphometric analysis of the uvula in patients with sleep-related breathing disorders.  Eur Arch Otorhinolaryngol . 2000;  257 232-236
  PubMedGoogle Scholar
• 30 Olofsson K, Mattsson C, Hammarstrom M L, Hellstrom S. Structure of the human uvula.  Acta Otolaryngol . 1999;  119 712-717
  CrossrefPubMedGoogle Scholar
• 31 Catalfumo F J, Golz A, Westerman S T, Gilbert L M, Joachims H Z, Goldenberg D. The epiglottis and obstructive sleep apnoea syndrome.  J Laryngol Otol . 1998;  112 940-943
  PubMedGoogle Scholar
• 32 Yasuda T, Senda Y, Koike Y, Hakusui S, Takahashi A. Bilateral abductor vocal cord paralysis (Gerhardt syndrome) in the Shy-Drager syndrome.  Rinsho Shinkeigaku . 1989;  29 1232-1236
  PubMedGoogle Scholar
• 33 Kakitsuba N, Sadaoka T, Kanai R, Fujiwara Y, Takahashi H. Peculiar snoring in patients with multiple system atrophy: Its sound source, acoustic characteristics, and diagnostic significance.  Ann Otol Rhinol Laryngol . 1997;  106 380-384
  PubMedGoogle Scholar
• 34 Loube D I, McCambridge M M, Andrada T. Persistence of apnea in wakefulness in a patient with postradiation pharyngitis.  Sleep Breathing . 1999;  3 9-121
  CrossrefPubMedGoogle Scholar