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Treatment ofEpiglottic Collapse
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withPositional Therapy
MickeyLeentjens, PattyE.Vonk, andNicode Vries
18.1 Introduction
It has been found that the majority of patients with obstructive sleep apnea (OSA)
have a higher frequency and duration of apneic events in the supine position
[1–3]. In literature, many denitions of position-dependent OSA (POSA) have
been applied. The most common approach is to categorize patients in two groups:
positional (PP) and non-positional (NPP) OSA patients [1, 2, 4, 5]. In PP, apneic
events appear almost exclusively in supine position and the severity of disease is
to a large extent dependent on the time spent sleeping in this posture [1, 2, 6–9].
Patients are classied as being NPP or PP using modied versions of Cartwright’s
criteria [1]. In this denition, there should be a difference of 50% or more in
apnea-hypopnea index (AHI) between supine and non-supine positions with a
total sleeping time in worst sleeping position of >10% and<90%. In PP, a further distinction can be made between supine isolated OSA (non-supine AHI <5
events/hour) and supine predominant OSA (non-supine AHI ≥5 events/hour)
[10, 11].
Overall, 56% to 75% of patients with OSA are classied as being positional [2,
3, 7, 9, 12]. POSA is in particular prevalent in mild to moderate OSA, as the
18
M. Leentjens (*)
Department of Otorhinolaryngology, OLVG, location West, Amsterdam, The Netherlands
e-mail: M.Leentjens@olvg.nl
P. E. Vonk
Department of Otorhinolaryngology, Academic Medical Center, Amsterdam, The Netherlands
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_18
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majority of PP (70–80%) is aficted with this form [2, 7, 8, 13]. In addition, the
prevalence of POSA decreases as the severity of OSA increases. There are also
several studies that have shown clinical differences in patient characteristics between
PP and NPP.For example, PP are younger and have a lower body mass index (BMI)
compared with NPP [2, 7, 8, 14]. In addition, the prevalence of POSA is higher in
Asian populations [15–17].
M. Leentjens et al.
18.2 Epiglottic Collapse inPP
In PP, the severity of OSA is to a large extent dependent on the total sleeping time
(TST) spent in the supine position. The effect of gravitational forces on the upper
airway (UA) when adopting the supine position is thought to be responsible for the
increase in UA collapse observed in this position [18]. One of the structures which
can be responsible for UA narrowing and obstruction is the epiglottis.
As discussed in Part 2 of this book, many different denitions of epiglottic
collapse (EC) are used. An EC can occur in two congurations: anteroposterior
(A-P) or, less common, lateral. An A-P collapse can result in posterior displacement of the entire epiglottis against the posterior pharyngeal wall due to various
causes. First, an EC can occur isolated in A-P conguration, which is also called
a oppy epiglottis (FE) or trapdoor phenomenon. This collapse pattern often
appears to be related to decreased structural rigidity of the epiglottis. Second, an
EC can be secondary to an A-P collapse of the tongue base. Less common is a
secondary collapse of the epiglottis due to a vallecular cyst. Third, a lateral collapse can be caused by anatomical variation or due to underdevelopment of the
epiglottis itself.
It has been suggested that a collapse at this level, in particular FE, is inuenced
by sleeping position and seems to occur more often in the supine position compared
to non-supine position [19, 20]. The increased usage of DISE and performing this
procedure in different body positions have given more insight into the involvement
of the epiglottis in OSA, with in particular an isolated EC (e.g., FE). In a study by
Vonk etal., the authors observed that a FE seems to be a position-dependent phenomenon. This study showed that this phenomenon appears almost exclusively in
the supine position and to a lesser extent during lateral head (and trunk) rotation [21].
Previously, several studies had already shown that base of tongue and epiglottic
collapse are more common in PP [7, 22]. Victores etal. found an overall improvement in UA collapse in PP while moving to lateral sleep position, this in contrast to
NPP. Moreover, the biggest improvement of UA obstruction in PP involved the
tongue base and epiglottis [19]. In addition, Saruddin etal. examined the inuence
of different head positions during DISE in patients with OSA and PP.They observed
a positive effect of lateral head rotation on UA patency in EC, predominantly in
PP [23].
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18.3 Treatment Options forEC
Over the past few years, interest in EC has been increasing. However, treatment of
patients with a FE remains challenging. A variety of treatment methods have been
attempted to resolve this, but both conservative and surgical treatment are hampered
by differences in success rates and possible complications accompanied with surgical interventions. As discussed in the previous chapters of this part of the book,
conservative treatment includes continuous positive airway pressure (CPAP), mandibular advancement device (MAD) treatment, and to a lesser extent myofunctional
therapy.
