Hypopharyngeal Level Research Articles

The role of video-fluoroscopy in the assessment of obstructive sleep apnea patients: comparative study

BackgroundPre-operative imaging tools play a crucial role in the anatomic assessment of the upper airway and adjacent structures in obstructive sleep apnea patients. The current study was aimed at comparing and correlating the results of videofluoroscopy in evaluating upper airway obstruction in surgically fit obstructive sleep apnea “OSA” patients with fiberoptic nasoendoscopic examination during the awake “Muller’s maneuver” and during sleep induced with propofol for better selection of the suitable surgical maneuver. The present study was an observational cross-sectional study of 69 surgically fit OSA patients (36 males and 33 females); their ages ranged between 29 and 65 years with mean age of 45.87 ± 9.68 years. The patients were selected from otorhinolaryngology, phoniatric, and pulmonology outpatient clinics during the period from February 2019 to January 2020.ResultsThe present study demonstrated that no statistically significant difference was found between the three techniques (video-fluoroscopy, awake fiber-optic nasoendoscopy, and drug-induced sleep nasoendoscopy “DISE”) as regards the shape of upper airway collapse at retropalatal, retroglossal, and hypopharyngeal levels in OSA patient (P: 0.621, 0.669, and 1.0 respectively). Statistically, a significant difference was observed between video-fluoroscopy, awake fiber-optic nasoendoscopy on one hand, and DISE on the other one regarding the grade of upper airway collapse at all levels (P: 0.006, 0.037, and 0.003). It was a mild significant difference in favor of DISE.ConclusionVideo-fluoroscopy is a good, reliable complementary preoperative assessment tool to identify obstruction patterns of the upper airway in OSA patients with quantitative measurements.

Retrospective study on the pharyngeal airspace in the lateral cephalogram - A mathematical model to predict changes due to bimaxillary orthognathic surgery

The aim of this study was the development of a statistical model for reliable prediction of Posterior Airway Space (PAS) changes in lateral cephalograms (LCR) of patients after bimaxillary orthognathic surgery. The LCRs of patients who underwent bimaxillary orthognathic surgery were retrospectively analyzed. The anteroposterior dimension of the PAS was measured at three levels in the pre-operative and postoperative LCR: On the nasopharyngeal (SPAS), oropharyngeal (MAS), and hypopharyngeal level (IAS). The data of 139 patients were collected. The following changes of the PAS were measured: in class II patients SPAS: 0.291 mm (SD = 2.570 mm); MAS: 2.444 mm (SD = 2.986 mm); IAS: 0.750 mm (SD = 3.017 mm); in class III patients SPAS: 1.377 mm (SD 3.212 mm); MAS: 0.962 (SD: = 3.135 mm); IAS: 0.370 mm (SD = 3.468 mm). Linear regression analysis showed for class II patients, a significant influence of mandibular movement on MAS (p = 0.049) and a significant effect of maxillary and mandibular movements on SPAS (p = 0.001) and MAS (p = 0.022) in class III patients. The other jaw displacements had no significant impact on the investigated PAS levels. While the presented method does not permit exact prediction of the dimension of the PAS, it is still an easily accessible method of orientation for the surgeon. The surgeon can initiate three-dimensional examinations to provide exact three-dimensional prediction based on this calculation.

Image Quality of High-Resolution 3-Dimensional Neck MRI Using CAIPIRINHA-VIBE and GRASP-VIBE: An Intraindividual Comparative Study.

