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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4586_Библиотеки_им_академика_М_И_Перельмана
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C. O’Connor-Reina and M. Carrasco-Llatas
16.1.3 Clinical Impact Measurement
OMT is considered to be an optional therapy in adults and children with mild to
moderate OSA (AHI<15 events/h). It has been shown to be effective in reducing
AHI, excessive sleepiness, and in improving quality of life, and adherence to other
therapies such as continuous positive airway pressure (CPAP). Patients prescribed
OMT should be examined weekly to assure adherence and proper performance of the
exercises. There is no consensus on whether these exercises should be performed
with a therapist or using other methods such as telemedicine. The impact of OMT by
providing feedback to the patient has been evaluated using different methods [22–24].
Some authors have recommended the use of the Iowa Oral Performance
Instrument (model 2.1; IOPI Medical LLC, Carnation, WA) (IOPI) or the tongue
digital spoon (TDS) to measure objectively the muscle tone of the UA [22–24].
These instruments can provide objective feedback to patients about whether they
are performing exercises properly and increasing the tone of the UA muscles. The
IOPI is a portable tool that measures variables related to tongue and lip function by
the amount of pressure exerted on a small air-lled bulb. Tongue strength is assessed
by measuring the maximum pressure exerted when the patient presses a disposable
standard-sized tongue bulb against the roof of the mouth. Lip strength is assessed by
measuring the maximum pressure on the bulb located between the cheek and closed
teeth, and the patient contracts the buccinator muscle without biting the bulb. The
pressure obtained (kPa) is digitally displayed on an LCD panel on the instrument. A
series of LED lights representing percentages in 10% increments of a manually set
pressure baseline acts in combination with a built-in timer to measure endurance. As
an instrument that measures tongue function, the IOPI has been used in several
published experiments and has high inter- and intra-rater reliability [25, 26].
Reference values had been obtained from measurements in the population and are
provided by the manufacturer [27, 28] (Fig.16.3).
The digital spoon is used as a kitchen tool to estimate the weight (g) of food [24].
To develop the TDS, we used the Soehnle Cooking Star Digital Measuring Spoon, a
hand scale with a spoon, with graduations from 0.1g to 500g. This TDS consists of
a handle containing the tare and hold buttons. Pressing the hold button allows one to
obtain the highest tared value, which is equivalent to the IOPI peak pressure
(Fig.16.4). To perform the measurements, the spoon is inverted and a 1cm2 circular
Fig. 16.3 Measurement of
the lip strength with
the IOPI
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sticker is placed on the underside to provide a surface measurement (g/cm2). The
patient holds the spoon by the handle and, with the elbow resting on a at surface,
brings the spoon close to the tongue with an elbow angle of ≈ 30°. The device is tared
by pressing the hold key to mark 0.0g. The patient then presses the vertex or tip of
the tongue as strongly as possible on the marked circumference. When nished,
using the index nger of the hand that holds the handle, the patient again presses the
hold button. This test is performed fully by the patient to avoid any movements of the
spoon that may interfere with the result. Our protocol recommends patients to use
this spoon and act on their own control and the IOPI as an additional monthly control
to conrm the changes in values as the patient performs the exercises over time. Also,
it is a possible alternative method to stimulate patients (Fig.16.5).
Fig. 16.4 Image of the
TDS with a dot to show the
patient where the tongue
should be placed
Fig. 16.5 Use of the TDS
measuring the tongue
strength
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C. O’Connor-Reina and M. Carrasco-Llatas
16.1.4 Side Effects, Adherence, andCompliance
Overall, OMT seems to be a safe treatment that has a low incidence of minor complications. Diaféria etal. reported that “there were very few side effects”; however, they
did not provide details about them [17]. Randerath etal. performed an RCT of patients
using passive OMT with electric stimulation of the tongue. Patients reported higher
rates of erythema, skin irritation, and facial pain compared with patients in the placebo group [29]. In a study of patients following a mobile app OMT program,
O’Connor etal. reported one case of tongue irritation, one case of temporomandibular
joint disorder, and three cases of fatigue that led to rejection of the use of the app [30].
In children, OMT is a safe treatment according to the available evidence. Chuang
etal. examined the use of passive OMT with an intraoral mandibular advancement
device (MAD). At 1-year follow-up, they found an increase in the vertical facial
growth and clockwise rotation of the mandible, which they attributed to the use of
the oral device [31].
16.1.5 OMT andTelemedicine
Telemedicine has earned signicance since the publication of the position paper
from the American Academy of Sleep Medicine for the diagnosis and treatment of
the sleep disordered breathing. Its importance has grown exponentially during
COVID-19 pandemic because it is a safe alternative to provide wellness to patient,
providers, and staff [32]. Thus, nowadays, it is considered a useful tool, especially
mobile technology, in supporting treatments to patients with OSA because of its
potential to promote patient empowerment and self-management.
Given the low adherence rates of OMT, in 2017 our research group developed an
app to instruct patients with OSA in the use of OMT and to monitor their progress.
