The clinical characteristics of patients with an isolate epiglottic collapse

Sleep apnea patients with epiglottic collapse elevate their larynx more with swallowing; videofluoroscopic swallowing study of 80 patients

OBJECTIVE

The epiglottis plays an integral role in the swallowing mechanism and is also implicated as an obstruction site in obstructive sleep apnea (OSA). The underlying causes of epiglottic collapse during sleep remain unclear. This study aimed to investigate the cognitive functions using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the neurophysiological and anatomical factors using videofluoroscopic swallowing studies (VFSS). We compared patients with OSA exhibiting epiglottic collapse to those without, assessing differences in anatomical or neurophysiological characteristics.

METHODS

The study included 12 patients with epiglottic collapse (Epi-group) and 68 without (non-Epi group), all undergoing overnight polysomnography (PSG), drug-induced sleep endoscopy (DISE), LOTCA, and VFSS. Oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were considered as neurophysiological traits, and laryngeal elevation length (LE) as anatomical trait, and were measured across various test diets (10 ml of liquid, soft, or solid).

RESULTS

The study comprised 80 individuals, 57 men and 23 women, with no significant age, sex, body mass index or PSG parameters between groups, or DISE findings, with the exception of epiglottic collapse. Swallowing metrics from VFSS were normal, with no differences in OTT, PDT, PTT, or LOTCA scores. Notably, patients with epiglottic collapse showed a greater laryngeal elevation when swallowing soft and solid foods (p = 0.025 and p = 0.048, respectively).

CONCLUSIONS

Patients with epiglottic collapse do not exhibit neurophysiological or cognitive impairments when compared to non-Epi group. However, the Epi-group displayed a significantly increased laryngeal elevation length. This suggests that anatomical factors may have a more substantial role in the development of epiglottic collapse than neurophysiological factors.

Types of Epiglottic Collapse in Breathing Sleep Disorder and Their Impact in Clinical Practice

Introduction  Obstructive sleep apnea (OSA) is a severe form of sleep-disordered breathing (SDB) that is strongly correlated with comorbidities, in which epiglottic collapse (EC) and other contributing factors are involved. Objectives  To evaluate the occurrence of EC in OSA patients through drug-induced sleep endoscopy (DISE) and to determine the factors contributing to EC. Methods  A retrospective study of 37 adult patients using medical history. Patients were assessed for laryngopharyngeal reflux (LPR) and lingual tonsil hypertrophy (LTH) using reflux symptom index and reflux finding score (RFS); for OSA using polysomnography, and for airway collapse through DISE. An independent t -test was performed to evaluate risk factors, including the involvement of three other airway structures. Results  Most EC patients exhibited trap door epiglottic collapse (TDEC) (56.8%) or pushed epiglottic collapse (PEC) (29.7%). Lingual tonsil hypertrophy, RFS, and respiratory effort-related arousal (RERA) were associated with epiglottic subtypes. Laryngopharyngeal reflux patients confirmed by RFS (t(25) = -1.32, p  = 0.197) tended to suffer PEC; LTH was significantly associated (X2(1) = 2.5, p  = 0.012) with PEC (odds ratio [OR] value = 44) in grades II and III LTH patients; 11 of 16 TDEC patients had grade I LTH. Pushed epiglottic collapse was more prevalent among multilevel airway obstruction patients. A single additional collapse site was found only in TDEC patients. Conclusion  Laryngopharyngeal reflux causes repetitive acid stress toward lingual tonsils causing LTH, resulting in PEC with grade II or III LTH. Trap door epiglottic collapse requires one additional structural collapse, while at least two additional collapse sites were necessary to develop PEC. Respiratory effort-related arousal values may indicate EC.

Treatment of a floppy epiglottis with upper airway stimulation therapy

PURPOSE

To evaluate the efficacy of upper airway stimulation therapy in patients with a floppy epiglottis who have experienced continuous positive airway pressure failure or intolerance.

METHODS

A retrospective single-center cohort study was conducted. Patients who received an Inspire Upper Airway Stimulation system and had a 1-year follow-up were included. Baseline and one-year in-laboratory polysomnography examinations were performed. Patient characteristics, Epworth Sleepiness Scale scores and upper airway stimulation device settings were collected.

RESULTS

A total of 75 patients were included, of whom 10 had a floppy epiglottis. Patients with a floppy epiglottis had a significant therapeutic response to upper airway stimulation therapy, similar to patients without a floppy epiglottis. According to the Sher's success criteria, 90% of patients with a floppy epiglottis and 68% of patients without a floppy epiglottis were responders to therapy (p = 0.149). In the floppy epiglottis group, the apnea-hypopnea index decreased from 35.1 ± 5.5 events/hour to 11.2 ± 11.3 events/hour (95% CI (15.0, 32.9), p < 0.001), similarly in the non-floppy epiglottis group, the decline was from 36.4 ± 8.3 events/hour to 14.4 ± 9.5 events/hour (95% CI (18.6, 25.2), p < 0.001, between groups p = 0.659). Comparable reductions were observed for the other respiratory parameters.