Acquiring high-quality magnetic resonance imaging (MRI) of the head and neck region is often challenging due to motion and susceptibility artifacts. This study aimed to compare image quality of 2 high-resolution three-dimensional (3D) MRI sequences of the neck, controlled aliasing in parallel imaging results in higher acceleration (CAIPIRINHA)-volumetric interpolated breath-hold examination (VIBE), and golden-angle radial sparse parallel imaging (GRASP)-VIBE. One hundred seventy-three patients indicated for contrast-enhanced neck MRI examination were scanned using 3 T scanners and both CAIPIRINHA-VIBE and GRASP-VIBE with nearly isotropic 3D acquisitions (<1 mm in-plane resolution with analogous acquisition times). Patients' MRI scans were independently rated by 2 radiologists using a 5-grade Likert scale for overall image quality, artifact level, mucosal and lesion conspicuity, and fat suppression degree at separate anatomical regions. Interobserver agreement was calculated using the Cohen κ coefficient. The quality ratings of both sequences were compared using the Mann-Whitney U test. Nonuniformity and contrast-to-noise ratio values were measured in all subjects. Separate MRI scans were performed twice for each sequence in a phantom and healthy volunteer without contrast injection to calculate the signal-to-noise ratio (SNR). The scores of overall image quality, overall artifact level, motion artifact level, and conspicuity of the nasopharynx, oropharynx, oral cavity, hypopharynx, and larynx were all significantly higher in GRASP-VIBE than in CAIPIRINHA-VIBE (all P 's < 0.001). Moderate to substantial interobserver agreement was observed in overall image quality (GRASP-VIBE κ = 0.43; CAIPIRINHA-VIBE κ = 0.59) and motion artifact level (GRASP-VIBE κ = 0.51; CAIPIRINHA-VIBE κ = 0.65). Lesion conspicuity was significantly higher in GRASP-VIBE than in CAIPIRINHA-VIBE ( P = 0.005). The degree of fat suppression was weaker in the lower neck regions in GRASP-VIBE (3.90 ± 0.72) than in CAIPIRINHA-VIBE (4.97 ± 0.21) ( P < 0.001). The contrast-to-noise ratio at hypopharyngeal level was significantly higher in GRASP-VIBE (6.28 ± 4.77) than in CAIPIRINHA-VIBE (3.14 ± 9.95) ( P < 0.001). In the phantom study, the SNR of GRASP-VIBE was 12 times greater than that of CAIPIRINHA-VIBE. The in vivo SNR of the volunteer MRI scan was 13.6 in CAIPIRINHA-VIBE and 20.7 in GRASP-VIBE. Both sequences rendered excellent images for head and neck MRI scans. GRASP-VIBE provided better image quality, as well as mucosal and lesion conspicuities, with less motion artifacts, whereas CAIPIRINHA-VIBE provided better fat suppression in the lower neck regions.

Comparative evaluation of the effects of bimaxillary and mandibular setback surgery on pharyngeal airway space and hyoid bone position in skeletal class III patients.

Background To compare the effects of bimaxillary surgery ( Maxillary advancement and mandibular setback) and mandibular setback surgery (Bilateral Sagittal Split Osteotomy) on the pharyngeal airway space (PAS) and the hyoid bone position in a skeletal class III patients. Material and MethodsThirty four subjects (21 males, 13 females, mean age 26.5 ± 8 years) with skeletal class III pattern (ANB angle of -2° to -6°) were divided into two groups of equal sizes. Group A consisted of 17 individuals who underwent Bilateral Sagittal Split Osteotomy (BSSO)and Group B consisted of 17 individuals who underwent bimaxillary surgery. In both the group, lateral cephalograms were taken, traced and analyzed for the specified parameters at 3 intervals, pre treatment (C1), post surgical (C2), and post orthodontic treatment (C3). Changes in PAS was evaluated at 3 levels i.e, nasopharynx (Upper PAS), oropharynx (Middle PAS) and hypopharynx (Lower PAS). Changes in hyoid bone position were evaluated in anteroposterior and vertical direction at all the 3 intervals. ResultsThere was a significant constriction of airway at oropharyngeal and hypo-pharyngeal level at C2 and C3 in both the groups. However, the reduction at the oropharyngeal airway was greater in group A. In group B, there was significant increase in the airway at the level of nasopharynx, Hyoid bone was positioned more posteriorly post-surgery in group A which did not return to its original position post treatment. In group B hyoid bone was positioned postero-inferiorly post surgically which came back to its original position by the end of orthodontic treatment. ConclusionsPatients undergoing bimaxillary surgery showed a significant increase in the airway at the level of nasopharynx. Hyoid bone returned to its original position by the end of orthodontic treatment in the bimaxillary surgery group. This study suggested that while treating a skeletal class III malocclusion it is advised to perform maxillary advancements along with mandibular setback surgery. Key words:Bimaxillary surgery, Hyoid bone, Bilateral Sagittal Split Osteotomy, Pharyngeal airway space.

