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Sleep Endoscopy for Sleep Apnea Surgery: Where’s the Obstruction?

Posted Nov 02 2009 10:01pm

One of the biggest challenges for sleep apnea surgeons is in figuring out where in the upper airway obstructions are happening, especially when patients are sleeping. The problem with looking in the office is that the patient is awake, and your muscles won’t be as relaxed as when you’re in deep sleep. 


A new study out of Baylor University described a procedure where patients are placed under sedation, but still breathing on their own. While the patient is sleeping, a thin flexible camera (fiberoptic endoscopy)is placed through the nose into the throat and the various structures are examined, including the soft palate, tongue, epiglottis, and tonsils.


Although this may seem like a novel idea, it was already described as early as 2000, with some other studies that followed. 


After reading the 2000 paper, I began performing sleep endoscopy on a dozen or so patients just before they underwent surgery. It literally took only a few minutes immediately before the endotracheal tube was placed. In all cases, the findings didn’t reveal anything more than what was already known before the procedure. As a results of these findings, I stopped looking while the patient was asleep.


An alternative to this procedure is to place a pressure catheter with multiple sensors at different levels (soft palate and tongue) while the patient sleeps at night. This can be performed along with a routine sleep study.


Various CT and MRI studies also report finding significant areas of narrowing and collapse.


My current way of discovering where obstruction is happening is to do a thorough history, exam and physical, and then perform the flexible fiberoptic exam with the patient sitting up as well as lying down flat on his or her back. This way, you’ll see the soft tissue structures collapse due to gravy. In many cases, tongue or palate collapse can be dramatic. If there is significant tongue collapse, I then have the patient thrust the lower jaw forward and in most cases, the space behind the tongue base opens up dramatically. This maneuver can predict whether or not thy can benefit from a mandibular advancement device. 


In my experience, except in severe sleep apnea situations, the palate is usually less of an issue than the tongue. By addressing the nose, the palate and tongue simultaneously, surgical success rates can be as high as 80%, rather than 40% for operating on the soft palate alone. 


When you went to your ENT for your sleep apnea, were you ever examined with the camera lying down? Please enter your experience below in the box.


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