Besides conventional treatments, several surgical techniques have been applied
to resolve an EC and will be described in Part 4. Various small-scale studies have
been published about techniques, success rates, and complications of epiglottis surgery [24–26]. Many sleep surgeons are hesitant to embark on epiglottis surgery,
because of the risk of irreversible dysphagia after partial or total epiglottectomy.
The risk of sequelae must be weighed individually, depending on, for example, the
severity of the disease.
18.4 Positional Therapy
Positional therapy (PT) aims at preventing patients from sleeping in supine position.
Various techniques have been described. The majority of studies on PT use the old
fashioned, so-called tennis-ball technique (TBT) [12]. This technique uses a passive
object, a bulky mass, which is strapped to the patients’ back avoiding them from
sleeping in the supine position. The advantage of TBT is that it is a simple and inexpensive treatment. More importantly, it has proven its effectiveness in reducing the
percentage of TST in supine position and therefore the total AHI in PP. However,
the long-term compliance of TBT is poor. The poor compliance can be mainly
explained by backache, discomfort and no improvement, or even deterioration, of
sleep quality and daytime alertness [27]. Another drawback is the inability to do
anything else in bed with such device installed, e.g., read, which means it must be
installed just before actually falling asleep. Compliance rates of TBT reported in
literature range from 40 to 70% short-term to only 10% long-term [12, 28, 29]. This
old school positional therapy is therefore obsolete and should be discouraged.
Hereafter, a new generation of small, lightweight, battery-powered vibro-tactile
devices was developed. These devices are either worn around the chest or secured
to the skin of the neck [30, 31]. When the supine position is identied, these devices
provide a vibrating stimulus aiming to turn the patient to a non-supine sleeping
position. Several studies have shown that PT with new-generation devices is effective in reducing the percentage of supine sleep in PP as well [32–35]. Data for studies reporting on the effect of new-generation devices for PT were combined in a
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M. Leentjens et al.
recent meta-analysis [35]. The pooled mean reduction in AHI was 11.3 events/hour
(54%) and the pooled mean reduction in percentage of TST in supine position was
33.6%; a mean difference of 84% [35]. Short-term compliance is high, varying from
76% to 96%, when dened as at least 4h of use per night during 7days a week [4,
31, 34]. Long-term compliance is varying among studies between 64.4% and 75.5%
[33, 36]. In another study, the proportion of patients using their device more than 4h
during 5days a week after 12months of follow-up was 100% [37].
18.4.1 The Amsterdam Positional Obstructive Sleep
Apnea Classification
To determine which patients are suitable candidates for PT, the Amsterdam
Positional Obstructive Sleep Apnea Classication (APOC) was introduced [8]. This
classication system gives a description of patients who probably will or will not
achieve clinical improvement of their OSA with PT. The APOC discriminates
between three categories: the true PP, the NPP, and the multifactorial patient
(Fig. 18.1). The true PP can be cured by PT alone and is categorized as APOC
I. Patients categorized as APOC II or III could benet from PT, but will not be
cured. These patients may benet from a combination of PT with, for example, less
invasive UA surgery, or a MAD.Obviously, the NPP will not benet from PT since
the severity of OSA is not inuenced by sleeping position.
OSA &
>10% in WSP & BSP?
yes
Lower OSA severity
AHI in BSP < 5?
yes yes
APOC I
cured
Fig. 18.1 Flow chart for the Amsterdam Positional Obstructive Apnea Classication (APOC).
The red boxes show the best possible outcome for these patients with successful positional
therapy (PT)
category in BSP than
overall OSA category?
APOC II
new treatment options
Overall AHI ≥ 40 &
AHI in BSP ≥ 2.5% reduced
compared to overall AHI
yes
APOC III
improved
quality of life and/or
improved compliance
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18.5 EC andPT
As described earlier in this chapter, it has been suggested that obstruction by an
isolated EC is enhanced by sleeping position and occurs more often in the supine
position compared to non-supine position [19, 20]. Vonk etal. described that a FE
appears almost exclusively in the supine position [21]. Therefore, avoiding the
supine position might be a rational and promising option that could be used as a
standalone treatment in patients with a FE.