Upper airway collapse characteristics in adult patients with OSA and previous tonsillectomy.

To analyze upper airway (UA) collapse patterns through drug-induced sleep endoscopy (DISE) in adult patients withobstructive sleep apnea (OSA) who previously underwent tonsillectomy. This was a retrospective study on patients withOSA who underwent DISE between June 1, 2013 and July 30, 2017 at Stanford Hospital. Subjects who had prior tonsillectomy history were classified into the tonsil0 group, whereas others were classified into the tonsil1 and tonsil2/3/4 group based on tonsil grade. UA collapse characteristics were recorded and analyzed among groups according to Velum, Oropharynx, Tongue base and Epiglottis (VOTE) classification. A total of 205 individuals were included, 38 in tonsil0 group, 104 in tonsil1 and 63 in tonsil2/3/4. The tonsil0 group had a higher percentage of anterior-posterior (AP) velum (58%) and tongue base (45%) collapse compared with the tonsil2/3/4 group (22%, P = 0.0003 and 22%, P = 0.02, respectively) but less oropharyngeal lateral wall collapses (29% vs 53%, P = 0.02). Most of the tonsil0 group (70%) showed multi-sites collapse pattern, the percentage of combined obstruction in both palatopharyngeal and hypopharyngeal region was higher (50% vs 29%, P = 0.03). The difference of velum complete AP collapse remained significant after adjusting for age and BMI (Odds Ratio = 0.33, 95% CI 0.12-0.86, P = 0.02). No significant differences were found between the tonsil0 and tonsil1 groups. Compared with individuals with larger tonsils (grade 2 to 4), those with previous tonsillectomy and OSA were susceptible to the velum AP configuration collapse. Diversity of multi-sites obstruction and combined collapse in both palatopharyngeal and hypopharyngeal level was the main characteristic.

Optimization of Simultaneous Multislice, Readout-Segmented Echo Planar Imaging for Accelerated Diffusion-Weighted Imaging of the Head and Neck: A Preliminary Study

To evaluate the feasibility of simultaneous multislice (SMS)-accelerated, readout-segmented echo-planar imaging (rs-EPI, RESOLVE) with the use of special-purpose coils for head and neck assessment, particularly in patients diagnosed with head and neck malignant tumors, through comparison with the conventional RESOLVE and RESOLVE with readout partial-Fourier technique (RESOLVE-RPF). Twenty-five healthy volunteers and 24 patients with histologically proven malignant head and neck tumors were included in this prospective study. The MR exam included conventional RESOLVE, RESOLVE-RPF, prototypic SMS-RESOLVE, and prototypic SMS-RESOLVE with special-purpose coils (SMS-RESOLVE + Coils), acquired at b-values of both 0 and 800 s/mm2. Image quality was evaluated qualitatively (reader score) and quantitatively (tumor distortion, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), SNR efficiency) and compared. For volunteer imaging, the image quality of target tissues at three different typical levels (oropharyngeal, hypopharyngeal, and thyroid level) were evaluated. For patient imaging, the image quality of primary tumors and metastatic lymph nodes was evaluated. The acquisition time was 3:37 minutes for RESOLVE, 2:58 minutes for RESOLVE-RFP, 2:01 minutes for SMS-RESOLVE and 2:01 minutes for SMS-RESOLVE + Coils, with a 44% reduction compared to the conventional RESOLVE. No significant differences in the reader scores, tumor distortion, or ADC values of the lesions were found among the protocols. The SNR and CNR at the oropharyngeal and hypopharyngeal level of SMS-RESOLVE + Coils were markedly improved and significantly higher than those of RESOLVE, as well as the SNR, SNR efficiency of tumors and lymph nodes. No significant differences in quantitative measurements were found at the thyroid level. SMS-RESOLVE + Coils protocol is an effective and promising approach to optimally reducing the total acquisition time, and could be a good alternative with a superior SNR and SNR efficiency in comparison with conventional RESOLVE. However, the limited application in the lower neck region needs further investigation.

