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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
Clinical, Occlusal,
andCephalometric Analyses
oftheOSA Patient
LarryWolford
Contents
23.1 Patient Evaluation – 343
23.1.1 Patient Concerns – 343
23.1.2 System-Oriented Physical Examination – 344
23.1.3 Patient Preparation forDentofacial Examination – 344
23.1.4 Facial Evaluation – 345
23.1.5 Lateral View – 346
23.1.6 Oral Examination – 347
23.1.7 Periodontal Evaluation – 347
23.1.8 Tongue Assessment – 348
23.1.9 Temporomandibular Joint – 348
23.1.10 The Nose – 349
23.1.11 Oropharyngeal Airway Assessment – 350
341
23
23.2 Radiographic Evaluation – 351
23.2.1 Types ofImaging Techniques – 351
23.2.2 Lateral Cephalometric Radiograph – 351
23.2.3 Cephalometric Analysis Versus Clinical Diagnosis – 351
23.2.4 Corrected Frankfort Horizontal Plane – 352
23.2.5 Cephalometric Analysis – 352
23.3 Dental Model Analysis – 354
23.3.1 Arch Length Measurements – 354
23.3.2 Tooth Size Analysis – 355
23.3.3 Tooth Position – 356
23.3.4 Arch Width Analysis – 356
23.3.5 Curve ofOcclusion (Curve ofSpee) – 356
23.3.6 Cuspid-Molar Position – 356
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_23
23.3.7 Tooth Arch Symmetry – 357
23.3.8 Buccal Tooth Tipping (Curve ofWilson) – 357
23.3.9 Missing, Broken Down, or Crowned Teeth – 357
23.3.10 Ankylosed Teeth – 358
23.4 Summary – 358
References – 358
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
343
23
Patients with obstructive sleep apnea (OSA) may have
upper airway obstruction and an associated dentofacial
deformity contributory to OSA, commonly involving
anteroposterior (A-P) and posterior vertical hypoplasia
of the maxilla and mandible. There are three basic areas
where upper airway obstruction can occur, which include
the following: nasal cavity, oral cavity and jaws, as well
as the oropharyngeal area. In addition, patients with
OSA may have temporomandibular joint (TMJ) conditions and pathology that are co-existent with the dentofacial deformity, are the cause of the dentofacial
deformity, or are a result of the preexisting dentofacial
deformity. Patients with OSA require a comprehensive
evaluation including clinical, radiology imaging, polysomnography, as well as any additional evaluations
deemed necessary to nalize the diagnoses and establish
an inclusive treatment plan to correct the OSA contributory factors. Many OSA patients with associated dentofacial deformities can benet from corrective
orthognathic surgical treatment. For patients to receive
the state-of-the-art care in correction, the orthognathic
team must be able to do the following: (1) correctly diagnose existing dentofacial deformities, areas of upper airway obstruction, and coexisting TMJ conditions if
present, (2) establish an appropriate treatment plan, and
(3) execute the recommended treatment. This chapter
focuses primarily on clinical, radiology imaging, and
dental model analyses, so important in diagnosing and
treatment planning for the correction of OSA patients
with dentofacial deformities.
The specic therapeutic goals for the OSA patient
with coexisting dentofacial deformity requiring orthognathic surgery vary from patient to patient. These goals
are directed toward the correction of specic musculoskeletal, dentoosseous, soft tissue deformities, and areas
of airway obstruction, and associated TMJ pathologies.
The specic therapeutic goals for the OSA patient may
include the following:
1. Correct the dentofacial deformity and create optimal
facial balance.
2. Establish a functional occlusion through normaliza-
tion of the occlusal relationship, overbite, overjet,
occlusal plane angulation, and transverse dimension.
3. Correct associated temporomandibular joint (TMJ)
pathosis, dysfunction, and pain.
4. Correct nasal airway obstruction that may be related
to narrow nostrils, constricted nasal valves, hyper-
plastic turbinates, nasal septal deviation, polyps, etc.
5. Correct oropharyngeal obstruction such as hyperplas-
tic soft palate/uvula, enlarged tonsils, hyperplastic
adenoid tissues, decreased oropharyngeal airway, etc.
6. Decrease or eliminate myofascial pain, TMJ pain,
and headaches.
23.1 Patient Evaluation
Thorough evaluation and diagnosis is one of the most
important aspects of overall patient management.