Initially named Apnea Bye, it later was renamed AirwayGym®. The app is currently
available for iOS and Android [10, 33]. It can be thought of as a portable tness app
except that its use is intended for OSA patients, rather than athletes, and that therapists, rather than trainers, provide the instructions. Its novelty is that it is the rst app
in the health-care market that allows the patient to interact directly with the smartphone without needing any other device. The app focuses on sleep apnea disease
and improving proprioceptive decits. When used with the app, the phone provides
acoustic feedback on the efcacy of the exercises performed. It includes nine exercises based on OMT that aim to improve the tonicity of the muscles involved in the
pathogenesis of OSA (Fig.16.6). Before every exercise, an animated demonstration
and a video show the patient how to perform the exercise. After each exercise, the
patient receives visual, acoustic, and tactile feedback on the success of their performance as a point score. When the patient nishes the exercises, the results are saved
on a networked online storage, and a therapist can evaluate the patient’s performance of the exercises. Users of the app can follow the progress of their daily activity over time (Fig.16.7). A chat function is available through which the patient can
contact the therapist directly.
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Fig. 16.6 (Video 16.3) An example of one of the exercises that the patient performs using the
Airway Gym app (► https://doi.org/10.1007/000-bff)
The main objective of the exercises in the app is to increase the tone of the extrinsic muscles of the tongue (genioglossus, hyoglossus, styloglossus, and palatoglossus). The exercises are based on those described by Guimarães etal. and have been
adapted to allow feedback using a smartphone [33]. The rst results obtained with
this app have been presented [33]. The app has been reported to be successful in an
isolated clinical case [34] and in a preliminary series of 20 patients [30]. In the preliminary series, 15 of 20 (75%) patients adhered to the use of the OMT as indicated
by their performance of the exercises 5 days a week. In patients who performed the
exercises, the AHI decreased signicantly from 25.78±12.6 to 14.1±7.7 events/h.
The ESS scores also decreased from 18.2±1.98 to 14.2±7.7 and the minimum O2
saturation decreased from 84.87%±7.02% to 89.27%±3.77%.
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Fig. 16.7 Interface where
patients can follow their
own progress, also
available for the doctor to
conrm the patient
compliance
C. O’Connor-Reina and M. Carrasco-Llatas
A pilot RCT was conducted afterwards to evaluate the effects of these exercises
in patients with severe OSA after a 3-month follow-up [35]. Forty patients with
severe OSA (AHI>30 events/h) were enrolled prospectively and randomized into
an intervention group that used the app for 90 sessions or a control group. After the
intervention, 28 patients remained adherent to OMT.No signicant changes were
observed in the control group. However, the intervention group showed signicant
improvements: AHI decreased by 53.4% from 44.7 to 20.88 events/h; the ESS score
decreased from 10.33 to 5.37; and minimum O2 saturation decreased by 46.5% from
36.31% to 19.4% (Fig. 16.8). The IOPI maximum tongue score increased from
39.83 to 59.06 kPa, and the IOPI maximum lip score increased from 27.89 to
44.11kPa. The nal AHI correlated signicantly with the improvements in IOPI
tongue and lip scores (Fig.16.9). This was the rst RCT performed with OMT in
patients with severe OSA, and the results were similar to those obtained with other
therapies [36].
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Fig. 16.8 Pre- and posttreatment AHI in the patients performing OMT (left side) or in the control
group (right side). Only in the OMT there was a signicant reduction in the AHI after therapy
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Fig. 16.9 Box plot showing the IOPI measurements of the tongue (right) and lips in the OMT and
control groups
16.2 Diagnosis ofOrofacial Myofunctional Disorders
andTheir Relationship withSDB
The diagnosis of an orofacial myofunctional disorder is based on an evaluation by
a speech therapist. Orofacial myofunctional disorder is dened as one or a combination of the following: (1) abnormal thumb-, nger-, lip-, or tongue-sucking habits; (2) inappropriate mouth-open lips-open resting posture (lip incompetence);
(3) forward interdental rest posture of the tongue; (4) forward rest position of the
tongue against the maxillary incisors; (5) lateral posterior interdental tongue rest
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Fig. 16.10 (Video 16.4) Pediatric orofacial myofunctional disorder (► https://doi.org/10.1007/000-bfd)
C. O’Connor-Reina and M. Carrasco-Llatas
posture; or (6) inappropriate thrusting of the tongue in speaking and/or swallowing (tongue thrusting) [37] (Fig.16.10). Guilleminault and others consider that
the presence of this disorder during childhood increases the risk of OSA in adulthood [38, 39].
The main test used to diagnose orofacial myofunctional disorder associated with
OSA is the orofacial myofunctional evaluation expanded with scores (OMES),
which includes several items and is administered by a speech therapist [40]. This
test requires a well-trained speech therapist not available anywhere. Our group is
conducting a case control study to evaluate the methods to select patients with OSA
for OMT. Our evaluation uses the IOPI and TDS. Our hypothesis is that lower
scores obtained with these instruments can complement the information obtained by
the OMES questionnaire. We have started this study designed as a protocol to identify suitable patients for OMT [41].
