The Role of Epiglottis in Obstructive Sleep Apnea

This book provides a unique, detailed, and cutting-edge guide to obstructive sleep apnea (OSA) and the epiglottis. It discusses in detail epiglottis collapse both as relevant for diagnosis (e.g., sleep studies, drug induced sleep endoscopy, imaging and sound analysis) and treatment of OSA. In addition to general information on OSA, the chapters explore the role of the epiglottis in evolution, swallowing function, pathophysiology and surgical anatomy. The central chapters deal with patient selection, diagnosis, indications, and contraindications. The last sections investigate non-surgical treatments, surgical techniques, their results, possible failures, and complications. A conclusive chapter discusses research and future perspectives. The volume offers a large number of high-quality photos and illustrations, and an extensive collection of educational videos that highlight all steps of the surgical procedures. The book will appeal to all caregivers working in the field of diagnosis and treatment of obstructive sleep apnea, in particular otolaryngologists, pulmonologists, neurologists, sleep doctors, maxillofacial surgeons, anesthetists, and also the personnel working in sleep labs, general nurses and scrub nurses, physician assistants, and sleep technicians. Foreword Contents Contributors List of Videos Part I: Introduction to OSA 1: OSA Epidemiology 1.1 Introduction 1.2 Brief Diagnostic Tools and Methods for Epiglottis Collapse 1.3 Prevalence of Epiglottis Collapse 1.4 Summary References 2: OSA Pathogenesis 2.1 Patient Phenotyping/Endotyping 2.1.1 Deficient Upper Airway Anatomy 2.1.2 Muscle Responsiveness 2.1.3 Loop Gain 2.1.4 Respiratory Arousal Threshold 2.2 PALM Scale for Patient Phenotyping 2.3 Phenotyping/Endotyping Conclusions 2.4 Analysis of Airflow Shape 2.5 Conclusions References 3: Current Diagnostics and Therapy Concept and Limitations 3.1 Introduction 3.2 Definition of Obstructive Sleep Apnea 3.3 Traditional Classification of Obstructive Sleep Apnea Severity 3.4 Clinical Consequences of Obstructive Sleep Apnea 3.4.1 Symptoms of Obstructive Sleep Apnea 3.4.2 End-Organ Impact 3.4.3 Risk of Accidents 3.5 New Approaches for Obstructive Sleep Apnea Classification 3.6 Clinical Diagnostics 3.6.1 Anamnesis 3.6.2 Physical Examination 3.6.3 Questionnaires 3.6.4 Computer-Based Tests 3.6.5 Sleep Studies 3.6.6 Carbon Dioxide Measurement 3.6.7 Electrophysiological Tests 3.6.8 Drug-Induced Sedation Endoscopy 3.7 OSA Therapy 3.7.1 Conservative OSA Treatments 3.7.2 Positive Airway Pressure Therapy 3.7.3 Continuous Positive Airway Pressure 3.7.4 Bilevel 3.7.5 Mandibular Advancement Device 3.7.6 Positional Therapy 3.7.7 Hypoglossal Nerve Stimulation 3.7.8 Pharmacotherapy 3.7.9 Combination Therapy References 4: Redefining Outcome Measures 4.1 Objective Outcome Measures 4.2 Variability of Objective Sleep Parameters 4.3 Clinical Endpoints 4.4 Treatment Success 4.5 Therapeutic Effectiveness 4.6 Taking Body Position into Account References Part II: Diagnosis of Epiglottis Collapse 5: Relevant Anatomy and Physiology of the Epiglottis 5.1 Introduction 5.2 Embryology 5.3 Developmental Anomalies 5.4 Maturation: Laryngeal Descent 5.5 Skeletal Framework 5.6 Muscles 5.7 Blood Vessels and Lymphatics 5.8 Innervation 5.9 Mucosa 5.10 The Role of the Epiglottis in OSA References 6: Clinical Assessment of OSA Patients 6.1 Introduction 6.2 History 6.3 BMI 6.4 Gender 6.5 Age 6.6 Craniofacial Features and Cephalometry 6.7 Upper Airway Evaluation 6.7.1 The Nose 6.7.2 The Oral Cavity (Skeletal Frame) 6.7.3 The Pharynx 6.7.4 The Larynx 6.8 Conclusion References 7: Sleep Studies 7.1 Introduction 7.2 In-Lab Attended Polysomnography 7.3 Report Format 7.4 Ambulatory