Models of anatomically based oropharyngeal rehabilitation with a multilevel approach for patients with obstructive sleep apnea: a meta-synthesis and meta-analysis.

Obstructive sleep apnea (OSA) is a sleep-related breathing disorder associated with dysfunction of oropharyngeal muscles to maintain upper airway patency during sleep. Oropharyngeal rehabilitation (OPR) was developed to restore, reconstruct, and reeducate oropharyngeal muscle function, but current protocols and effectiveness of OPR have been inconsistent. The purpose of this study was to review (1) indications of OPR, (2) protocols of OPR, and (3) effectiveness of OPR. We searched MEDLINE, EMBASE, and the Cochrane Library and then conducted both meta-synthesis and meta-analysis according to the statement of Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). A total of eight studies with 203 patients were included. By means of meta-synthesis, the patients with middle age, BMI < 40kg/m2, mild-to-moderate OSA, and non-severe upper airway anatomical abnormality were found to benefit from OPR. The protocol of OPR was summarized to be an anatomically based, multilevel approach, including the retropalatal, retroglossal, hypopharyngeal, TMJ, and facial levels. By using meta-analysis, overall outcomes were presented as apnea hypopnea index (AHI) with significant improvement from 25.2 ± 7.8/h to 16.1 ± 6.6/h (mean difference [MD] -9.8 [95% CI - 11.0 to - 8.6], p < 0.0001); the lowest oxygen saturation (LSAT) improved from 80.2 ± 4.7 to 83.8 ± 2.9% (MD 3.0% [95% CI 2.0 to 4.0], p < 0.0001); Epworth sleepiness scale (ESS) improved from 11.8 ± 1.9 to 6.3 ± 1.6 (MD - 5.9 [95% CI - 7.5 to - 4.2], p < 0.001), neck circumference (NC) from 35.2 ± 1.1 to 34.7 ± 0.9cm (MD - 0.6 [95% CI - 0.9 to - 0.2], p = 0.002), BMI from 24.8 ± 3.7 to 24.8 ± 4.1kg/m2 (MD - 0.0; 95% CI - 0.5 to 0.5, p = 0.95). All outcomes except BMI demonstrated significant improvement from OPR. Meta-analysis of previous OPR reports shows an improvement in AHI of 39%, compared with the usual surgical definition of success at 50%. Only mild and moderate cases of OSA were referred for OPR in the prior studies. In order to improve outcomes with OPR, a comprehensive approach to rehabilitation should be emphasized.

Genioglossus Advancement and Hyoid Surgery.

The structure and dimensions of the mandible, tongue, and hyoid complex are important variables in the pathophysiology of obstructive sleep apnea at the hypopharyngeal level. Genioglossus advancement is based on mandibular osteotomy, which brings the genioglossus muscle (GGM) forward and prevents posterior collapse during sleep. The genioglossus advancement technique has recently undergone several modifications; each has attempted to minimize surgical morbidity while improving the incorporation and advancement of the GGM. The hyoid bone has been of interest in sleep apnea and apnea-related surgical procedures because of its integral relationship with the tongue base and hypopharynx. Hyothyroidopexy is illustrated.