Failure to recognize major functional and aesthetic
problems may lead to compromise, complications, and
unfavorable outcomes. OSA patient evaluation for corrective surgery may be divided into ve main areas:
1. Patient concerns/chief complaints
2. Medical history
3. Clinical examination
4. Radiographic and imaging analysis
5. Dental model analysis
This diagnostic sequence may identify OSA patients
who are candidates for orthognathic surgery and determine whether ancillary dental, medical, or other surgical
procedures may be benecial. Such patients may require
further specialist evaluations for speech, audiometric,
periodontal, general dental, psychological, neurological, ophthalmological, medical, otolaryngological, pulmonary, etc. or other concerns.
23.1.1 Patient Concerns
Not only do OSA patients have concerns about their
sleep apnea and breathing difculties, but they may also
express concerns relative to their aesthetic appearance,
difculty eating, impaired jaw function, pain, headaches, etc. A patient’s ultimate satisfaction with treatment outcome often depends on attention to the patient’s
concerns [1, 2]. An understanding of the patient’s concerns, motivations, and expectations helps dene treatment parameters and provides insight to the
psychological health of the patient. Specic questions
that may help identify the patient’s chief concerns
include the following:
1. What are your concerns or problems?
2. Have you had previous treatment for this condition, what was the treatment, and what was the
outcome?
3. Why do you want treatment?
4. What do you expect from treatment?
This assessment of patient concerns helps develop a preliminary problem list and helps identify patients with
unrealistic expectations. Patients need to understand
treatment options, the anticipated outcomes, and the
potential risks and complications. Accordingly, the surgeon and orthodontist must be careful not to mislead
the patient into perceiving greater expectations than can
be provided [3–5].
344
L. Wolford
23.1.2 System-Oriented Physical
Examination
Usually, orthognathic surgery is performed on reasonably healthy patients. However, OSA patients are often
older and may have signicant health issues that increase
potential risks and complications. Presurgical evaluation,
including medical and dental histories, physical examination, and appropriate laboratory studies are very important [6]. Obtaining an appropriate and current medical
history may affect treatment planning and may help the
surgeon avoid potentially life-threatening complications.
Patient examination should rule out or identify patients
with difcult airways, connective tissue or autoimmune
diseases, bleeding disorders, or other pathological conditions that may preclude or modify surgery. OSA patients
may have a tendency for obesity, high blood pressure,
cardiac issues, pulmonary conditions, pain, allergies,
nasal and sinus problems, endocrine issues, diabetes, etc.
23.1.3 Patient Preparation forDentofacial
Examination
The patient is evaluated best while sitting upright in a
straight-backed chair with the examiner seated directly
opposite at eye level. Generally, examine the patient
with his or her pupillary plane parallel to the oor
Fig. 23.1a). Compensatory positioning may be
(.
appropriate for patients exhibiting orbital dystopia. The
ear lobes can be used to establish a plane parallel to the
oor. Orient the patient’s head so that the clinical
Frankfort horizontal plane (a line from the tragus of the
ear to the bony infraorbital rim) is parallel to the oor
(. Fig. 23.1b). This is a reproducible position that
mimics the natural head posture of most individuals
with normal facial balance. This position may be used to
obtain standardized measurements throughout the
treatment sequence [7]. Patients with dentofacial deformities often develop alternative head postures for functional reasons particularly for OSA patients where they
often tip the mandible and chin upward and forward as
well as posture the head in a head postured forward
neck position, which opens the oropharyngeal airway,
improving the patients breathing abilities. Adjustment
for such compensatory head posture is important during clinical, radiographic, and photographic evaluation
by orienting the clinical Frankfort horizontal plane parallel to the oor [8]. Following surgical orthodontic correction, the OSA patient’s “natural” head posture often
reverts to a more normal position because functional
and aesthetic compensations are no longer necessary to
maintain the airway. Selecting a standardized and reproducible head position aids in proper diagnosis and evaluation of posttreatment results.
23
ab
. Fig. 23.1 a Vertically, the face can be divided into equal thirds
for assessment. The lower third of the face can be divided into thirds
with the distance from subnasale to upper lip stomion equaling onethird, and lower lip stomion to soft tissue menton equaling twothirds. This ratio provides optimal vertical facial balance in the lower
third of the face. b In prole, the face is divided in the same manner.
