Friedman Tongue Position Research Articles

Diagnostic Value of the Friedman Tongue Position and Mallampati Classification for Obstructive Sleep Apnea: A Meta‐analysis

To assess the association between the Mallampati classification and Friedman tongue position for obstructive sleep apnea severity as determined by apnea-hypopnea index and to determine which method is most closely correlated with prediction of obstructive sleep apnea severity. English-language searches of PubMed, MedLine, and the Cochrane database. Reference sections of identified studies were examined for additional articles. Databases through December 2011 were searched, combined with review of relevant article bibliographies, and assessed by 4 reviewers. Systematic review and random-effects meta-analysis of studies evaluating tongue position and obstructive sleep apnea severity were performed. Outcomes were reported as correlations. Ten studies met inclusion criteria and had data for pooling (2513 patients). Friedman tongue position and Mallampati classification were significantly associated with obstructive sleep apnea severity, with a correlation of 0.351 (0.094-0.564, P = .008). Analysis of the correlation of tongue position with obstructive sleep apnea severity reveals correlations of 0.184 (0.052, 0.310, P = .006) and 0.388 (0.049, 0.646, P = .026) for the Mallampati classification and Friedman tongue position, respectively. Publication bias does not yield a significant Egger regression intercept; however, 4 imputed values to the right of the mean were found using Duval and Tweedie's trim-and-fill method, yielding an overall correlation of 0.498 (confidence interval = 0.474-0.521). The Mallampati classification and Friedman tongue position assessment techniques are significantly correlated with predicting obstructive sleep apnea severity. Publication bias does not significantly affect our results. The strength of this correlation is higher for Friedman tongue position, although 95% confidence intervals for the respective correlation coefficients overlap.

Evaluation of Open Midline Glossectomy in the Multilevel Surgical Management of Obstructive Sleep Apnea Syndrome

To analyze the overall success rate of open midline glossectomy with lingual tonsillectomy in the surgical management of obstructive sleep apnea syndrome (OSAS) as well as a subset analysis to determine whether certain patient factors influence clinical outcome. Case series with retrospective data collection. Private practice with surgeries performed at a single community hospital (St Johns-Riverside Hospital). Fifty consecutive patients who had moderate to severe OSAS with Friedman tongue position III or IV and underwent midline glossectomy with lingual tonsillectomy as part of multilevel sleep apnea surgery and had pre- and postsurgery in-laboratory sleep studies performed. The overall success rate was 56.0% using success defined as a postoperative apnea-hypopnea index (AHI) less than 20 and a decrease of greater than 50%. Median AHI decreased from 52.0 to 18.3 with a median change of -26.1 (interquartile range, -41.6 and -17.1). Of significance on subset analysis, patients with a preoperative AHI <60 had a 68.8% success rate (P = .02), and patients with Friedman tongue position III had a 75.9% success rate (P = .0009). The findings of this case series would suggest that multilevel sleep apnea surgery, incorporating midline glossectomy with lingual tonsillectomy, is a valid alternative for managing moderate to severe OSAS in patients who do not respond or are resistant to continuous positive airway pressure therapy. In patients with a preoperative AHI <60 or Friedman tongue position III, surgical success rate is significantly improved.

Drug‐Induced Sleep Endoscopy vs Awake Müller’s Maneuver in the Diagnosis of Severe Upper Airway Obstruction