CONCLUSION

Treatment of patients with obstructive sleep apnea and a floppy epiglottis can be challenging. Continuous positive airway pressure may aggravate the epiglottis collapse. Upper airway stimulation therapy can be considered an effective alternative treatment option for patients with a floppy epiglottis who have encountered either continuous positive airway pressure failure or intolerance.

Quantitative Measurement of Pharyngeal Dimensions During Drug-induced Sleep Endoscopy for Oral Appliance Outcome

OBJECTIVE

To quantitatively investigate the effect of mandibular advancement devices (MADs) on pharyngeal airway dimensions in a transverse plane as measured during drug-induced sleep endoscopy (DISE).

METHODS

Data from 56 patients, treated with MAD at 75% maximal protrusion and with baseline Apnea-Hypopnea Index ≥10 events/h, were analyzed. For each patient, three snapshots were selected from DISE video footage at baseline, with MAD presence, and during chin lift, resulting in 498 images (168/168/162, baseline/MAD/chin lift). Cross-sectional areas, anteroposterior (AP) and laterolateral (LL) dimensions on both retroglossal and retro-epiglottic levels were measured. To define the effect of MAD and chin lift on pharyngeal dimensions, linear mixed-effect models were built. Associations between MAD treatment response and pharyngeal expansion (MAD/chin lift) were determined.

RESULTS

Significant differences were found between retroglossal cross-sectional areas, AP, and LL dimensions at baseline and with MAD presence. At a retro-epiglottic level, only LL dimensions differed significantly with MAD presence compared to baseline, with significant relation of LL expansion ratio to treatment response (p = 0.0176). After adjusting the response definition for the sleeping position, greater retroglossal expansion ratios were seen in responders (1.32 ± 0.48) compared to non-responders (1.11 ± 0.32) (p = 0.0441). No significant association was found between response and pharyngeal expansion by chin lift.

CONCLUSION

Our observations highlight the additional value of quantitative pharyngeal airway measurements during DISE with MAD presence in evaluating MAD treatment outcome. These findings demonstrate an increase in retroglossal airway dimensions during DISE, with MAD presence, and more pronounced increase in retroglossal expansion ratios in MAD treatment responders compared to non-responders after sleeping position correction.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:3619-3627, 2023.

Surgical Treatment Options for Epiglottic Collapse in Adult Obstructive Sleep Apnoea: A Systematic Review

The critical role of epiglottis in airway narrowing contributing to obstructive sleep apnoea (OSA) and continuous positive airway pressure (CPAP) intolerance has recently been revealed. This systematic review was conducted to evaluate available surgical treatment options for epiglottic collapse in adult patients with OSA. The Pubmed and Scopus databases were searched for relevant articles up to and including March 2022 and sixteen studies were selected. Overall, six different surgical techniques were described, including partial epiglottectomy, epiglottis stiffening operation, glossoepiglottopexy, supraglottoplasty, transoral robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. All surgical methods were reported to be safe and effective in managing selected OSA patients with airway narrowing at the level of epiglottis. The surgical management of epiglottic collapse can improve OSA severity or even cure OSA, but can also improve CPAP compliance. The selection of the appropriate surgical technique should be part of an individualised, patient-specific therapeutic approach. However, there are not enough data to make definitive conclusions and additional high-quality studies are required.

Patients with Epiglottic Collapse Are Less Adherent to Autotitrating Positive Airway Pressure Therapy for Obstructive Sleep Apnea

Rationale: The anatomic orientation of the epiglottis is such that it points in the opposite direction to inspiratory flow, thereby potentially making positive airway pressure (PAP) treatment challenging in patients with epiglottic collapse. However, no previous studies have analyzed PAP adherence in these patients. Objectives: This study aimed to analyze adherence to autotitrating PAP (APAP) treatment in patients with epiglottic collapse. Methods: We performed an age- and sex-matched case-control study. On the basis of their overnight level-I polysomnogram, patients were prescribed APAP in a tertiary hospital between July 2018 and March 2019. The site of airway collapse was diagnosed with drug-induced sleep endoscopy. Demographic factors, sleep questionnaire, polysomnography, and APAP usage statistics were analyzed. Results: Eighteen patients with epiglottic collapse (epi-group) and 36 without epiglottic collapse (control group) were analyzed. We found that 22.8% of patients in the epi-group terminated APAP within 2 weeks, whereas only 2.8% of patients in the control group terminated APAP within 2 weeks (P = 0.048). The percentage of days with usage over 4 hours was significantly lower in the epi-group (64.6% vs. 75.6%; P = 0.008). In addition, the adherence failure rate was 66.7% in the epi-group and 33.3% in the control group (P = 0.039). Patients with epiglottic collapse were also found to have lower body mass index, which is an unfavorable predictor of APAP adherence. Conclusions: This study suggests that patients with epiglottic collapse have a higher APAP adherence failure rate than patients without epiglottic collapse. Thus, patients with epiglottic collapse should be followed closely during treatment, and alternative therapies should probably be considered for these patients.