Head orientation is important, with the clinical Frankfort horizontal
plane oriented parallel to the oor. Clinical Frankfort horizontal
plane is a line from the tragus of the ear to the bony infraorbital
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
Once the head is oriented properly, seat the mandibular condyles in the glenoid fossae with the teeth lightly
touching together (centric relation). Although it is
important to evaluate centric occlusion, perform the
denitive clinical examination relative to surgical orthodontic diagnosis and treatment planning with the
patient in centric relation. Failure to evaluate in centric
relation may result in a misdiagnosis or incomplete diagnosis, inappropriate or compromised treatment plan,
and unacceptable or compromised treatment outcome.
For proper evaluation, the patient’s lips should be
relaxed and not forced together. This relaxed lip posture
allows evaluation of vertical facial height and the morphology and drape of the soft tissues. Relaxation of the
lips allows evaluation of upper lip length, tooth-to-lip
measurements, possible lip incompetence, and coincidence of the facial, dental, and chin midlines. Combined
with mentalis muscle relaxation, lip relaxation also
allows evaluation of the chin position and the presence
or absence of skeletal abnormalities such as vertical
maxillary excess or vertical maxillary deciency. The lip
posture frequently is overclosed in patients with vertical
maxillary deciency.
345
. Fig. 23.2 Upper lip length is measured from subnasale to upper
lip stomion. For males, the normal value is 22 ± 2 mm, and for
females, 20±2mm
23
23.1.4 Facial Evaluation
We have previously described in detail, the comprehensive method for facial evaluation [9]. In this section, we
will describe those factors more commonly associated
with OSA patients, focusing on the deformities associated with the lower third of the face that are the primary
factors that can contribute to OSA.For vertical facial
analysis, the face is divided into equal thirds
(. Fig.23.1a). The upper facial third extends from the
hairline to glabella. The middle third extends from glabella to subnasale. The lower third extends from subnasale to soft tissue menton. Orthognathic surgery most
commonly alters the lower third of the face, with some
inuence on the middle third. In addition to this vertical
analysis, pretreatment facial evaluation also should
address the frontal and lateral facial planes. Evaluation
from the frontal view of the lower third face should
include the following seven important anatomical relationships:
1. The upper lip length: The distance from subnasale to
upper lip stomion in a relaxed state. The normal
upper lip length is 22 ± 2 mm for males and
20±2mm for females (.
Fig.23.2).
2. Tooth to upper lip relationship: The distance form
the incisor edge to the upper lip with the lip in repose.
The normal distance is 2.5±1.5mm (. Fig.23.3).
3. Midlines: The midlines of the face, nose, lips, denti-
tion, and chin should be congruent, and the face
. Fig. 23.3 The normal upper tooth-to-lip relationship is
2.5±1.5mm
should be reasonably symmetrical, vertically and
transversely (.
Figs.23.4 and 23.5).
4. Lips overclosed: If the patient’s lips are overclosed,
rotate the mandible open until the lips just begin to
separate. The condyles should remain seated in centric relation. Then evaluate the true lip length and
the tooth-to-lip relationship.
5. Smile: The smile is frequently one of the patient’s
chief concerns. When smiling, the vermilion of the
346
L. Wolford
23
. Fig. 23.4 The facial midlines are assessed, including the nasal,
maxillary and mandibular dental midlines, and the chin midline,
relative to the facial midline. Left to right facial symmetry also is
evaluated
upper lip should fall at the cervicogingival margin
with no more than 1–2 mm of exposed gingiva
(. Fig.23.4). In addition to this relationship, surgical decisions also must consider the tooth-to-lip relationship with the lips in repose, because many factors
may inuence lip posture during animation. The
amount of upper lip elevation during smiling may be
affected by the following:
(a) Anteroposterior position of the maxilla and
mandible in relation to the cranial base as well as
to each other.
(b) Amount of overjet and overbite.
(c) Angulation of the anterior teeth and dentoal-
veolus.
(d) Occlusal plane angulation.
(e) Clinical crown length.
(f) Neuromuscular function of the lips.
(g) Dental coverage of periodontium.
Each of these factors may contribute to inaccuracies
in the determination of the proper maxillary vertical
position if this position is determined only by evaluation of the tooth-to- lip position during smiling.
6. Facial height balance: The distance from glabella to
subnasale and subnasale to menton should be a 1:1
ratio, providing that the upper lip length is normal
(. Fig.23.1a).
