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13 The Role oftheNose inPharyngeal Obstructions
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35. Wheatley JR, Amis TC, Lee SA, Ciesla R, Shanga G.Objective and subjective effects of a
prototype nasal dilator strip on sleep in subjects with chronic nacturnal congestion. Adv Ther.
2019;36:1657–71.
36. Moxness MH, Nordgard S.An observational cohort study of the effects of septoplasty with or
without inferior turbinate reduction in patients with obstructive sleep apnea. BMC Ear Nose
Throat Disord. 2014;14:11.
37. Park CY, Hong JH, Lee JH, Lee KE, Cho HS, Lim SJ, Kwak JW, Kim KS, Kim HJ.Clinical
effect of surgical correction for nasal pathology on the treatment of obstructive sleep apnea
syndrome. PLoS One. 2014;9:e98765.
38. Shuaib SW, Undavia S, Lin J, Johnson CM, Stupak HD.Can functional septothinoplasty independently treat obstructive sleep apnea? Plast Reconstr Surg. 2015;135:1554–65.
39. Xiao Y, Han D, Zang H, Wang D. The effectiveness of nasal surgery on psychological
symptoms in patients with obstructive sleep apnea ans nasal obstruction. Acta Otolaryngol.
2016;136:626–32.
40. Kim SD, Jung DW, Lee JW, Park JH, Mun SJ, Cho KS.Relationship between allergic rhinitis
and nasal surgery success in patients with obstructive sleep apnea. Am J Otolaryngol Head
Neck Surg. 2021;42:103079.
41. Verse T, Baisch A, Maurer JT, Stuck BA, Hörmann K.Multilevel surgery for obstructive sleep
apnea: short-term results. Otolaryngol Head Neck Surg. 2006;134:571–7.
42. Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC.Critical appraisal and meta-analysis of
nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2011;25:45–9.
43. Rombaux P, Liistro G, Hamoir M, Bertrand B, Aubert G, Verse T, Rodenstein D.Nasal obstruction and its impact on sleep-related breathing disorders. Rhinology. 2005;43:242–50.
44. Li HY, Lee LA, Wang PC, Chen NH, Lin Y, Fang TJ.Nasal surgery for snoring in patients with
obstructive sleep apnea. Laryngoscope. 2008;118:354–9.
45. Li HY, Lin Y, Chen NH, Lee LA, Fang TJ, Wang PC.Improvement in quality of life after
nasal surgery alone for patients with obstructive sleep apnoea and nasal obstruction. Arch
Otolaryngol Head Neck Surg. 2008;134:429–33.
46. Stapelton AL, Chang YF, Soose RJ, Gillman GS.The impact of nasal surgery on sleep quality:
a prospective outcome study. Otolarynghol Head Neck Surg. 2014;151:868–73.
47. Verse T, Hörmann K.The surgical treatment of sleep-related upper airway obstruction. Dtsch
Arztebl Int. 2011;108:216–21.
48. Randerrath WJ, Verbraecken J, Andreas S, Bettega G, Boudewyns A, Hamans E, Jalbert F,
Paoli JR, Sanner B, Smith I, Stuck BA, Lacassagne L, Marklund M, Maurer JT, Pepin JL,
Valipour A, Verse T, Fietze I.Non-CPAP therapies in obstructive sleep apnoea. Eur Respir
J. 2011;37:1000–28.
49. Reilly EK, Boon MS, Vimawala S, Chitguppi C, Patel J, Murphy K, Doghramji K, Nyquist
GG, Rosen MR, Rabinowitz MR, Huntley CT.Tolerance of continuous positive airway pressure after sinonasal surgery. Laryngoscope. 2021;131:E1013–8.