PSG/PG 7.4.1 Equipment for Ambulatory PSG/PG Versus the Gold Standard Approach 7.4.2 Why/Why Not Ambulatory PG/PSG? 7.4.3 Indications for Ambulatory PG: International Guidelines 7.4.4 Low or High Pretest Probability of (Obstructive) Sleep Apnea 7.4.5 Additional Requirements 7.4.6 Other Indications for OSA 7.4.7 PG: Limitations of the Current Evidence 7.4.8 When Not to Perform Respiratory PG 7.4.9 Methodological Considerations 7.4.10 Equipment of Choice 7.5 Smart Watches/Wearables and Their Usefulness in Sleep Analysis 7.6 Assessment of Epiglottic Collapse Based on Flow Shape Analysis during PSG/PG 7.7 Conclusion References 8: Diagnostic Workup by DISE 8.1 Introduction 8.2 DISE Basics 8.3 Body Position and Maneuvers 8.4 When to Perform DISE 8.5 Classification Systems for DISE 8.6 Definition of EC 8.7 FE and Body Position 8.8 FE, CPAP Failure, and DISE 8.9 Conclusion References 9: Manometry 9.1 Introduction 9.2 Overview of Manometry Systems 9.3 Clinical Use 9.4 Comparison to DISE and Use in Epiglottic Collapse 9.5 Outlook References 10: Acoustic Analysis 10.1 Introduction 10.2 Clinical Background 10.3 Characteristic Snoring Sound Parameters and Prediction Models 10.4 Limitations of Previous Studies 10.5 The Role of the Epiglottis in Snoring 10.6 Conclusion References Part III: Special Section 11: The Role of the Epiglottis in Pediatric OSA 11.1 Introduction 11.2 Evaluation and Diagnosis 11.3 Management of Laryngomalacia 11.4 Postoperative Management 11.5 Complications 11.6 Current Gaps in Knowledge 11.7 Summary References 12: The Role of Obesity in Epiglottis Collapse 12.1 Obesity 12.2 Obesity and Obstructive Sleep Apnea (OSA) 12.3 Fat Tissue in the Pharyngeal Airway 12.4 Role of BMI in Epiglottis Shape 12.5 BMI and Epiglottis Collapse References 13: The Role of the Nose in Pharyngeal Obstructions 13.1 Introduction 13.2 Pathophysiology 13.2.1 Nasal Breathing During the Awake State 13.2.2 Nasal Breathing During Sleep 13.2.3 How Can Nasal Obstruction Nonetheless Promote Upper Airway Collapse? 13.2.3.1 Starling Resistor Increase in Oral Breathing Loss of Nasal Reflexes Nitrogen Monoxide (NO) Potential Causal Connection of Nasal Breathing and Epiglottic Obstruction in OSA 13.3 Clinical Results 13.4 Results of Conservative Treatments 13.4.1 Medication 13.4.1.1 Anti-Allergic Treatments 13.4.2 Nasal Dilators 13.5 Results of Surgical Treatments 13.5.1 Nasal Surgery for OSA 13.5.2 Nasal Surgery and PAP 13.5.3 Nasal Surgery and Simple Snoring 13.6 Conclusion References Part IV: Conservative Treatment of Epiglottis Collapse 14: Therapy Decision-Making in Epiglottis Collapse 14.1 Introduction 14.2 CPAP 14.3 Mandibular Advancement Devices 14.4 Restoring Nasal Breathing 14.5 Myofunctional Therapy 14.6 Positional Therapy 14.7 Surgical Treatment 14.8 Conclusion References 15: Treatment with CPAP 15.1 Introduction to PAP: An Overview 15.1.1 CPAP 15.1.2 Effects of CPAP in the Upper Airway 15.1.3 Clinical Impact of CPAP 15.1.4 Side Effects, Adherence, and Compliance 15.1.5 BiLevel PAP 15.1.6 Adaptive Servo-Ventilation (ASV) 15.2 CPAP Diagnostic Possibilities 15.3 CPAP Treatment in Certain Epiglottic Pathologies 15.4 Epiglottis Collapse as Cause of CPAP Failure and how to Diagnose it References 16: Orofacial Myofunctional Therapy 16.1 Introduction to Orofacial Myofunctional Therapy: An Overview 16.1.1 Exercises 16.1.2 Scientific Evidence 16.1.3 Clinical Impact Measurement 16.1.4 Side Effects, Adherence, and Compliance 16.1.5 OMT and Telemedicine 16.2 Diagnosis of Orofacial Myofunctional Disorders and Their Relationship with SDB 16.3 OMT Treatment and Epiglottic Collapse References 17: Oral Appliance Therapy 17.1 Introduction 17.2 Mechanism of Action 17.3 Role of MAD in Cases with Epiglottis Collapse 