. Fig. 23.5 Transversely, the occlusal plane should parallel the
pupillary plane, providing there is no orbital dystopia
7. Lower third facial balance: The length of the upper
lip should be one-third of the length of the lower
facial third; that is, lower lip stomion to soft tissue
menton should be twice the vertical dimension of the
upper lip, providing that the upper lip is normal in
length (. Fig.23.1a).
23.1.5 Lateral View
Evaluation of the lateral facial view is usually the most
valuable assessment in determining vertical and anteroposterior problems of the jaws:
1. Facial height balance: The distance from glabella to
subnasale and from subnasale to soft tissue menton
should be in a 1:1 ratio if the upper lip length is normal (see . Fig.23.1b).
2. Facial morphology: Evaluate the morphology and
relationships of the nose, lips, cheeks, and chin to
each other.
3. Evaluate the cervicomandibular angle in reference to
the chin position.
4. The length of the upper lip should be one-third of
the length of the lower facial third; that is, lower lip
stomion to soft tissue menton should be twice the
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
347
23
vertical dimension of the upper lip if the upper lip is
normal in length (see . Fig.23.1b).
5. Upper lip projection: The upper lip labrale superius
should be 1–3mm anterior to the subnasale perpendicular plane; a line through subnasale perpendicular to the clinical Frankfort horizontal plane
(. Fig.23.6).
6. Chin-neck line and angle: The distance from soft tissue pogonion to the chin-neck angle. Although there
is a wide variation in this dimension, the normal
measurement is around 65± 5 mm for males and
55±5 mm for females (. Fig.23.6, green reference
lines).
23.1.6 Oral Examination
Oral examination helps identify functional and aesthetic
deformities of the dentoosseous and soft tissue structures. Occlusal and dental factors to be evaluated in the
oral examination are discussed under Dental Model
Analysis. The factors oral examination should evaluate
the following issues:
1. Occlusal relationship (Class I, II, or III)
2. Anterior overbite or open bite, overjet, crossbites
3. Tooth size discrepancies, dental crowding or spacing
4. Curve of Wilson, curve of Spee
5. Missing, decayed, retained primary, nonsalvageable
teeth
6. Discrepancies between centric occlusion and centric
relation
7. Periodontal evaluation
8. Transverse, anteroposterior, or vertical asymmetries
9. Anatomical or functional tongue abnormalities
10. Any masticatory difculties and dysfunctions
11. Any other pathological processes
23.1.7 Periodontal Evaluation
There are several periodontal factors that should be evaluated before orthodontic treatment and orthognathic surgery. Patients with preexisting periodontal disease or
gingivitis have an increased risk of disease exacerbation
during orthodontic treatment and posttreatment, particularly in areas where interdental osteotomies may be
required [10–16]. Factors that can affect periodontal health
adversely in relation to orthognathic surgery include smoking, excessive alcohol or caffeine consumption, bruxism
and clenching, connective tissue/autoimmune diseases, diabetes, malnutrition, and so on [11]. Address all periodontal
diseases before orthodontics and orthognathic surgery.
Inadequate attached gingiva, most frequently associated with the mandibular anterior teeth, may contribute
to the development of periodontal problems such as
gingival retraction, tooth sensitivity, and bone loss
(.
Fig.23.7). In areas of inadequate attached gingiva,
consider gingival grafting. When indicated, perform gingival grafting before the initiation of orthodontics.
Providing adequate attached gingival tissue before orthodontic and orthognathic surgical intervention protects
this tissue and minimizes gingival tissue retraction.
. Fig. 23.6 A line perpendicular to the clinical Frankfort horizon-
tal plane (ClFH) through subnasale (A) should be 3±3mm anterior
to the chin in males and 5± 3 mm in females. Upper lip stomion
should be 2±2mm anterior to the subnasale perpendicular plane
. Fig. 23.7 Healthy attached gingiva should be present around the
teeth. This patient shows lack of attached gingiva around the anterior teeth. If orthodontics or surgery performed in this area, periodontal problems can develop if this issue is not appropriately
addressed prior to treatment
348
L. Wolford
23
23.1.8 Tongue Assessment
An enlarged tongue can cause dentoskeletal deformities,
instability of orthodontics and orthognathic surgical
treatment, and can create masticatory, speech, and airway management problems. The condition can be
dened as true macroglossia or pseudomacroglossia.
True macroglossia indicates an increased disproportionate size of the tongue commonly caused by (1) muscular
hypertrophy (. Fig. 23.8), (2) glandular hyperplasia,
(3) hemangioma, or (4) lymphangioma. A number of
congenital and acquired causes of true macroglossia
exist, including conditions such as Down syndrome and
Beckwith- Wiedemann syndrome. Acquired factors may
include acromegalia, myxedema, amyloidosis, tertiary
syphilis, cysts or tumors, and neurological injury [17].