To compare fiber-optic nasal endoscopy with Müller's maneuver (FNMM) against drug-induced sleep endoscopy (DISE) in diagnosing the presence of severe level-specific upper airway collapse in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). Case series with chart review. Tertiary care academic center. Medical records of all adult patients undergoing diagnostic DISE as part of their surgical evaluation were reviewed. Patients were included if they had undergone FNMM and had documented Friedman tongue position and tonsillar grade prior to DISE. Airway obstruction on both endoscopic procedures was described according to airway level and severity. Severe airway obstruction was defined as >75% collapse on endoscopy. Fifty-three patients were included in this study. Fiber-optic nasal endoscopy with Müller's maneuver and DISE did not differ significantly regarding the presence of severe retropalatal airway collapse. There was a statistically significant difference in the incidence of severe retrolingual collapse identified via DISE (84.9% [45/53]) compared with FNMM (35.8% [19/53]; P < .0001). This discrepancy between FNMM and DISE findings was statistically significant in individuals with Friedman I and II tongue positions (FNMM = 16.7%, DISE = 88.9%, P < .0001) and individuals with Friedman III tongue position (FNMM = 31.8%, DISE = 81.8%, P = .002). Patients with Friedman IV showed no significant difference (P = .65) between FNMM (69.2%) and DISE (84.6%). This study shows a significant difference between FNMM and DISE in the identification of severe retrolingual collapse. Since the effectiveness of surgical interventions depends largely on the accurate preoperative identification of the site of obstruction, further scrutiny of each diagnostic endoscopic technique is warranted.

Friedman and Mallampati Tongue Positions and Obstructive Sleep Apnea Severity

Objective: 1) To assess the association between tongue position, classified by both Mallampati (MP) and Friedman Tongue Position (FTP) scales, and severity of sleep apnea (OSA) as determined by the apnea-hypopnea index (AHI). 2) To determine which of these assessment methods is most closely correlated with OSA severity. Method: PubMed, MEDLINE, and Cochrane Trial Registry through December 2011 were searched, combined with review of relevant article bibliographies. All studies were assessed by 3 reviewers. Systematic review and random-effects meta-analysis of studies assessing the association of tongue position and OSA severity were performed. Outcomes are reported as correlations. Results: Ten studies met inclusion criteria and had data suitable for pooling (2515 patients). Overall, increasing tongue position (categorical variable) was significantly associated with increasing OSA severity (continuous variable of AHI) with a correlation of .351 (95% CI .094, .564; P = .008). Sensitivity analysis revealed correlations of .184 (95%CI .052, .310; P = .006) and .388 (95% CI .049, .646; P = .026) for MP and FTP, respectively. Analysis of publication bias revealed a nonsignificant Egger’s regression intercept; however, 4 imputed values to the right of the mean were found using Duval and Tweedie’s trim and fill method. Adding these values yielded an overall correlation of .498 (95% CI .474, .521). Conclusion: Both the MP and FTP assessment techniques are significantly correlated with OSA severity. Publication bias does not affect or skew our results. The strength of the correlation between AHI and tongue position is greater for FTP than for MP, though the 95% confidence intervals for their respective correlation coefficients overlap.

Diagnosing Obstructive Sleep Apnea: Predictive Value of Friedman Tongue Position

Objective: 1) Assess the association between tongue position and risk of obstructive sleep apnea (OSA) as measured by both Mallampati (MP -including classic 3-level and modified 4-level scoring with tongue protrusion) and Friedman Tongue Position (FTP-no tongue protrusion). 2) Determine which of these assessment scales best predicts OSA risk. Method: PubMed, MEDLINE, Cochrane Trial Registry (through 12/2011), and relevant article bibliographies were searched. All studies were assessed by 3 reviewers. Systematic review and random-effects meta-analysis of studies assessing the association of tongue position and risk of OSA were performed. Outcomes are reported as odds ratios (OR). Results: Combined data from 5 studies (46,264 patients) revealed an overall OR of 2.436 (1.828, 3.248; P &lt; .001) for presence of OSA with MP/FTP 3 or 4 compared with MP/FTP 1 or 2. Sensitivity analysis revealed OR of 2.185 (1.643, 2.905; P &lt; .001) for MP 3/4 and 4.408 (2.651, 7.327; P &lt; .001) for FTP 3/4, respectively. Combined data from 2 studies (240 patients) revealed an OR for OSA per 1-point increase in MP/FTP of 2.351 (1.430, 3.865; P &lt; .001). Sensitivity analysis revealed OR of 2.5 (1.225, 5.103; P = .012) and 2.219 (1.109, 4.437; P = .024) per 1-point increase in MP and FTP, respectively. Conclusion: Tongue position 3 or 4, whether classified by MP or FTP, is significantly associated with increased OSA risk. In the clinical assessment of patients with suspected OSA, FTP 3/4 appears to have a higher predictive value for OSA than classic MP 3 or modified MP 3/4.