Role of transpalatal advancement pharyngoplasty in management of lateral pharyngeal wall collapse at the hypopharyngeal level in OSA patients

Role of transpalatal advancement pharyngoplasty in management of lateral pharyngeal wall collapse at the hypopharyngeal level in OSA patients

Nasal and oral snoring endoscopy: novel and promising diagnostic tools in OSAS patients.

The aim of the present study was to investigate if any of the three awake procedures [fiberoptic nasopharyngoscopy with modified Müller Maneuver (FNMM), nasal snoring endoscopy (NSE), or oral snoring endoscopy (OSE)] could efficiently predict the grade or pattern of upper airway (UA) collapse found with drug-induced sleep endoscopy (DISE), which is considered by many authors as the current gold standard in optimizing obstructive sleep apnea syndrome (OSAS) patient selection for UA surgery. Twenty consecutive patients (simple snorers and OSAS patients) were studied with FNMM, NSE, OSE, and DISE. The inter-test agreement was evaluated with Cohen's kappa coefficient (κ). In the current series, we found that NSE and OSE were better than FNMM in predicting the pattern of collapse found with DISE. A significant pattern agreement between NSE and DISE was present in all sub-sites, and the agreement was measured with a scale proposed by Landis and Koch as: moderate in velo- and oropharynx (κ = 0.52, p = 0.001, and κ = 0.47, p = 0.003, respectively), and substantial in hypopharynx (κ = 0.63, p < 0.00001). Comparing OSE with DISE, the pattern agreement was almost perfect at oropharyngeal level (κ = 0.82, p < 0.00001), and moderate at hypopharyngeal level (κ = 0.55, p = 0.0002); while a trend towards significance was found at velopharyngeal level (κ = 0.20, p = 0.07). FNMM showed a fair pattern agreement with DISE only at oropharyngeal level (κ = 0.31, p = 0.009); while in the other sub-sites, no significant agreement was found. NSE and OSE are new promising diagnostic tools in OSAS patients. Further investigations are needed to see if they could predict the effectiveness of UA surgery.

Evaluation of pharyngeal airway space changes after bimaxillary orthognathic surgery with a 3-dimensional simulation and modeling program

The aims of this study were to use 3-dimensional simulation and modeling programs to evaluate the effects of bimaxillary orthognathic surgical correction of Class III malocclusions on pharyngeal airway space volume, and to compare them with the changes in obstructive sleep apnea measurements from polysomnography. Twenty-five male patients (mean age, 21.6years) with mandibular prognathism were treated with bilateral sagittal split osteotomy and LeFort I advancement. Polysomnography and computed tomography were performed before surgery and 1.4±0.2years after surgery. All computed tomography data were transferred to a computer, and the pharyngeal airway space was segmented using SimPlant OMS (Materialise Medical, Leuven, Belgium) programs. The pretreatment and posttreatment pharyngeal airway space determinants in volumetric, linear distance, and cross-sectional measurements, and polysomnography changes were compared with the paired samples t test. Pearson correlation was used to analyze the association between the computed tomography and polysomnography measurements. The results indicated that setback procedures produce anteroposterior narrowing of the pharyngeal airway space at the oropharyngeal and hypopharyngeal levels and the middle and inferior pharyngeal volumes (P<0.05). In contrast, advancement of the maxilla causes widening of the airway in the nasopharyngeal and retropalatal dimensions and increases the superior pharyngeal volume (P<0.05). Distinctively, bimaxillary orthognathic surgery induces significant increases in the total airway volume and the transverse dimensions of all airway areas (P<0.05). Significant correlations were found between the measurements on the computed tomography scans and crucial polysomnography parameters. Bimaxillary orthognathic surgery for correction of Class III malocclusion caused an increase of the total airway volume and improvement of polysomnography parameters. A proposed treatment plan can be modified according to the risk of potential airway compromise or even to improve it with 3-dimensional imaging techniques and polysomnography.