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Part IV
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Conservative Treatment of Epiglottis Collapse
Therapy Decision-Making inEpiglottis
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Collapse
MatejDelakorda andNicode Vries
14.1 Introduction
The epiglottis has long been a neglected structure in the etiology of obstructive
sleep apnea (OSA), and consequently, treating OSA by addressing epiglottic collapse (EC) is relatively new as well. Such neglect of the epiglottis and its role is
indeed the main motivation behind this book. In this section of the book, both nonsurgical and surgical treatment modalities are described and discussed. In general,
after a careful diagnostic workup (including a meticulous examination of medical
history, clinical assessment, a comprehensive sleep study, drug-induced sleep
endoscopy (DISE), and imaging when indicated), the doctor and patient should, in
a process of shared decision-making, reach a well-balanced choice based on treatment options available in the specic situation. Nonsurgical treatments options
include positive airway pressure therapy (CPAP), mandibular advancement devices
(MAD), positional therapy, and to a lesser extent myofunctional therapy. On the
other hand, a considerable variety of surgical options is available as well.
It is important to realize that in case of EC, treatment might be essentially different from standard OSA therapy. For instance, while CPAP is still the gold standard
of therapy for moderate to severe OSA, it can sometimes induce EC that can, in
turn, even be an overlooked cause of CPAP failure. In this chapter, we will summarize and comment on these options. We also propose an algorithm for assessment of
patients with suspected EC.For further details, we refer to particular chapters in
this book.
14
M. Delakorda (*)
General Hospital Celje, Celje, Slovenia
N. de Vries
Jan Tooropstraat, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
e-mail: n.vries@olvg.nl
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_14
197
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M. Delakorda and N. de Vries
14.2 CPAP
CPAP is considered the gold standard of therapy for moderate to severe OSA.CPAP
has proven to be benecial and safe, but its efcacy can be limited by poor longterm adherence. Moreover, EC has been linked to (unsuccessful) use of CPAP, suggesting that the epiglottis in some cases is pushed further down into the laryngeal
inlet on application of CPAP [1], which aggravates the EC.For further reference,
see Chap. 15.
14.3 Mandibular Advancement Devices
A mandibular advancement device (MAD) may also be a treatment option for EC,
although there is some controversy regarding its efcacy. In our experience and
according to most studies to date, however, MADs are an efcient nonsurgical treatment option for tongue base and/or epiglottis collapse, particularly in patients with
mild to moderate OSA.Its effect can be tested with Esmarch repositioning maneuver during DISE.For further reference, see Chap. 17.
14.4 Restoring Nasal Breathing
Mouth breathing during sleep alters the relative positions of the soft structures in the
oropharynx. When not in contact with the hard and soft palate, the tongue base
moves back, and the epiglottis follows it. This is often seen in DISE when patients
open their mouth, and the epiglottis collapses already in the shallow phase of sedation. In this group, it is reasonable to recommend the use of a chin strap to evaluate
the effectiveness of nasal breathing restoration. According to patient reports, waking up with a distinctly dry mouth could point to mouth breathing. If the patient
cannot breathe satisfactorily through the nose with the chin strap in place, then
treatment of nasal obstruction should be considered (surgical or nonsurgical).
According to the results of the studies carried out so far, OSA cannot be successfully treated only by restoration of nasal breathing; however, breathing through the
mouth can certainly worsen the results of other treatment methods, and this is especially important in cases of obstructions at the level of the tongue base and the epiglottis (for further reference, see Chap. 13).
14.5 Myofunctional Therapy
Myofunctional therapy is interesting and relatively new. The experience with it in
general, and in case of epiglottis collapse in particular, is very limited. Further studies are awaited. Since the position of the epiglottis is related to the tongue position,
14 Therapy Decision-Making inEpiglottis Collapse
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the use of this method should be more sensible in patients with a hypotonic tongue.
Newer applications that improve patient participation and progress monitoring can
help us with this. Some research already points to the success of such approach (for
further reference, see Chap. 16).
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14.6 Positional Therapy
The majority of patients with early-stage disease, mild OSA, have a higher frequency and duration of apneic events in the supine position. It has been suggested
that epiglottic collapse at this level is affected by sleeping position and seems to
occur more often in the supine position compared to non-supine position. The
increase in the use of DISE, and performing this procedure in different body positions has given more insight in the involvement of the epiglottis in OSA, particularly with an isolated EC in antero-posterior direction—oppy epiglottis (FE). Vonk
etal. showed that a FE is a position-dependent phenomenon. Like a collapse at the
level of the tongue base, EC can also be suspected in patients with positional dependence. In case of FE, therefore, positional therapy might be a viable treatment
option—proven to be effective [2, 3]. For further reference, see Chap. 18.