Pseudomacroglossia is a condition in which the tongue
may be normal in size, but it appears large in relation to
its anatomical interrelationships, such as maxillary and
mandibular hypoplasia, where the oral cavity volume is
diminished. In either true or pseudomacroglossia, the
relative excessive size of the tongue can contribute signicantly to OSA and surgical correction may need to
be considered. Patients with true macroglossia may be
candidates for reduction glossectomy. Specic clinical
and cephalometric features may help the clinician identify the presence or absence of macroglossia [17].
Pseudomacroglossia is commonly associated with
maxillary and mandibular A-P hypoplasia and can usually
be corrected by counterclockwise rotation- advancement
of the maxillomandibular complex, increasing the oral
cavity volume providing increased intraoral space to
accommodate the tongue.
Most open bites are not related to macroglossia. In
fact, it has been established that closing open bites with
. Fig. 23.8 Macroglossia indicates an enlarged tongue relative to
the size of the oral cavity, and can contribute to malocclusion, speech
and swallowing difculties, and oropharyngeal airway obstruction
contributing to sleep apnea
orthognathic surgery allows a normal tongue, which is
an adaptable organ, to readjust to the altered volume of
the oral cavity, with little tendency toward relapse [18,
19]. If true macroglossia is present with an anterior open
bite, then instability of the orthodontics and orthognathic surgery are likely to occur, with a tendency for the
open bite to return.
Although the indications for reduction glossectomy
are few, when the procedures are indicated for true macroglossia, the following conclusions can be drawn: (1)
reduction glossectomy can improve functional and aesthetic outcomes signicantly, (2) the anterior resection
combined with the midline keyhole type procedure is the
best technique, (3) improved function relative to airway,
speech, and mastication can be anticipated, and (4) if
the excessively large tongue is causing signicantly unfavorable mandibular growth, reduction of the tongue
may help control the problem [17–19].
23.1.9 Temporomandibular Joint
The TMJs provide the foundation for orthognathic surgery. OSA patients commonly have TMJ conditions that
may require surgical intervention to provide outcome stability for those patients requiring orthognathic surgery to
correct the OSA (. Fig.23.9). Presurgical TMJ dysfunction or undiagnosed TMJ pathosis can result in orthognathic surgery unfavorable outcomes such as postoperative
pain, condylar resorption, condylar over- growth, malocclusion, jaw dysfunction, and relapse resulting in recurrence of the facial deformity and sleep apnea issues [20,
21]. Common TMJ conditions and treatment are
addressed in 7 Chaps. 23 and 27. Assess the TMJs before
treatment and periodically throughout the treatment.
Basic TMJ factors to consider include the following:
1. The patient history may reveal: TMJ pain, dysfunc-
tion, clicking and popping, crepitation, limited open-
ing, difculty chewing, headaches, ear problems,
myofascial pain, progressive development of reces-
sion of the mandible and open bite, shifting of the
mandible and bite, neck and shoulder pain problems,
and so on. Document etiological factors, time of
onset, signs and symptoms, previous treatments and
outcomes, symptom frequency and duration para-
functional habits, and other modifying factors.
2. Identify or rule out polyarthritides or other systemic
conditions. These conditions may include connective
tissue or autoimmune diseases such as rheumatoid
arthritis, juvenile idiopathic arthritis, systemic lupus
erythematosus, scleroderma, sarcoidosis, reactive
arthritis, psoriasis, psoriatic arthritis, Sjögren’s dis-
ease, ankylosing spondylitis, Reiter syndrome, etc.
Fig.23.9c) [20, 21].
(.
ab
Clinical, Occlusal, andCephalometric Analyses oftheOSA Patient
abc
349
23
. Fig. 23.9 MRI imaging of TMJs. a Normal condyle and disc in
fossa. b TMJ arthritis and anteriorly displaced articular disc that is
signicantly deformed. c TMJ with juvenile idiopathic arthritis
. Fig. 23.10 a Severe constricture of the nostrils and nasal valves. b Wide columella creating narrow nostrils. Narrow nostrils will restrict
air from passing into the nose and is the rst component of nasal airway obstruction
3. Clinical examination should assess pain, function,
and joint noise. Deviation of the mandible during
opening, for example, may indicate a unilateral
closed lock or brous ankylosis. Joint noises such as
clicking and popping may suggest articular disk displacement. Crepitation within the joint may indicate
osteoarthritis or perforation of the retrodiscal tissues.