Comparison of findings of awake and induced sleep fiberoptic nasoendoscopy in cases of snoring and obstructive sleep apnea

BackgroundIdentifying the site of obstruction and the pattern of airway change during sleep are the key points essential to guide surgical treatment decision making for snoring and obstructive sleep apnoea–hypopnoea syndrome (OSAHS) in adults. The use of nasopharyngoscopy during the application of the Müller maneuver is frequently employed to establish the site of upper airway obstruction. The Müller maneuver, however, is used when the patient is awake and therefore may not correlate with obstruction occurring during sleep. Drug-induced sleep endoscopy (DISE) avoids these drawbacks and may provide a more accurate evaluation of the upper airway. ObjectiveThe goal of this study is to compare videoendoscopic findings under induced sleep and those during the awake Müller’s maneuver in order to provide an ideal and objective method for accurate assessment of upper airway in cases of snoring and obstructive sleep apnea. This will facilitate choosing the proper line of treatment and monitoring the effect of management. Design50 adult subjects (42 males and 8 females) with an age range from 21 to 66years complaining of snoring and obstructive sleep apnea underwent nasopharyngoscopy to assess airway during the Müller maneuver while awake and during sleep induced by i.v. propofol infusion 100–150μg/kg/min. comparison between the awake and induced sleep fiberoptic nasoendoscopy findings regarding the degree and shape of airway obstruction at the retropalatal, oropharyngeal and hypopharyngeal levels was done. ResultsThere was statistically significant difference between the two groups regarding the shape of obstruction at the retropalatal and oropharyngeal levels; while there was no statistically significant difference between the two groups regarding the degree of obstruction at the three levels. ConclusionThe drug induced sleep endoscopy was more accurate than the Müller maneuver in assessing the shape of obstruction at the retropalatal and the oropharyngeal level, while it was the same as the Müller maneuver in assessing the degree of obstruction at retropalatal, oropharyngeal and hypopharyngeal levels.

Rare Tumours and Tumour-like Lesions of Pharynx That Cause Dysphagia

Methods: Twenty-one cases with masses causing dysphagia at the oropharyngeal, hypo-pharyngeal and laryngeal levels were identified among patients admitted to our hospital with the complaint of difficulty with swallowing between the years 2009 and 2011. Detailed anamneses and physical examinations were performed. In addition, for the purpose of diagnosis, the following were applied: Magnetic Resonance Imaging with and without contrast, Computerized Tomography, Three-Dimensional Computerized Tomography, Multiple row-Detector Computerized Tomography, MR Angiography and 99m Tc Scintigraphy.

Hyoid Expansion With Titanium Plate and Screw

Hyoid expansion with suspension can potentially increase the upper airway at the hypopharyngeal level, benefitting patients with sleep-related breathing disorder. To document the effect of hyoid expansion using titanium plate and screw on retrolingual hypopharyngeal airway dimension and to compare the airway dimension after isolated hyoid expansion with hyoid expansion + hyomandibular suspension. Anatomical cadaveric dissection study. This study was performed in a laboratory setting using human cadavers. This is an anatomical feasibility study of hyoid expansion using titanium plate and screw on 10 cadaveric human heads and necks. The hyoid bone is trifractured with bony cuts made just medial to the lesser cornu. The freed hyoid body and lateral segments are expanded and stabilized to a titanium adaptation plate. Computer-assisted airway measurement (CAM) was used to measure the airway dimension at the hypopharynx at the level of the tongue base before and after the hyoid expansion. The expanded hyoid bone was then suspended to the mandible, and the airway dimension was measured again with CAM. Airway dimension after isolated hyoid expansion with hyoid expansion with hyomandibular suspension. RESULTS Hyoid expansion with titanium plate and screw resulted in statistical significant increase in the retrolingual hypopharyngeal airway space in all of the 10 human cadavers. The mean (SD) increase in retroglossal area was 33.4 (13.2) mm² (P < .005) (range, 6.0-58.7 mm²). Hyoid expansion with hyomandibular suspension resulted in a greater degree of airway enlargement. The mean (SD) increase in retroglossal area was 99.4 (15.0) mm² (P < .005) (range, 81.9-127.5 mm²). The retrolingual hypopharyngeal airway space increased with hyoid expansion using titanium plate and screw in our human cadaveric study, measured using CAM. The degree of increase is further augmented with hyomandibular suspension.