14.7 Surgical Treatment
In addition to conventional treatments, several surgical techniques exist. They are
described in Part 4 of this book. Several small-scale studies have been published
about the techniques, success rates, and complications of epiglottis surgery. Many
sleep surgeons are hesitant to opt for epiglottis surgery because of the potential risk
of irreversible dysphagia after partial or total epiglottectomy. Fortunately, evidence
on and experience with the surgical techniques described in this section do not support the fears of severe irreversible complications. The risk of sequelae must be
weighed individually, depending on the severity of the disease, success of conservative treatments, and patient’s motivation for such approach. The choice of the
described surgical techniques depends on the surgeon’s experience, doctor’s and
patient’s preference, severity of the disease, extent, and pattern of the collapse, i.e.,
isolated epiglottic collapse vs. multilevel obstructions, and availability of, for
instance, a laser and robot platform.
In the following section, we will propose an algorithm for assessment of patients
with EC as conducted in the authors’ institution. It is based on the results of some
studies, as well as on the authors’ own observations and experience. Before deciding on the surgical treatment of EC, it is necessary to perform follow-up poly(somno)
graphy in order to objectify the effect of any previous conservative treatments. The
new generation of devices that are being developed for monitoring various OSArelated signs and symptoms can be helpful in evaluating different nonoperative
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M. Delakorda and N. de Vries
approaches or their combination. Their development has progressed signicantly in
recent years, and heralds a new era in the eld of OSA diagnostics and monitoring.
Assessment of all OSA patients begins with clinical examination. Some studies
have shown that patients with EC differ from other patients with OSA in terms of
certain poly(somno)graphic and clinical characteristics. EC appears to occur more
frequently in men and in patients with a lower average BMI than in other OSA
patients [3–8]. The EC group is also characterized by milder degrees of OSA, with
less severe desaturations [2]. When dealing with such patients, especially in the
initial stage, we must therefore maintain a high level of suspicion for EC.This is
especially true for patients in whom CPAP therapy has failed to stabilize the upper
airway [1]. If we have a recording of snoring, we can also suspect obstruction at the
level of the epiglottis based on the characteristic sound with a higher frequency,
usually with occasional complete interruptions [9–11].
EC is conrmed during DISE.We must pay particular attention to the assessment
of possible obstructions at the level of the epiglottis in patients who, according to
P(S)G and clinical characteristics, correspond to the group of patients with EC.Since
the position of the epiglottis is related to the position of the tongue base, the protocol according to which DISE is performed is extremely important. Especially when
using propofol, we must be careful not to over-sedate the patient, because the resulting hypotonia of the genioglossus can create “false ECs” [12]. The mentioned effect
of the sedation agent can to some extent be avoided by using dexmedetomidine,
which has a smaller effect on the tone of upper airway dilators [13]. To assess possible EC, it is necessary to take enough time for DISE and observe as many repetitions of breathing cycles as possible. Therefore, the cooperation between the
surgeon and the anesthesiologist is of utmost importance. We should observe and
describe the severity and pattern of the EC and check the effects of different maneuvers on EC (mouth closure, jaw thrust, lateral body position). It is important to realize that EC does not behave according to the tube law principle; rather, it is more
like a one-way valve with unlimited collapsibility. Once the critical pressure is
reached, the epiglottis closes the laryngeal inlet abruptly [14, 15]. As such, EC can
be severely inuenced by very small changes in UA airow dynamics.
In the majority of cases, EC is a part of a multilevel obstruction [2]. The prevalence of epiglottis obstructions requiring surgery seems to be lower than that found
during DISE, so it is not necessary to perform surgery on all levels/structures causing obstruction or collapses, which are detected during this investigation [16]. In
cases of isolated antero-posterior EC, conservative treatment options should be
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201
tested rst. If the EC is a part of a multilevel obstruction with palatal involvement,
we can check the effect of a pharyngeal tube placement during DISE to simulate the
palatal surgery (UPPP, or contemporary palatal reconstructive approaches) results.