In our practice, we use the results of drug-induced sleep endoscopy (DISE) to
explain to the patient the reason for UA collapse and to improve adherence to
OMT.Our group has published correlations between IOPI scores and tongue base
and classication (T stage) during DISE [22]. Providing patients’ information
obtained by PSG, DISE, IOPI, TDS, and OMES gives them feedback on the state of
their UA muscles and helps them to understand the disease. In our experience, the
rate of adherence to OMT is 65%.
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16.3 OMT Treatment andEpiglottic Collapse
Kuo et al. consider the epiglottis as a potential collapse site among multilevel
obstructions in patients with moderate to severe OSA.They noted that the epiglottic
length is highly sensitive for predicting epiglottis attachment to the posterior pharyngeal wall and found a cut-off value of 16.6mm. Patients with epiglottic collapse
have signicantly lower body mass index (BMI) that does not correspond with the
severity of OSA.Patients with epiglottic collapse are expected to respond well to
oral devices or positional therapy [42].
Floppy epiglottis causing a trapdoor collapse is one of the most challenging conditions for sleep surgeons [43]. Its diagnosis is based on the results of DISE, which
allow the surgeon to identify the site of obstruction causing OSA [44]. Until now,
the only effective treatment has been surgery to remove the epiglottis totally or partially. However, this surgery involves serious risks such as permanent bronchoaspiration, inspiratory dyspnea, or xed swallowing problems. Using OMT, we
have conrmed that some patients with epiglottic collapse have improved.
The rst patient reported was a 50-year-old man who came to our ear, nose, and
throat (ENT) department, as recommended by his pneumologist, after diagnosed
with OSA because he could not tolerate CPAP or MAD.He complained of progressive somnolence and headaches. He had had two heart infarctions and bypass surgery 3years previously. He was taking anticoagulant medication and had high blood
pressure, which was controlled with calcium channel blockers. The ENT examination showed no anatomical ndings to explain his OSA.The patient had Friedman
stage 1 and tonsil size grade 1. An examination showed no obstruction and a normal
size of the tongue. In a sleep study performed using PSG, his AHI was 31.2 events/h.
His BMI was 22.1kg/m2, ESS score was 22, minimal O2 saturation was 91.3%,
tongue IOPI score was 34kPa, and lips score was 15kPa. Given this history, we
offered him to perform DISE, which revealed a oppy, “trap door” type of epiglottis
closure. Three expert sleep surgeons evaluated the video and considered that the
only viable option was a partial epiglottectomy or epiglottoplasty under general
anesthesia. For personal reasons, the patient declined surgery and did not tolerate
the use of MAD. After obtaining his consent for OMT, he started using Airway
Gym app for 90 sessions and arranged periodic follow-up. The patient noticed that
his headaches and somnolence decreased gradually. His IOPI score improved
monthly and reached a tongue score of 51kPa and lips score of 25kPa. DISE was
repeated after 3 months and found that the epiglottis collapse had improved
(Fig.16.11). A new sleep study found that his AHI had decreased to 17.2 events/h,
minimal O2 saturation improved to 95.1%, and ESS score decreased to 15. There
was no change in his BMI.The patient is still performing the exercises and a MAD
was recommended to improve the residual OSA [33].
The second patient was a 36-year-old man who came to our ENT department
with the same problem. The patient exhibited severe OSA with an AHI of 44
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Fig. 16.11 (Video 16.5) Floppy epiglottis with anteroposterior collapse before and after 90 sessions of OMT (► https://doi.org/10.1007/000-bfh)
C. O’Connor-Reina and M. Carrasco-Llatas
events/h, minimum O2 saturation of 81%, Friedman stage 2, tongue IOPI score of
38kPa, and lips score of 21kPa. He did not tolerate CPAP or MAD, and DISE was
performed. In this DISE, a lateral type of epiglottis collapse was observed. Surgery
was offered to the patient, but he rejected it. Therefore, OMT for 90 sessions was
suggested and the patient improved progressively. His IOPI tongue score increased
to 48kPa and lips score to 30kPa. His AHI decreased to 29 events/h and his minimum O2 saturation improved to 90%. DISE was repeated and it was observed that
the collapsibility during an Esmarch maneuver disappeared. Likewise, a recommendation was made to the patient to use his MAD again (Fig.16.12). A new sleep
study with MAD showed that his AHI was 12 events/h and his minimum O2 saturation was 92%. The patient continues to decline surgery (Unpublished data).
These are the two rst cases reported for which the anatomical changes (type of
epiglottis collapse) that patients experience after OMT were documented with
DISE.The mechanism that explains how these exercises modify the epiglottis collapse is unknown. However, in patients who are noncompliant with other treatments, OMT could be a helpful therapy with few side effects, as has been
demonstrated in these patients [34] Nevertheless, the real-life effect needs to be
conrmed in larger series.
In conclusion, OMT is a comprehensive approach that begins by creating awareness of the reciprocal impact of OSA on the orofacial musculature and oronasal
functions. OMT is a reasonable option for increasing adherence to conventional
therapies and, in selected patients, may offer a valid option for treating OSA [45].
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Fig. 16.12 (Video 16.6) DISE video showing the epiglottis with lateral collapse before and after
OMT (► https://doi.org/10.1007/000-bfj)
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