Role of sleep endoscopy in obstructive sleep apnea syndrome

AimThere are limited data about the role of sleep endoscopy in obstructive sleep apnea syndrome (OSAS). The aim of this study was to evaluate the level, degree and shape of obstruction of the upper airway in patients with OSAS by sleep endoscopy and their relation to OSAS severity. Patients and methodsFifty consecutive patients with OSAS were prospectively enrolled in this cross sectional analytic study. All patients underwent history, a full night-attended polysomnography and sleep endoscopy. The degree of pharyngeal narrowing (grades I–IV) was evaluated at retropalatal, retroglossal and hypopharyngeal levels. Shape of pharyngeal collapse was classified into circular, lateral or antero-posterior at retropalatal and retroglossal levels. Shape of the epiglottis was also observed. ResultsAll patients showed multisegmental levels of obstruction. Moderate OSAS had a higher percentage of grade II obstruction but a lower percentage of grade I at hypopharyngeal level compared to mild OSAS (P<0.05). Also, in moderate OSAS, tongue base obstruction was 47.4% which was significantly higher comparing to mild OSAS (16.7%) (P<0.05). There was no significant difference between different grades of obstruction at all anatomical levels in polysomnographic parameters. Omega shaped epiglottis was associated with the highest apnea hypopnea index, desaturation index, lowest average and minimum O2 level. ConclusionSleep endoscopy is a useful tool for the assessment of level, degree and shape of the upper airway obstruction during sleep in OSAS and this could be helpful in preoperative evaluation. Presence of obstruction at hypopharyngeal level or tongue base obstruction is an indicator of OSAS severity.

Die Nicht-CPAP-Therapie des obstruktiven Schlafapnoe-Syndroms: ein Überblick

Optimal treatment of the obstructive sleep apnoea syndrome (OSAS) requires an individually designed and interdisciplinary approach. Continuous positive airway pressure (CPAP) is accepted as the first line therapy for patients with OSAS. However, non-CPAP therapies may be indicated as supportive therapeutical approach in CPAP failure or as an alternative approach in CPAP intolerance. Overall, the level of evidence for the majority of non-CPAP therapies is low. Mandibular advancement devices as a medical non-CPAP treatment have proven to reduce respiratory disturbances to a level which may be sufficient in mild to moderate sleep apnoea. Apnoea triggered neurostimulation of upper airway muscles is an innovative approach that has shown promising results in preclinical studies. Surgical treatment has previously been performed as single level surgery of the nasal, the oropharyngeal or hypopharyngeal level. However, only tonsillectomy in the presence of tonsillar hypertrophy and maxillomandibular advancement are recommended in carefully selected cases. Due to low success rates for single level surgery, multilevel surgery has been proposed as the surgical approach for the future.

The Upper Airway Evaluation of Habitual Snorers and Obstructive Sleep Apnea Patients