4. Obtain imaging to assess the TMJs such as cone
(JIA), with signicant loss of condylar vertical height, although the
disc is in normal position, but surrounded by a reactive pannus that
is causing bone and disc destruction
may inuence the orthodontic and orthognathic surgery outcome, even if these conditions do not require
intervention.
6. If preexisting TMJ pathologies or conditions are
present in patients requiring orthognathic surgery
for correction of OSA, consideration must be made
for surgical correction of the TMJ pathologies in a
preliminary surgery or concomitantly with the
required orthognathic surgery.
beam imaging, panoramic radiographs, transcranial
radiographs, transpharyngeal radiographs, tomograms, computed tomography (CT) scans, magnetic
23.1.10 The Nose
resonance imaging (MRI) (. Fig. 23.9), (see
7 Chaps. 23), and other imaging modalities as indi-
cated.
5. Properly diagnose existing TMJ conditions and discuss them with the patient. The surgeon should
properly sequence and plan treatment for conditions
requiring correction. Inform the patient of any
abnormal TMJ ndings and how such conditions
There are a number of anatomical factors that can contribute to nasal airway obstruction including the following: (1) narrow nostrils, (2) wide columella (. Fig.23.10),
(3) constriction of luminal (nasal) valves, (4) transverse
collapse of nose, (5) deviated nasal septum, (6) hypertrophied turbinates (. Fig. 23.11), (7) nasopharyngeal
adenoid tissue (. Fig.23.12), and (8) other anatomical
23
ab
350
L. Wolford
. Fig. 23.11 a Coronal tomographic view of hyperplastic nasal turbinates with almost total obliteration of the nasal airway. b Axial view
of bilateral hyperplastic turbinates, creating nasal airway obstruction
cause increased swelling of the turbinates, further blocking off the functional airway. Allergic rhinitis is a common contribution to nasal obstruction. Hypertrophied
turbinates are the most common factor causing nasal
airway obstruction [23]. A deviated nasal septum also
can cause signicant obstruction as well as bending the
nose off to one side or the other or with septal spurs that
may be present. Nasopharyngeal adenoid tissue can
cause a major blockage of the nasopharynx and posterior nasal choanae (. Fig.23.12). This can be a problem in young kids, although adenoid tissues are usually
resorbed by the age of 14, but may remain present in
some patients for many years longer.
Upper airway obstruction involving the nose and
oropharyngeal areas, can have signicant adverse effects
on facial growth and development when occurring in
growing children creating an increased vertical facial
growth pattern with downward and backward growth
. Fig. 23.12 Hyperplastic nasopharyngeal adenoid tissue creating
oropharyngeal airway obstruction
vectors for the maxilla and mandible. Upper airway
obstruction can affect the health and well-being of children and adults aficted with this anatomical variance
of obstruction and can create functional and aesthetic
variances and pathologies [22]. Clinical, radiographic,
facial, skeletal, muscular, and dental imbalances.
beroptic scoping, etc. are methods for evaluating nasal
airway obstruction. Evaluation begins by assessing the
nasal width of the nostrils and columella (. Fig.23.10).
23.1.11 Oropharyngeal Airway Assessment
A nasal speculum can be used to evaluate the luminal
nasal valves inside the nose and to evaluate the anterior
aspect of the turbinates and nasal septum. The most
common forms of nasal obstruction are hyperplastic
nasal turbinates (. Fig. 23.11). The turbinates are a
honeycombed bony structure covered with glandular
and erectile tissues covered with ciliated mucosa. When
these turbinates are enlarged, and/or septum is deviated
or spurring is present, this can cause signicant nasal
airway obstruction. Usually, laying down at night will
Common factors that contribute to airway obstruction
of the oropharyngeal area include the following: (1)
mandibular and maxillary hypoplasia displacing the
tongue posteriorly, (2) elongated (hyperplastic) soft
palate, (3) hyperplastic uvula (. Fig. 23.13), (4) constriction of the fascial pillars, (5) hypertrophied tonsils
and adenoids (. Fig.23.12), (6) decreased oropharyngeal airway, (7) tumors or other pathologies decreasing
the oropharyngeal airway, and (8) pharyngeal aps (in