In institutions where this option is available, titration with CPAP can also be performed during DISE to check for the minimal positive pressure needed to stabilize
the epiglottis. In cases of secondary EC, it is necessary to evaluate the size of lingual
tonsils.
When EC is identied during the DISE, and conservative treatment has failed,
then epiglottis surgery should be considered. Epiglottis is located relatively low in
the upper respiratory tract and therefore, when assessing its stability, it is also
necessary to look for the primary ow-limiting site that may be located at a higher
UA level [17]. When there is a signicant obstruction at the upper levels of the UA
(soft palate, tonsils/lateral pharyngeal walls), it is reasonable to expect that resolving this primary ow-limiting site will also affect the EC.This especially holds
true when EC is not complete or when it only occurs intermittently. In such cases,
the authors advise a staged approach with palatal surgery (e.g., UPPP with/without tonsillectomy, barbed wired pharyngoplasty) and epiglottis surgery as a secondary intention. Such an approach is also in concordance with the results of
some published studies [18]. An exception would be a severe EC in lateral direction (soft, tubular epiglottis type), which usually presents a narrowing with high
compliance. In our opinion, this type of obstruction should be addressed with the
initial surgical treatment.
The choice of surgical technique in a patient with EC must be adapted to the
type of obstruction at this level. EC in anteroposterior direction (oppy epiglottis)
is much more common than the lateral type [2]. In the case of EC in the lateral
direction with a thin and softened omega-shaped epiglottis, a partial epiglottectomy is probably the most appropriate. Epiglottis stiffening operation or glossoepiglottopexy techniques are the preferred option for EC in the antero-posterior
direction, since in the case of lateral EC, in our experience, these techniques most
often fail. In cases of secondary EC, tongue base obstruction should be addressed.
In patients with severe enlargement of lingual tonsils (Friedman grade 3–4), tongue
base reduction either by TORS or coblation should be performed. This procedure
can be combined with partial epiglottectomy. When tongue base collapse is a consequence of hypotony, then upper airway stimulation would most probably be the
best option.
In Fig.14.1, we present a proposed algorithm that is used at our institution.
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M. Delakorda and N. de Vries
Fig. 14.1 An algorithm for assessment of patients with suspected EC. TCI target controlled infusion, MAD mandibular advancement device, UPPP uvulo-
palatopharyngoplasty, MMA maxillomandibular advancement
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203
14.8 Conclusion
Patients with EC differ from other OSA patients in terms of some demographic and
anthropometric characteristics. In most patients, EC is a part of a multilevel obstruction, and the choice of the optimal treatment or combination of different treatment
approaches should be carefully selected according to patient’s characteristics and
preferences. For many patients with EC, positional therapy and MADs may prove
very successful. Another important issue is nasal patency that should be resolved
when obstructions at the tongue base and/or epiglottis are related to mouth breathing. When those measures fail, surgical treatment should be considered and planned.
For this treatment modality, there are many options that should be selected and
adapted based on DISE ndings.
References
1. Verse T, Pirsig W. Age-related changes in the epiglottis causing failure of nasal continuous
positive airway pressure therapy. J Laryngol Otol. 1999;113(11):1022–5; [cited 2020 Mar 21].
https://www.cambridge.org/core/product/identier/S0022215100145888/type/journal_article.
2. Kim H-Y, Sung C-M, Jang H-B, Kim HC, Lim SC, Yang HC.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. J Clin Sleep Med.
2021;17(3):413–9; [cited 2020 Nov 23]. http://www.ncbi.nlm.nih.gov/pubmed/33094721.
3. Sung CM, Kim HC, Yang HC.The clinical characteristics of patients with an isolate epiglottic
collapse. Auris Nasus Larynx. 2020;47(3):450–7.
4. Moore KE, Phillips C.A practical method for describing patterns of tongue-base narrowing
(modication of Fujita) in awake adult patients with obstructive sleep apnea. J Oral Maxillofac
Surg. 2002;60(3):252–60.