Objective: To investigate the relationship between the Apnea Hypopnea Index (AHI) and upper airway examination findings of habitual snorers and obstructive sleep apnea (OSA) patients. Materials and Methods: This study included 264 patients whose tonsils were evaluated in 4 grades. The Mallampati classification was used to determine the relationship between tongue and palate. All patients performed the Müller maneuver in a sitting position. The Fujita classification was used to define the type of obstruction. All patients had polysomnography and were divided into 4 groups according to AHI. Statistical analysis was performed to evaluate the relationship between examination findings and AHI. Results: Of the patients, 133 (50.4%) were habitual snorers, 66 (25%) were mild OSA, 40 (15.2%) were moderate OSA and 25 (9.5%) were severe OSA patients. There was a positive correlation between neck circumference, BMI and AHI in males (p < 0.001). There was a significant difference between patient groups according to Mallampati classification, collapse at the velopharyngeal level and hypopharyngeal level and Fujita classification (all p < 0.001). There were significant relationships between tonsil size, Fujita classification, Mallampati classification, collapse ratios and AHI. Conclusion: We saw that hypopharyngeal area often contributes to obstruction and some examination methods correlate more with AHI. This can aid sleep physicians in the evaluation of OSA patients.

Differential diagnosis of obstructive sleep apnea for the management by skeletal surgery

Obstructive sleep apnea may pose serious health problems due to its adverse effects. Those risks related to obstructive sleep apnea that may be encountered have an impact on the quality of life including from day time sleeplessness to fatal consequences. Usually multiple sites are encountered in cases presenting with hypnoic or apneic episodes. Oropharyngeal and hypopharyngeal levels are the causative sites with higher incidences. This feature lends the problem to be diagnosed and treated properly where in severe and/or refractory cases maxillomandibular advancement might be carried out to improve posterior airway space.

The effect of maxillary advancement and impaction on the upper airway after bimaxillary surgery to correct Class III malocclusion

The aim of this study was to evaluate the upper airway changes after simultaneous maxillary advancement/impaction and mandibular setback in skeletal Class III malocclusion. The subjects included 76 patients whose treatment included 1-piece LeFort I and bilateral sagittal split osteotomies. Lateral cephalograms were taken before surgery and 2 months and 3 years postoperatively. In order to analyze the effect of maxillary repositioning, the material was divided into subgroups according to whether the maxillary impaction and advancement were clinically significant (≥2 mm) or not. Advancement of the maxilla with or without impaction resulted in a significant long-term increase (P<0.001) in airway dimension at the nasopharyngeal level (13%-21% increase). At the oropharyngeal and retrolingual levels, a decrease took place but was significant (P<0.05) only at the oropharyngeal level when the maxilla was not impacted. When the maxilla was not advanced, there was no significant change, except at the hypopharyngeal level (12% decrease) (P<0.01). Clinically significant advancement (≥2 mm) of the maxilla significantly increased the airway dimension at the nasopharyngeal level and to some extent compensated for the effect of mandibular setback at the hypopharyngeal level.

Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of Class III malocclusion

The aim the study was to evaluate area and volumetric changes in the upper airway after bimaxillary correction of Class III malocclusion by the means of computer tomography (CT), and to compare these to the changes in linear measurements from lateral cephalograms. This was a prospective clinical trial. Lateral cephalograms and CT scans of 10 Class III patients were evaluated 1 week before and 6 months after surgery. Wilcoxon matched pairs signed ranks test was used to determine the differences in measurements pre- and postoperatively. Spearman's rank correlation was used to test the association between the CT and cephalometric measurements. CT measurements: The oropharyngeal and hypopharyngeal volumes increased by 3.98 +/- 4.18 cm(3) (P = .015) and 2.51 +/- 1.92 cm(3) (P = .021), respectively. The total volume of the posterior airway space increased, but the increase was not statistically significant. After surgery no change in the cross-sectional area of the upper airway was recorded at the retropalatal, oropharyngeal, or hypopharyngeal levels. Cephalometric measurements: The nasopharyngeal space increased 4.08 +/- 5.07 mm (P = .039) and the tongue increased in length by 4.84 +/- 5.93 mm (P = .22). No correlation was found between the measurements on CT scans and corresponding measurements on the lateral cephalograms. Bimaxillary surgery for correction of Class III malocclusion did not cause decrease of the posterior airway space. Three-dimensional imaging techniques are preferable to 2-dimensional lateral cephalograms for evaluation of the upper airway after orthognathic procedures.