hand-out the awake examination of the osa patient
TRANSCRIPT
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
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