The Awake Examination of the OSA Patient K. Tschopp Chairman of the Working Group Sleep Medicine Swiss Society of ORL ENT-Clinic Cantonal Hospital Basel County Liestal
Hand-out_The awake examination of the OSA patient
[Schreibgeschützt] [Kompatibilitätsmodus]K. Tschopp Chairman of the
Working Group Sleep Medicine
Swiss Society of ORL
Content
Examination of the larynx and tongue base
Analysis of the face: Type of face
Brachiocephalic
Dolichocephalic
Nasal polyps ?
Adenoid hypertrophy ?
Mouth breathing
Increases the resistance in the upper airway by 2.5 x
Examination of the oral cavity Palatine Tonsils Grade 0 (no
tonsils) Grade 1 Grade 2
Grade 3 Grade 4
grade 1
grade 4
the tonsils hidden between the pillars the tonsils extending to the
pillars the tonsils beyond the pillars, but not to the midline the
tonsils extend to the midline
Examination of the oral cavity Tongue position
Grade I Grade II
Grade III Grade IV
Friedman tongue position = Mallampati grade
Visualization of structures is done with the mouth open widely
without protrusion of the tongue:
grade I the entire uvula and tonsils visible grade II the uvula,
and only the upper part of tons ils visible grade III the soft
palate, but not the uvula visibl e grade IV only the hard palate
visible
Clinical significance of Tongue position & Tonsil S ize
Friedman M. et al. Laryngoscope 1999; 109: 1901-190 7
Tongue position Tonsil size BMI
correlate significantly with OSA severity
Tongue position Tonsil size BMI
accounts for RDI variability of:
12% 4% 4%
Grade I Grade II Grade II Grade III
The grade of the uvula. Visualization of structures is done with
the mouth open widely without protrusion of the tongue.
Pressing gently,the anterior part of tongue is allo wed in order to
see the uvula.
long and wide uvula:
the length of the uvula is >15 mm and the width of the base of
uvula is >10 mm
short uvula:
the length <15 mm and the width of the base of the uvula < 10
mm
long & slim uvula :
length >15 mm but the width of the base of uvula <10 mm
wide & short uvula :
the width of the base of uvula is more than 10 mm but the length is
<15mm
Bäck L et al. Sleep Breath (2012) 16:199–204
Examination of the oral cavity Uvula
Clinical significance of uvula grade
Interstitial radiofrequency surgery of the soft pal ate for
snoring:
The grade of the uvula correlated significantly wit h the
post-treatment change in snoring.
The group of patients with successful treatment out come 81% had a
uvula grade of I and 19% of grade II.
No patient with uvula grade III had a successful ou tcome.
Bäck L et al. Sleep Breath (2012) 16:199–204
Pillar implants for snoring
Logistic regression revealed the uvular length to b e the decisive
factor in subjective success
Akpinar M.E. et al: Laryngoscope 2011; 121: 1112-11 16
Patients with an uvula length >15mm had significant ly less
improvement of snoring
Examination of the oral cavity Pharyngeal webbing
Grade I Grade II Grade II Grade III
Bäck L et al. Sleep Breath (2012) 16:199–204 Tsai WT et al. Am J
Respir Crit Care Med 2003; 167: 1427–1432
the palato- pharyngeal arch intersects with the edge of the
tongue
Visualization of structures is done with the mouth open widely and
protrusion of the tongue. Pressing gently on the anterior part of
tongue is a llowed in order to see the pharynx.
the palato- pharyngeal arch intersects at 25% or more of the tongue
diameter
the palato- pharyngeal arch intersects at 50% or more of the tongue
diameter
the palato- pharyngeal arch intersects at 75% or more of the tongue
diameter
Examination of the oral cavity Pharyngeal webbing
Clinical significance of pharyngeal webbing
Bäck L et al. Sleep Breath (2012) 16:199–204
The pharyngeal webbing did not affect the treatment results of
interstitial RF surgery.
Figure from Hörmann & Verse. Surgery for Sleep rela ted
breathing disorders. Springer 2005
Examination of the oral cavity Tongue position
Grade I Grade II
Grade III Grade IV
the uvula, but not the entire tonsils are visible
the soft palate but not the uvula are visible
only the hard palate is visible
Examination with the mouth open widely -without protrusion of the
tongue -with the patient breathing trough the mouth
Clinical significance of the Friedman tongue positi on
Friedman M. et al. Laryngoscope 1999; 109: 1901-190 7 Tsai W.H. et
al. Am J Resipir Crit Care Med 2003; 1 67: 1427-1432
A high tongue position is a predictor of OSA.
Retrogathia ?
Anomalies of the teeth Teeth
Do you grind your teeth when asleep?
BruxismTeeth
Dentin Enamel
Examination of the tongue base & larynx: fiberoptic examination
Tongue base
Lymphatic hyperplasia ?
Endolarynx ? - cyst ?
Omega-shaped epiglottis Long-standing compression by the lateral
pharyneal walls/tonsills
Lingua -Epiglottis -Postition
Li S. et al. Eur. Arch. Otorhinolaryngol 2014; 271: 2737-2743
Type I
The epiglottis is separate from the tongue base and the vallecula
epiglottica can be easily seen
Type II
The epiglottis is in contact with the tongue base and the vallecula
epiglottica is obstructed
Type III
The tongue base is pressed against the epiglottis and obstructing
partly the glottis
Examination of the tongue base & larynx: fiberoptic
examination
Evaluation of patients with the mouth closed and br eathing through
the nose.
Lingua -Epiglottis -Postition
Li S. et al. Eur. Arch. Otorhinolaryngol 2014; 271: 2737-2743
Type I
The epiglottis is separate from the tongue base and the vallecula
epiglottica can be easily seen
Type II
The epiglottis is in contact with the tongue base and the vallecula
epiglottica is obstructed
Type III
The tongue base is pressed against the epiglottis and obstructing
partly the glottis
Examination of the tongue base & larynx: fiberoptic
examination
Evaluation of patients with the mouth closed and br eathing through
the nose.
Figures from: Li S. et al. Eur. Arch. Otorhinolaryngol 2014; 271:
2737-2743
Type I Type II
Li S. et al. Eur. Arch. Otorhinolaryngol 2014; 271: 2737-2743
Lingua -Epiglottis -Postition acc. to Li:
predicts glossopharyngeal obstruction
is associated with the retroglossal cross sectional are in CT
scans
is correlated with the severity of OSA
is only moderately correlated with the Friedman tongue
position
Lingua -Epiglottis -PostitionExamination of the tongue base &
larynx: fiberoptic examination