5. Sung C-W, Chan W, Chang C-H, Huang P-C, Lien W-C, Chang W-T, et al. Associations
between male gender, body size and dimension of the epiglottis. Authorea Prepr. 2020
6. Ma MA, Kumar R, Macey PM, Yan-Go FL, Harper RM. Epiglottis cross-sectional area and
oropharyngeal airway length in male and female obstructive sleep apnea patients. Nat Sci
Sleep. 2016;8:297–304; [cited 2021 Aug 9]. https://pubmed.ncbi.nlm.nih.gov/27757056/.
7. Sung CM, Tan SN, Shin M-H, Lee J, Kim HC, Lim SC, etal. The site of airway collapse in
sleep apnea, its associations with disease severity and obesity, and implications for mechanical interventions. Am J Respir Crit Care Med. 2021;204(1):103–6; [cited 2021 Dec 1]. http://
www.ncbi.nlm.nih.gov/pubmed/33826879.
8. Kim HY, Sung CM, Bin JH, Kim HC, Lim SC, Yang HC.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. J Clin Sleep Med.
2021;17(3):413–9.
9. Agrawal S, Stone P, McGuinness K, Morris J, Camilleri AE.Sound frequency analysis and the
site of snoring in natural and induced sleep. Clin Otolaryngol Allied Sci. 2002;27(3):162–6.
http://www.ncbi.nlm.nih.gov/pubmed/12071989.
10. Huang Z, Aarab G, Ravesloot MJL, Zhou N, Bosschieter PFN, van Selms MKA, et al.
Prediction of the obstruction sites in the upper airway in sleep-disordered breathing based
on snoring sound parameters: a systematic review. Sleep Med. 2021;88:116–33. https://doi.
org/10.1016/j.sleep.2021.10.015.
11. Lee CH, Bin WT, Kim SY, Lee WH, Han DH, Kim DY, etal. Acoustic characteristics of snoring according to obstruction site determined by sleep videouoroscopy. Acta Otolaryngol.
2012;132(SUPPL. 1):S13.
204
https://t.me/medicina_free
12. Hong SD, Dhong HJ, Kim HY, Sohn JH, Jung YG, Chung SK, et al. Change of obstruction
level during drug-induced sleep endoscopy according to sedation depth in obstructive sleep
apnea. Laryngoscope. 2013;123(11):2896–9.
13. Viana A, Zhao C, Rosa T, Couto A, Neves DD, Araújo-Melo MH, etal. The effect of sedating agents on drug-induced sleep endoscopy ndings. Laryngoscope. 2019;129(2):506–13.
https://doi.org/10.1002/lary.27298; [cited 2019 Sep 8].
14. Genta PR, Sands SA, Butler JP, Loring SH, Katz ES, Demko BG, etal. Airow shape is associated with the pharyngeal structure causing OSA.Chest. 2017;152(3):537–46; [cited 2019 mar
29]. http://www.ncbi.nlm.nih.gov/pubmed/28651794.
15. Azarbarzin A, Marques M, Sands SA, Op de Beeck S, Genta PR, Taranto-Montemurro L,
et al. Predicting epiglottic collapse in patients with obstructive sleep apnoea. Eur Respir
J. 2017;50(3):1700345. https://doi.org/10.1183/13993003.00345; [cited 2021 Jul 13].
16. Blumen MB, Latournerie V, Bequignon E, Guillere L, Chabolle F.Are the obstruction sites
visualized on drug-induced sleep endoscopy reliable? Sleep Breath. 2015;19(3):1021–6.
17. Yanagisawa-Minami A, Sugiyama T, Iwasaki T, Yamasaki Y. Primary site identication in
children with obstructive sleep apnea by computational uid dynamics analysis of the upper
airway. J Clin Sleep Med. 2020;16(3):431–9; [cited 2021 Jun 27]. http://www.ncbi.nlm.nih.
gov/pubmed/31992411.
18. Kwon OE, Jung SY, Al-Dilaijan K, Min JY, Lee KH, Kim SW, etal. Is epiglottis surgery
necessary for obstructive sleep apnea patients with epiglottis obstruction? Laryngoscope.
2019;129(11):2658–62. https://doi.org/10.1002/lary.27808; [cited 2019 Nov 20].
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