Retrolingual Region Research Articles

The role of ultrasound in the diagnosis of obstructive sleep apnea

Abstract OBJECTIVE. This study examines the association between the severity of obstructive sleep apnea and the pharyngeal parameters using the ultrasound of the submental region. MATERIAL AND METHODS. For this study, data obtained from 40 patients, who had undergone investigations in the Galenus Medical Centre in order to diagnose sleep apnea, was analyzed. The following parameters were compared: the transverse diameter of the retrolingual region, the transverse diameter of the retropalatal region and the tongue base thickness. These regions were measured at different moments of respiration such as: during forced expiration, during forced inspiration and while the patients performed Müller’s Manoeuvre. The neck circumference, the body mass index of patients and the severity of sleep apnea obtained from polysomnography were analyzed. RESULTS. The evaluation of the results revealed: severe obstructive sleep apnea in 16 patients, respectively moderate severity in 10 patients, mild apnea in 4 patients, and no obstructive sleep apnea in 10 patients. Statistically significant results (p<0.05) were found after comparing the parameters obtained in patients with severe apnea versus the parameters in patients without apnea, with mild or respectively moderate apnea. CONCLUSION. Based on the results obtained, we consider that cervical ultrasound is useful in the diagnosis of severe obstructive apnea, identifying the pathological changes of the anatomical structures that basically cause this category of disease. Due to the fact that in our country ultrasound is a relatively inexpensive method, being also a non-irradiating, repeatable and accessible method, it should be more widely applied also in the field of otorhinolaryngology in order to view structures accessible to this type of imaging.

Cephalometric analysis of modifications of the pharynx due to maxillo-mandibular advancement surgery in patients with obstructive sleep apnea

Cephalometry has been used to measure hard and soft facial tissues, as well as the pharyngeal air space for the diagnosis of obstructive sleep apnea (OSA). The changes occurring in the pharynx due to maxillo-mandibular advancement (MMA) have not been established or quantified. The objective of this study was to identify the anatomical changes of the pharynx and of hard tissues that occur in patients with OSA after MMA. 19 patients with a polysomnographic diagnosis of OSA were submitted to cephalometric analysis before and 6 months after surgery in order to evaluate the changes produced by MMA in the pharynx and soft tissues. Cephalometry was standardized in order to obtain descriptive measurements of the dimensions of the airways, the position of the hyoid bone, and maxilla-mandibular relations. The modifications of the pharynx due to MMA showed a significant relation obtained by cephalometry. For each millimeter of maxillary and mandibular bone advancement there was a 0.76mm increase in the retropalatal region and a 1.2mm increase in the pharynx in the retrolingual region. In addition, MMA promoted a significant repositioning of the hyoid bone in the cranial direction.

Volumetric analysis of the pharynx in patients with obstructive sleep apnea (OSA) treated with maxillomandibular advancement (MMA)

Maxillomandibular advancement (MMA) has been reported to be the most effective surgical treatment of obstructive sleep apnea (OSA). Most reports about MMA aim to confirm the efficiency of this treatment modality, but few describe the anatomical changes produced in the pharynx by the surgery. Thus, the objective of the present investigation was to quantify the anatomical changes of the pharynx that occur in patients with OSA after MMA surgery using magnetic resonance (MR). Twenty patients with a polysomnographic diagnosis of OSA participated in the study. All patients were submitted to image acquisition by MR performed during wakefulness. Polysomnography and MR were performed preoperatively and 6months after MMA. Volume analysis (in cubic millimeters) was performed as the sum of the areas multiplied by their thickness, with no intervals between sections. The pharyngeal air space of the region between the hard palate and the base of the epiglottis was divided into a retropalatal (RP) region and a retrolingual (RL) region. Postoperative MR showed a mean volumetric increase of 26.72% in the RP region and of 27.2% in the RL region. MMA increases the air space of the pharynx by expanding the facial skeletal structure to which the soft tissues of the pharynx and tongue are fixed, with a consequent reduction of collapsibility in the presence of negative pressure during inspiration. This reduced possibility of pharyngeal collapse may contribute to the reduction of obstructive events.