As mentioned above, the multifactorial patient could benet from PT, as the
severity of disease is inuenced, in part, by sleeping position. In APOC II, the
patients have a best sleeping position (BSP) AHI in a lower OSA severity category
than the overall AHI.Theoretically, the patients can decrease overall AHI and OSA
severity category when treated with PT.Consequently, patients could potentially be
treated with less aggressive treatment. Studies report that 42–75% of NPP improve
to less severe PP after UA surgery [32, 38–44]. The effect of UA surgery is thought
to be greater in the lateral position. This might result in residual OSA in the supine
position post-surgery. In patients with partial effective surgery, additional treatment
with PT could be offered as adjuvant therapy. Catalfumo etal. evaluated 104 patients
who underwent uvulopalatopharyngoplasty (UPPP) with postoperative persistent
OSA.Using awake beroptic endoscopy, they observed 11.5% of these patients to
have an abnormal position of the epiglottis as it was pushed against the posterior
pharyngeal wall further down into the laryngeal inlet during inspiration [24].
Patients with a postoperative persistent EC could benet from PT, as the epiglottis
has previously been identied as a primary site to improve in the lateral position
[19]. Several studies observed benecial effect of adjuvant PT in patients with postoperative persistent POSA [32, 40].
In APOC III, patients have an overall AHI of at least 40 events/hour and at least
a 25% lower BSP AHI.CPAP is undoubtedly regarded as the gold standard treatment in these patients. The patient would remain in the same OSA severity category
when avoiding the supine position, but as the AHI decreases, so does the CPAP
pressure needed, which potentially leads to better compliance. In case the patient
does not tolerate CPAP or MAD, PT can be considered as salvage therapy since this
could lower the AHI.
18.6 Further Considerations
There are a few considerations that need to be kept in mind when choosing PT as a
treatment option. As described above, the distinction between PP and NPP is crucial. The NPP patient will not benet from PT, since UA narrowing will be present
in both supine and non-supine sleeping position. Also, patients are not good candidates for PT when they are unable to sleep in the lateral position due to physical
discomfort (e.g., neck or shoulder problems) or any other disabilities that interfere
when sleeping in lateral position. It is important to take into account that the effectiveness of a treatment depends not only on the effect on UA obstruction, but also
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on compliance. Last, PT may not be the treatment of choice when the patient’s main
complaint is snoring in all body positions.
18.7 Conclusion
In this chapter, we described the role of the epiglottis in PP.For PP, avoiding the
supine position is key. A primary EC (e.g., FE), not secondary to collapse of the
base of tongue, is a phenomenon that appears almost exclusively in supine position
and disappears when the patient is positioned in lateral position [21]. Therefore,
these patients are suitable candidates for PT.Also, tongue base and epiglottic collapse have been shown to improve in the lateral position [7, 22]. The multifactorial
patient could also benet from PT, by going down in OSA class (APOC II) or a
decrease in AHI (APOC III). Postoperative residual POSA, which may possibly be
due to an EC, can be a good indication for additional PT as well.
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M. Leentjens et al.
Part V
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Surgical Treatment of Epiglottis Collapse
Epiglottectomy
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19
BhikT.Kotecha
19.1 Introduction
Hypopharynx is a challenging anatomical upper airway segment from a surgical
perspective. It is crucial that the evaluation of the obstructive upper airway is conducted very carefully in order to identify exactly where the problem is. Druginduced sleep endoscopy (DISE) has been pivotal in the evaluation process of the
upper airway obstruction [1, 2]. This technique allows a three-dimensional visualisation of the dynamic upper airway during sedation and enables identication of the
epiglottic obstruction be this as the only obstructive element or indeed as part of
multi-level obstruction and this is particularly important in patients who have failed
CPAP therapy [3].
Epiglottic collapse is now more actively sought for and the nding is more common than previously thought with the prevalence range of 12.5% to just above 70%
[4, 5]. Epiglottic surgery is surrounded by fear of potential complications that
could result, namely that of excessive bleeding into the airway and of course the
risk of swallowing difculty and/or aspiration. With regard to swallowing, there
are reports to conrm that process of swallowing is not signicantly affected [6, 7].
Advance in technology has aided in performing the procedure in a safer manner
and these include surgical tools such as coblation, laser and the trans-oral robotic
approach [7].
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_19. The videos can be accessed individually by click-
ing the DOI link in the accompanying gure caption or by scanning this link with the SN More
Media App.
B. T. Kotecha (*)
Nufeld Health Brentwood, Essex, UK
© 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_19
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