Relocation pharyngoplasty

Relocation pharyngoplasty

Oropharyngeal Examination to Predict Sleep Apnea Severity

To evaluate the usefulness of the examination of the upper airway, paying special attention to the Friedman tongue position (FTP), to confirm obstructive sleep apnea syndrome (OSAS) and its severity. Prospective, single-center, cross-sectional study. Sleep disorders unit of a community hospital. A total of 301 consecutive patients admitted to the sleep disorders unit due to suspicion of OSAS. Assessments included body mass index calculated as weight in kilograms divided by height in meters squared (BMI); neck perimeter measurement; oropharyngeal examination; fiberendoscopy; rhinomanometry; and a sleep study. Apnea-hypopnoea index (AHI), FTP, the uvula size, and certain complementary examinations (sex, age, BMI, cervical perimeter, nasal flow) whose importance has not been clearly established, and to explore their potential value as predictors of the AHI. Findings included the following: the mean (SD) age of the patients was 51 (12) years; 71.1% were male; the mean (SD) BMI was 29.8 (4.6); and the mean (SD) cervical perimeter, 40.5 (3.7) cm. In 94.0% of the patients the AHI value was at least 5.0/hour. Patients with FTP scores of 2 and 3 accounted for 74.1% of the whole cohort: 14.3% had an FTP score of 1, and only 11.6% had a score of 4. Of the 6.0% of cases with a normal AHI, 16 patients were classified as having FTP scores of 1, and 2 as having a score of 2. Tonsil size score (P = .005), uvula score (P = .003), BMI (P < .001), cervical perimeter (P < .001), nasal flow at 150 Pa (P = .02), and age (P = .007) were related to OSAS severity. Curiously, AHI in patients who had undergone tonsillectomy was higher than in the TS1 group (tonsils inside the tonsillar fossa) and quite similar to the TS 2 group (tonsils that extend beyond the tonsillar pillars). In the multiple regression model, only the FTP score showed a relevant relationship to OSAS severity. First, since the FTP score is almost the only parameter related to OSAS severity, a simple oropharyngeal examination can provide key information on this issue. Second, tonsillectomy does not seem to protect against development of OSAS.

Acoustic Features of Voice in Patients with Snoring

Objective: Determine whether the acoustic characteristics of snoring sounds differed between 30 simple male adult snorers (group A) and 30 healthy adult male subject (group B) by using a multidimensional voice program (MDVP), which is a commonly used computer program that analyzes various aspects of voice. Method: Group A patients presented a Friedman tongue position grade I, tonsil size 2 to 3, a body mass index of 15. Phonetically balanced sentences and sustained vowels a, e, and i were digitally recorded with the MDVP; evaluation of voice handicap index (VHI) was done too. Results: Compared with control group, in group A: the acoustic parameters presented a statistically significantly higher value ( P &lt; .05) of fundamental frequency (158.2 Hz vs 120.2 Hz), jitter (2.03 % vs 0.66 %), shimmer (6.54 % vs 3.77 %), NHR (0.24 vs 0.11), SPI (13.7 vs 8.71), DVB (2.23 % vs 0.12 %), DUV (9.31 % vs 0.54 %) and vAm (22.09 % vs 11.13 %), according to the degree of hearing loss; VHI had a mean value of 66 (vs 37 of group B). Conclusion: The study indicates that snoring affects voice production by changing its acoustic parameters. A voice analysis program MDVP can be used for snoring sound analysis as a noninvasive procedure for examination of sleep-related breathing disorders.

Does the length of uvula affect the palatal implant outcome in the management of habitual snoring?