Morphometric endoscopic study of the pharynx in patients with sleep apnea

PurposeThe aims of the study were to measure endoscopically the retrolingual pharynx during wakefulness and sleep before and after maxillomandibular advancement surgery and to quantify the changes observed. Materials and MethodsEighteen patients with mild to severe grade obstructive sleep apnea hypopnea were evaluated during wakefulness while sitting and lying down and during induced sleep in dorsal decubitus while breathing naturally. Images of the retrolingual region of the pharynx were captured with a nasofibroscope and recorded on a DVD using the Sony Vegas 8.0 software (Sony Creative Software, Madison, WI). The images captured in greater and smaller aperture were measured with the Image J software (produced by Wayne Rasband, United States National Institutes of Health, Bethesda, MD) in linear anteroposterior and linear laterolateral areas. A correction factor was then applied to equalize the size of the images and thus compare them to one another. ResultsThe postoperative dimensions of the pharynx always increased significantly in all measurements compared with the preoperative ones. During induced sleep in dorsal decubitus, there was a greater gain in the area of smaller aperture (201.33%). ConclusionsThe proposed method showed that the dimensions of the pharynx always increased significantly after surgery for maxillomandibular advancement, although the gain was not homogeneous in all dimensions and also varied according to state of consciousness. The greatest gain was observed in the area of smaller aperture with the patient in induced sleep, thus reducing the collapse of the pharynx.

Pulling on Hyoid Reduces Airway Collapse in Human Cadavers

Objective: This study examined the changes in upper airway dimensions and collapsibility associated with force applied to the hyoid bone using a suture and a novel magnetic system (internal magnet secured to the hyoid and external magnet) in un-fixed human cadavers. Method: Eight cadavers were tested with traction on the hyoid using 1) suture around the hyoid to apply 0.5-5 Newtons of force and 2) a novel magnetic system. Changes in airway dimensions were measured with fluoroscopy and 3-dimensional computed tomography reconstructions. Airway collapsibility was measured using a previously-described flow-based model. Results: A 2N (0.5 lb) force applied to the hyoid bone increased airway dimensions, with greatest effect in the retrolingual region. The anterior direction of traction was more effective than inferior or superior. There was a linear association between the magnitude of force and critical airflow, at 1.5L/min/N (R2 = 0.75). All magnitudes of pull increased the critical airflow ( P < .001). At 2N, the hyoid was advanced 1cm, and the critical airflow was increased 3-fold (3.0 ± 1.71L/min). The magnet system showed similar airway effects to the direct 2N applied force. An increase in upper airway dimensions occurred with inter-magnet distances of 2cm. Conclusion: Forces applied to the hyoid improve upper airway dimensions and collapsibility in the human un-fixed cadaver model. A novel magnet system may represent a promising therapy for treatment of upper airway obstruction in disorders such as obstructive sleep apnea.

Surgical Treatment of the Sleep Apnea Syndrome in the Twenty-First Century

Sleep apnea syndrome is a disease of high prevalence and high morbidity, for which surgery used to be the only possible therapeutic approach. Uvulo-palatopharyngoplasty (UPPP) was the technique used until the nineteen eighties. However, surgery has largely been abandoned since the introduction of nasal continuous positive airway pressure (CPAP), which has become the main treatment option today. Surgery remains an alternative for patients who do not tolerate nasal CPAP. Since the range of surgical techniques available is wide, patients must be carefully evaluated with fiberoptic nasopharyngoscopy and lateral cephalometric radiograph to determine the level of the obstruction. In almost 98% of sleep apnea patients the soft tissue structures of the upper airway and the underlying maxillo-mandibular skeleton are disproportionate. Therefore, the choice of surgical procedure depends on the site of obstruction (nose, retropalatal or retrolingual region, or a combination). Here we review the various surgical procedures available and their efficacy when performed alone or in combination. These procedures are: classical uvulopalatopharyngoplasty and its modifications, genioglossus advancement techniques combined with UPPP, and retropalatal and maxillo-mandibular advancement, a highly aggressive technique which treats retropalatal and retrolingual regions simultaneously and is effective in 95% of cases, but has a high morbidity. We also discuss nasal surgical procedures (though they are unlikely to solve the problem), radiofrequency, and palatal implants. We assess the efficacy of these methods, bearing in mind; a) the differences in the criteria used for defining surgical success and b) the fact that they are often applied simultaneously or sequentially.