17.4 Future Directions 17.5 Conclusion References 18: Treatment of Epiglottic Collapse with Positional Therapy 18.1 Introduction 18.2 Epiglottic Collapse in PP 18.3 Treatment Options for EC 18.4 Positional Therapy 18.4.1 The Amsterdam Positional Obstructive Sleep Apnea Classification 18.5 EC and PT 18.6 Further Considerations 18.7 Conclusion References Part V: Surgical Treatment of Epiglottis Collapse 19: Epiglottectomy 19.1 Introduction 19.2 Indications/Rationale 19.3 Contraindications 19.4 Surgical Technique 19.5 Post-Operative Care and Complications 19.6 Discussion References 20: Epiglottis Stiffening Operation (ESO) 20.1 Introduction 20.2 Indications 20.3 Preoperative Work-Up 20.4 Surgical Technique 20.5 Tips and Tricks 20.6 Postoperative Management 20.7 Contraindications 20.8 Complications 20.9 Our Experience 20.10 Summary References 21: Glossoepiglottopexy 21.1 Introduction 21.2 Indications and Contraindications 21.3 Surgical Technique 21.4 Postoperative Care 21.5 Complications References 22: Upper Airway Stimulation 22.1 Introduction 22.2 Available Technologies 22.3 The Anatomy of the Hypoglossal Nerve and its Anatomical Stimulations Sides 22.4 Active Hyoid Suspension 22.5 Anatomical Variations of the First Cervical Nerve (C1) 22.6 Scientific Evidence of Activating C1 22.7 Conclusion References 23: Tongue Base Surgery 23.1 Introduction 23.2 Relevant Surgical Anatomy of the Tongue Base 23.3 Addressing Secondary Epiglottic Collapse with Tongue Base Surgery 23.3.1 Patient Selection 23.3.2 Technology 23.4 Surgical Technique 23.4.1 Intubation and Extubation 23.4.2 Complications 23.4.3 Post-Operative Management 23.5 Conclusion References 24: Transoral Robotic Surgery (TORS) 24.1 Introduction 24.2 Indications 24.3 Surgical Technique 24.3.1 Exposure 24.3.2 Tongue Base Reduction 24.3.3 Supraglottoplasty 24.4 Post-operative Care Management 24.5 Complication Management 24.5.1 Intraoperative Bleeding/Hemostasis 24.5.2 Post-operative Complications 24.6 Conclusion References 25: Maxillomandibular Advancement 25.1 Introduction 25.2 Indication and Contraindication 25.3 Surgical Technique 25.3.1 Preoperative Planning 25.3.2 Surgical Procedure 25.3.2.1 Bilateral Sagittal Split Osteotomy 25.3.2.2 Le Fort I Osteotomy 25.4 Postoperative Care 25.5 Complications 25.6 Outcome of MMA 25.7 Role of MMA for Epiglottis Collapse 25.8 Conclusions References 26: Anesthesia Management in OSA Patient 26.1 Introduction 26.2 Preoperative Assessment and Optimization 26.2.1 The Role of 3D Reconstruction and Virtual Endoscopy (VE) 26.3 Airway Management 26.3.1 Optimizing Preoxygenation, Positioning (Safety Apnea Rescue Time) 26.3.2 Airway Management Plans: Risk Assessment and Patient Categorization 26.3.3 Direct Laryngoscope (DL) Versus Video Laryngoscope (VL) 26.3.4 Fiberscopic-Assisted Video-Laryngoscope Intubation (FAVI) or Combined Technique 26.3.5 Use of Supraglottic Airway Devices (SADs) as Intubating Adjuncts 26.3.6 Awake Fiberoptic Intubation (AFOI) 26.3.7 The Role of Tracheostomy 26.4 Intraoperative Management 26.4.1 Mechanical Ventilation 26.4.2 Special, Possibly Life-Threatening, Situations 26.4.3 Transoral Robotic Surgery (TORS) and LASER for Epiglottoplasty 26.5 Safe Extubation 26.6 Postoperative Care Management 26.6.1 Postoperative Analgesia 26.6.2 Patient Position in Bed 26.6.3 Oxygenation, Lung Recruitment, and CPAP 26.6.4 Ward Versus Intensive Care Unit (ICU)? 26.6.5 Criteria for Discharge Home 26.7 Obstructive Sleep Apnea (OSA) and Postoperative Complications 26.8 Conclusion References 27: Future Directions 27.1 Introduction 27.1.1 The Problem 27.1.2 Relevant Anatomy 27.1.3 Diagnosis 27.2 Surgical Indication (What to Know) 27.3 Surgical Techniques 27.4 Future Research 27.5 Conclusion References