To evaluate the impact of the uvular length on the efficacy of palatal implants in primary snoring. Prospective case series, tertiary hospital, snoring and respiratory sleep disorders center. Forty subjects with inserted palatal implants and diagnoses of primary snoring were included. All met the inclusion criteria of age >18 years, body mass index <30, apnea-hypopnea index <5, tonsil grade <3, soft-palate length >25 mm, and Friedman tongue position <3 following clinical, endoscopic, and polysomnographic evaluation. Epworth sleepiness scale (ESS) and the snoring-intensity visual analogue scale (VAS) were recorded before and 9 months after the implant. Four subjects with extruded implants were excluded; the remaining 36 subjects were divided into two groups, Group I and Group II, with uvular lengths of ≤15 mm and >15 mm, respectively. The study assessed and compared subjective outcome measures including the partner's satisfaction (PS), partner's reported improvement (PRI), 50% VAS and ESS reduction, and subjective success (SS) defined as 50% VAS reduction. The Student t test, χ(2) test, and logistic regression models were used for statistical evaluation. SS (50% VAS reduction), PS, PRI, and 50% ESS reduction were significantly higher in Group I (P < .001, P = .0257, P = .027, P < .001). The overall SS, PRI, PS, and 50% ESS reduction were 33%, 78%, 50%, and 50%, respectively. The uvular length was found to be the determinant factor of SS (P = .005; odds ratio = 0.75), PRI (P = .039; odds ratio = 0.83), and 50% ESS reduction (P = .038; odds ratio: 0.84) following implant insertion through stepwise logistic regression analysis. Excess uvular length (>15 mm) is an important anatomic feature decreasing the efficacy of palatal implants in snoring, and additional measures, such as uvulectomy, should be considered simultaneously for better outcomes (level 4).

Screening for obstructive sleep apnea/hypopnea syndrome: Subjective and objective factors

Objectives To determine the sensitivity and specificity of the Berlin Questionnaire and the Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) score for individually predicting a diagnosis of OSAHS, and to propose a method for OSAHS screening incorporating objective and subjective factors. Study Design Cross-sectional survey. Setting Tertiary care center. Methods Charts were reviewed from 223 consecutive patients for whom complete data regarding the Berlin questionnaire, OSAHS score (Friedman tongue position + tonsil size + body mass index grade), Epworth Sleepiness Scale, and visual analog scale for snoring were obtained prior to polysomnography (PSG). Sensitivity and specificity were determined for the Berlin questionnaire and OSAHS score for predicting an apnea hypopnea index (AHI) ≥ 5. Patient data were subjected to multivariate stepwise discriminant analysis and used to construct a screening system based on the Fisher's linear classification equation. Results were cross-validated by PSG findings. Results In predicting an AHI ≥ 5, the sensitivity and specificity, respectively, were 0.615 and 0.226 for the Berlin questionnaire, 0.863 and 0.468 for OSAHS score, and 0.82 and 0.834 for our predictive equation. When applied case-wise to the study population, this equation correctly predicted 82.5 percent of diagnoses. Accuracy was highest for severe OSAHS (87.4%) and lowest for mild disease (77.0%). Sensitivity was lowest for mild OSAHS (0.50). Conclusions Neither the Berlin questionnaire nor the OSAHS score alone was both highly sensitive and specific for diagnosing OSAHS. By incorporating subjective and objective metrics into a single predictive equation, sensitivity and specificity were maximized, and 82.5 percent of diagnoses were accurately predicted.

Effectiveness of Pillar palatal implants for snoring management

Determine patient factors associated with the success and complications of using the Pillar palatal implants for snoring management. Retrospective series of 79 consecutive adult patients receiving Pillar implants for snoring management between January 2005 and December 2007. Multiple regression analysis was used to determine factors associated with initial and final bed partner satisfaction with the snoring result, and factors associated with Pillar-related complications. A total of 64 of 79 (81%) bed partners reported snoring improvement in patients after initial Pillar implantation; however, only 31 (39%) were satisfied with the level of reduction. Following secondary procedures, the number of satisfied bed partners improved to 52 (66%). Factors associated with final bed partner satisfaction included lower initial apnea-hypopnea index (AHI) (P = 0.029), Friedman tongue position I or II (P = 0.008), and shorter follow-up time (P = 0.001). Sixteen patients (20%) experienced procedure-related complications. Factors associated with Pillar complications included female gender (P = 0.001) and placement under general anesthesia (P = 0.009). Initial AHI values and tongue position scores are important determinants of final snoring success. Pillar implants placed in women and under general anesthesia may have a higher risk of poor placement and extrusion.

Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome

To report the findings of five years' experience using standardized coblation intracapsular tonsillectomy with adenoidectomy for treatment of pediatric sleep apnea. Case series. A five-year retrospective analysis of coblation tonsillectomy performed by a single department for sleep apnea was completed. A total of 159 tonsillectomy and adenoidectomy (T&A) cases performed with coblation technique were reviewed. The mean preoperative apnea-hypopnea index (AHI) was 17.8 and mean postoperative AHI was 3.3. Polysomnogram (PSG) normalization (AHI < 1), was achieved in 54.7% patients. Normalization of PSG data was achieved in only 42.2% of overweight patients (body mass index [BMI] >or= 85th percentile). Based on regression analysis, Friedman tongue position (III and IV) and elevated AHI were determined to be independent predictors of poor response to T&A. Contrary to popular belief, a review of 159 cases demonstrates that T&A does not always result in normalization of polysomnographic data. Although complete resolution is not achieved in most cases, T&A offers significant improvements in AHI. Predictive variables such as BMI, FTP, and AHI should be taken into account when designing a treatment plan. It is important to recognize the need for close follow-up and early detection of residual disease in the pediatric population.

Obstructive site localization using multisensor manometry versus the Friedman staging system in obstructive sleep apnea

The aim of this study was to find the correlation between an anatomy-based staging system and pressure manometry performed during sleep. A retrospective study of 45 patients with obstructive sleep apnea (OSA) was carried out. All patients were evaluated by polysomnography, and obstruction sites were localized using a multisensor manometer during the full night. Obstruction sites were classified into retropalatal and retroglossal. The patients were also staged by anatomic findings of tonsil size and palate position. The % retroglossal obstruction was 29.4, 33.5 and 48.6% in stages I, II and III, respectively. There was no significant difference between stages. In contrast, when compared according to the Friedman tongue position (FTP), the mean % retroglossal obstruction of FTP grade 3 was significantly higher than that of FTP grade 1 (P = 0.009) although apnea hypopnea index, body mass index and lowest SpO2 were not different among FTP grades. It seems that FTP correlates with retroglossal obstruction and may be used to select patients in need of retroglossal modification of the airway.

Prediction of Uvulopalatopharyngoplasty Outcome: Anatomy-Based Staging System Versus Severity-Based Staging System

To evaluate and compare outcomes of uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea/hypopnea syndrome (OSAHS) using anatomy- and severity-based staging systems. Prospective design with a retrospective review. A tertiary-care, sleep disorder referral center. In total, 110 patients with OSAHS (105 men, 5 women; mean age, 43 years; apnea-hypopnea index, 44.4 +/- 28.8 events per hour; body mass index, 27.1 +/- 3.3 kg/m2). An anatomy-based staging system (stages I-IV) was used to classify patients with OSAHS by examining tongue-palate position, tonsil size, body mass index, and craniofacial deformities. Patients were also classified as having mild, moderate, moderate-severe, or severe OSAHS based on preoperative apnea-hypopnea index from polysomnography (a severity-based staging system). Surgical success was defined as a 50% or greater reduction in the apnea-hypopnea index and a postoperative apnea-hypopnea index of less than 20 events per hour. UPPP was performed in all patients. The overall success rate of UPPP was 78%. Success rates for mild (90%), moderate (73%), moderate-severe (81%), and severe (74%) diseases were similar (p = .10). Conversely, success rates for patients with anatomy-based stages I, II, III, and IV were 100%, 96%, 65%, and 20%, respectively; these rates were significantly different (p < .001). Changes in apnea-hypopnea index were significantly correlated with Friedman tongue position (FTP) (r = -0.33, p = .0004) and tonsil size (r = -0.37, p < .0001). The FTP (odds ratio = 0.43, SE = 0.13, p = .005, 95% confidence interval = 0.24-0.78) and tonsil size (odds ratio = 3.13, SE = 1.53, p = .02, 95% confidence interval = 1.20-8.17), but not the severity-based staging (odds ratio = 0.77, SE = 0.18, p = .283, 95% confidence interval = 0.49-1.23), were predictive of surgical success. The anatomy-based staging system predicted UPPP outcomes more effectively than did the severity-based staging. The anatomy-based staging system facilitates good case-selection information for counseling patients before UPPP surgery.