Lingual Nerve Injury During Suspension Microlaryngoscopy

Lingual nerve injury is an uncommon complication of laryngoscopy. We report a case of isolated unilateral lingual nerve injury that occurred during suspension microlaryngoscopy. The injury was transient, with complete return of sensation within 3 months after surgery. Several mechanisms have been proposed to explain the occurrence of lingual nerve injury during laryngoscopy, including direct compression of the nerve caused by the laryngoscope, stretching of the nerve caused by cricoid pressure or instrumentation, and compression of the nerve between the medial and lateral pterygoid caused by manipulation of the mandible. The precise mechanism of injury in this case was not obvious, but stretching of the lingual nerve caused by pressure of the suspended laryngoscope on the tongue or retrolingual region was likely. The transient nature of the injury and the rapid return of the nerve to baseline function in this case are consistent with a neurapraxic injury.

The pyramidal lobe--a helpful criterion in the differential diagnosis of thyroid diseases.

In cases of hyperthyroidism it may sometimes be difficult to distinguish between autonomous adenoma and autoimmune thyroiditis. For example, in some cases of Graves" (Basedow's) disease, symptoms as ophthalmopathy, pretibial myxoedema or specific antibodies may be missing. In a 39 yr old woman with subclinical symptoms of Graves' disease, the diagnosis "three adenomas of the thyroid" was made by means of a 99mTc-scintigram (Fig. 1A). One half yr later, scintigraphy was repeated, this time using ~z3I instead of 99mTc and a scinticamera with pinhole collimator in place of a scanner with honeycomb collimator. One of the formerly supposed adenomas was now clearly identified as a pyramidal lobe with the thyroglossal duct reaching into the retrolingual region (Fig. 1 B). In a retrospective evaluation of 164 123I-scintigrams that were made in the yrs 1985-1988, only two of 54 patients with thyroid adenomas had scintigraphically detectable pyramidal lobe or thyroglossal duct; in 52 of these patients, these remnants were not detectable. However, in ten of eleven cases of Graves'

Non-Hodgkin's lymphomas in the oropharynx in children - a histological study in 11 patients

In the period from 1965 to 1979 biopsies from the oropharynx of 11 children with non-Hodgkin's lymphoma were collected at the Lymph Node Registry in Kiel. Palatine tonsil tissue was examined in all cases and, in addition, specimens from the retrolingual region of one child and the epipharynx of two patients. All biopsies showed infiltration with lymphoblastic lymphoma (LB). LB of Burkitt type was diagnosed in eight cases, T-LB (convoluted-cell type, acid phosphatase positive) in one, and unclassified LB in two. Thus, there was a strong predominance of B-cell-lymphomas.

Familial occurrence of syngnathia congenita syndrome

A case of familial occurrence of syngnathia congenita in mother and child is described; this syndrome has been seen only sporadically until now. Due to the distinct appearance of the intraoral chords--they were situated on both sides between the ridges of the jaw and also between the left half of the bifid uvula and the retrolingual region--a relationship to the autosomal-dominantly transmitted Cleft Palate Lateral Synechiae Syndrome (CPLS-Syndrome) is suspected. Complete penetrance with different expressivity may explain the different clinical manifestations of the cases seen up to now and the absence of bifid uvula in the mother of our patient. The probable pathogenesis during embryological development is discussed.