Epiglottopexy Is a Treatment of Choice for Obstructive Sleep Apnea Caused by a Collapsing Epiglottis

Drug-induced sleep endoscopy (DISE) reveals epiglottic collapse to be a frequent cause of obstructive sleep apnea (OSA) and intolerance of positive airway pressure (PAP). These patients require different management. This prospective study aimed to compare transoral laser epiglottopexy outcomes in patients with OSA caused by epiglottic collapse with the patients’ previous PAP outcomes. Fifteen consecutive adult patients with OSA and epiglottic collapse during DISE were included; ten were analyzed. Before inclusion, PAP was indicated and ineffective in six patients, one of whom underwent unsuccessful uvulopalatopharyngoplasty. PAP was performed during DISE in all patients before epiglottopexy and was uniformly ineffective. ENT control was performed at 1 week and 1 month, and control limited polygraphy to 6 months after surgery. The apnea−hypopnea index (AHI) and Epworth Sleepiness Scale (ESS) were significantly improved (p < 0.001 and p = 0.003, respectively) in all patients after epiglottopexy. Surgery was successful in 9/10 patients; the remaining patient had a significantly decreased AHI and could finally tolerate PAP. Transoral laser epiglottopexy is used to treat OSA in patients with epiglottic collapse. Unlike other methods, it significantly reduces both AHI and ESS and should be considered for these patients. An active search for OSA patients with epiglottic collapse is recommended to prevent treatment failure.

Guidelines of the French Society of ENT (SFORL): Drug-induced sleep endoscopy in adult obstructive sleep apnea syndrome

OBJECTIVES

To determine the indications, anesthesiological and surgical procedure and interest of drug-induced sleep endoscopy in the treatment of adult obstructive sleep apnea syndrome.

DESIGN

A redactional committee of 17 experts was set up. Conflicts of interest were disclosed and followed up throughout the process of drawing up the guidelines. The work received no funding from any firm dealing in health products (drugs or devices). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) method was applied to assess the quality of the data on which the guidelines were founded. It was stressed that strong recommendations should not be made on the basis of poor-quality or insufficient data.

METHODS

The committee studied 29 questions on 5 topics: indications and contraindications, anesthetic technique, surgical technique, interpretation and reporting of results, and management guided by results.

RESULTS

Expert review and application of the GRADE method led to 30 guidelines: 10 with high level of evidence (Grade 1+ or 1-), 19 with low level (GRADE 2+ or 2-) and 1 expert opinion.

CONCLUSION

Experts fully agreed on the strong guidelines formalizing the indications and modalities of drug-induced sleep endoscopy for adult obstructive sleep apnea syndrome.

Patients with epiglottic collapse showed less severe obstructive sleep apnea and good response to treatment other than continuous positive airway pressure: a case-control study of 224 patients

STUDY OBJECTIVES

The purpose of this study was to analyze patients with epiglottic collapse, especially their clinical characteristics related to obstructive sleep apnea and phenotype labeling using drug-induced sleep endoscopy.

METHODS

An age-sex matched case-control study was conducted to compare the clinical characteristics of patients with epiglottic collapse (Epi group) and patients without epiglottic collapse (non-Epi group). All patients underwent drug-induced sleep endoscopy January, 2015, to March, 2019, in a tertiary hospital for suspected sleep apnea symptoms. Demographic factors, underlying disease, overnight polysomnography, and their phenotype labeling using drug-induced sleep endoscopy were analyzed.

RESULTS

There was no difference in age, sex, the prevalence of hypertension, diabetes, cerebrovascular disease, and coronary artery disease. However, the body mass index was significantly lower in patients in the Epi group (P < .001). Additionally, the apnea-hypopnea index was lower (P = .001), and the lowest oxygen saturation was significantly higher in the Epi group (P = .042). The phenotype labeling on drug-induced sleep endoscopy showed that the prevalence of velum concentric collapse and oropharyngeal lateral wall collapse was lower, and that of tongue-base collapse was higher in the Epi group. Multilevel obstructions were more common in the Epi group. However, the Epi group showed a good response to mandibular advancement or positional therapy.

CONCLUSIONS

Although there was no difference in the underlying characteristics and self-reported symptom scores between the groups, the patients with epiglottic collapse showed significantly lower body mass index and obstructive sleep apnea severity. Additionally, patients with epiglottic collapse were expected to respond well to oral devices or positional therapy.

Partial epiglottectomy improves residual apnea-hypopnea index in patients with epiglottis collapse

Continuous positive airway pressure treatment aggravates airway obstruction in patients with epiglottis collapse. In these patients, partial epiglottectomy can resolve epiglottis collapse by partial excision of the obstructed epiglottis. However, patients with epiglottic collapse usually have simultaneous obstructions on multiple levels, such as the soft palate, base of the tongue, etc. Therefore, sleep apnea cannot be controlled merely by resolving epiglottis collapse. The use of additional continuous positive airway pressure treatment after partial epiglottectomy is considered essential. However, no studies have yet evaluated the effect of partial epiglottectomy on continuous positive airway pressure treatment. In this study, we report on 2 patients with obstructive sleep apnea who underwent partial epiglottectomy. These 2 patients used autotitrating positive airway pressure treatment pre- and postoperatively. The present case report will provide insight into the effects of partial epiglottectomy on the use of positive-pressure devices.