Severity of obstructive sleep apnea: Correlation with clinical examination and patient perception

To correlate clinical history, patient self-perception of obstructive sleep apnea, and physical examination with the severity of OSA. One hundred and two consecutive patients were prospectively enrolled over a 6-month period. All patients underwent a comprehensive history and clinical examination, nasopharyngoscopy, and an overnight-attended polysomnogram. There were 65 males and 37 females with a mean age of 50.2 +/- 11.3 years (range, 24 to 76 years). The mean apnea-hypopnea index (AHI) was 37.9 +/- 27.7 (range, 0.7 to 111.2). There was a strong correlation between patient self-perception of OSA severity and AHI (r = 0.499, P < 0.0001), and the correlation with AI was 0.577 (P < 0.0001). OSA severity strongly correlated with Friedman Tongue Position grade, (r = 0.389, P < 0.0001), Friedman clinical staging, (r = 0.331, P = 0.0007). Of significance, only 6.9% of patients with mild OSA had a >50% collapse of the base of tongue region, as compared to 65.9% of patients with severe OSA. There is good correlation between clinical examination parameters and the severity of OSA. An algorithm for surgical treatment of OSA should acknowledge both the site of obstruction and the severity of disease.

Patient Selection and Efficacy of Pillar Implant Technique for Treatment of Snoring and Obstructive Sleep Apnea/Hypopnea Syndrome

Pillar implant (PIT) is a simple, office-based procedure with minimal morbidity that was introduced in 2003 to treat snoring and mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). We studied the: (1) success rate using subjective symptoms and objective polysomnographic improvement; (2) success rate based on BMI, OSAHS severity and Friedman tongue position (FTP); and (3) its value as an adjunctive or revision procedure. Retrospective review of 125 patients who underwent the PIT for snoring and OSAHS. Patients were grouped: Group I had PIT only (n = 29); Group II received adjunctive nasal procedures (n = 37), Group III received adjunctive oropharyngeal procedures (n = 55); and Group IV had failed previous UPPP (n = 4). Overall subjective and objective "cure" rates were 88.0% and 34.4%, respectively. Group IIb had the best objective cure rate of 46.7%. Neither AHI nor BMI correlated with outcome measures, whereas FTP did correlate. (FTP I and II had improved success vs FTP III and IV). Ten patients had partial extrusion of the PIT. These were removed and new PIT were carried out at a later date. Based on a short-term study, the Pillar implant is an effective treatment for snoring and OSAHS in selected patients and can be combined with adjunctive procedures to treat OSAHS.

Z-palatoplasty (ZPP): A technique for patients without tonsils

Objective Patients without tonsils and with Friedman tongue position (FTP) III and IV are poor candidates for uvulopalatopharyngoplasty (UP3). Even when combined with adjunctive hyopharyngeal techniques, results are poor. We assessed a modified uvulopalatoplasty based on a bilateral Z-plasty in treating patients without tonsils who have obstructive sleep apnea/hypopnea syndrome (OSAHS). Methods 25 patients treated with a modified technique were matched with 25 patients previously treated with classic UP3. All patients in both groups also had radiofrequency tongue base reduction. Preoperative vs. postoperative measures of objective treatment success and subjective symptoms were compared for the 2 groups. Morbidity, including pain levels, narcotic use, and return to solid diet and normal activity, as well as complications were studied. Results Subjective improvement was good for both groups, but objective clinical improvement was significantly better for the experimental group. Morbidity and complications for the experimental group were comparable to the control group and to other published series on UP3. Conclusions A modified technique for patients without tonsils who have OSAHS is presented. The new technique is more successful with acceptable morbidity for patients with OSAHS than classical techniques.