Computer-Assisted Quantitative Evaluation of Obstructive Sleep Apnea Using Digitalized Endoscopic Imaging with Muller Maneuver

ArticleinThe Laryngoscope 118(5):909-14 · June 2008with17 Reads
DOI: 10.1097/MLG.0b013e3181638187 · Source: PubMed
To validate the technique of the Muller maneuver (MM) using videoendoscopy and to quantify the correlation between its clinical results and variables of polysomnography. Prospective, controlled study. Videoendoscopy with MM was performed in 70 patients who were categorized into two groups, with 35 patients giving a history suggestive of snoring and 35 patients without such history. The snoring group underwent further examination with polysomnography. Cross-sectional areas at the retropalatal (RP) and retrolingual (RL) levels during quiet respiration (RP(0) or RL(0)) and the maximal effort of MM (RP(1) or RL(1)) were calculated with the digital measurement software "Image J." One hundred forty pairs of data were acquired. The collapsing ratio (CR) was defined as the difference of RP(0) (or RL(0)) between RP1 (or RL(1)) divided by RP(0) (or RL(0)) to compare the difference between the two phases. These results were compared with each other and correlated to the variables obtained from polysomnographic studies. There were significant differences in the CR of RP (CR(RP)), the CR of RL (CR(RL)), and body mass index (BMI) when comparing the two groups. In snoring patients, BMI was positively related to the respiratory disturbance index (RDI) and obstructive sleep apnea (OSA) staging but not to CR(RP) and CR(RL). CR(RP) had a significant positive relationship with RDI and OSA rather than CR(RL). MM with videoendoscopy can be a simple, cost-effective, quantitative, and even predictable technique. This method allows us to examine the dynamic upper airway for more precise preoperative planning.
    • "To avoid the complexity to induce sleep in OSA patients, the Müller maneuver, which consists of a forced inspiratory effort with the mouth and nose closed, could be applied as substitute of real sleep. This maneuver can mimic the pathophysiological condition of OSA during wakefulness, and has been applied to the studies of OSA (Ko and Su 2008; Gregorio et al. 2007; Liao et al. 2003; Terris et al. 2000; Jäger et al. 1998). A successful example of the Müller maneuver application is the evaluation of upper airway function by fiberoptic nasopharyngoscopy with this maneuver before surgical intervention to predict surgical outcome and to improve patient selection (Sher et al. 1985). "
    [Show abstract] [Hide abstract] ABSTRACT: The Müller maneuver has been widely applied to mimic the pathophysiological condition of obstructive sleep apnea (OSA) during wakefulness. We applied cine MRI to elucidate dynamics of the upper airway during the Müller maneuver in healthy subjects (n = 7). Three sets of images (during quiet nose breathing, quiet mouth breathing, and Müller maneuver) were recorded on sagittal midline plane together with impedance pneumography. The position of the tongue root changed during a respiratory cycle when subjects breathed quietly. At the early inspiratory phase the tongue root moved forward and upward, the retroglossal airway size increased toward the middle of inspiration, and the airway size became smaller again toward the end of inspiration. During expiration the airway size became further smaller. When the subject performed the Müller maneuver, the movement of the oropharynx and its narrowing were greater than those of the velopharynx. However, the airway was not completely obstructed. A relatively large morphological change was observed in the retropalatal and retroglossal regions with the backward and downward motion of the tongue root and flattening of the tongue shape during the Müller maneuver. Although patterns of upper airway narrowing and tongue shape alterations were variable among subjects, upper airway narrowing was commonly prominent in the retroglossal area. Cine MRI with the Müller maneuver enables to visualize the upper airway dynamics and could be easily applied to evaluate upper airway collapsibility during wakefulness.
    Full-text · Article · Jul 2013
    • "It has also been reported that changes in body positions during MM did not result in significant differences in either airway caliber or airway dimension [17]. In an effort to make MM a quantitative method, Ko and Su [18] measured cross-sectional areas at the retro palatal and retrolingual levels during MM using a digital measurement software in patients with and without snoring. They concluded that this method was a simple, cost-effective and quantitative technique. "
    [Show abstract] [Hide abstract] ABSTRACT: To our knowledge, no studies up to date have investigated the correlation of rapid eye movement (REM) dependent obstructive sleep apnea syndrome (OSAS) and Muller maneuver. The aim of this study is to investigate whether REM-dependent OSAS is predicted by the findings of the Muller maneuver. The study was conducted on 149 patients with witnessed apnea and daytime sleepiness. Muller maneuver was performed to all patients and the obstruction site was determined using a five-point scale. Then, polysomnography of the patient was obtained and the apnea-hypopnea indexes were determined in total sleep time, REM-dependent sleep and non-REM-dependent sleep. The correlations between the Muller maneuver findings and polysomnographic data were analyzed. The ages of the patients included in the study ranged between 25 and 73 years with a mean age of 49.3 ± 10.1 years. Their mean body mass index was 30.8 ± 5.1 kg/m(2) (range 21.9-55.4 kg/m(2)). The patients' mean apnea-hypopnea indexes in total sleep time was 28.1 and ranged between 5.4 and 124.3. REM-dependent OSAS was determined in 49 patients. When the data were analyzed, it was determined that there were no statistically significant correlations between tongue base or lateral pharyngeal band obstruction at the level of hypopharynx and the REM-dependent OSAS. At the level of the soft palate, the obstruction caused by the lateral pharyngeal bands or soft palate and REM dependency did not show any statistically significant correlation (p > 0.05). In conclusion, Muller maneuver does not provide useful data to predict REM dependency of OSAS.
    Full-text · Article · Apr 2013
    • "Retropalatal or retroglossal areas may be the most susceptible to collapse due to small areas. Ko and Su reported that the collapsing ratios of the retropalatal and retrolingual areas allowed for differentiation between snoring and nonsnoring individuals, but that only the collapsing ratio of the retropalatal area was positively correlated with RDI (equivalent to AHI in our study) and OSA staging among snorers [11]. Our results indicate that retropalatal area collapsibility could be used to differentiate patients with early and advanced OSA. "
    [Show abstract] [Hide abstract] ABSTRACT: The aim of this study was to investigate whether physical evaluations could be used for predicting the presence and severity of obstructive sleep apnea (OSA) in non-obese snoring patients. This is a retrospective study, and a total of 244 non-obese (body mass index, BMI, <27 kg/m(2)) snoring patients (178 men and 66 women; mean age = 43.1 ± 12.1 years) were included. Each patient underwent polysomnography and a thorough physical examination, including flexible nasopharyngoscopy and Müller maneuver. Patients were divided into four groups based on apnea-hypopnea index (AHI) scores: normal (simple snoring), AHI < 5; mild OSA, 5 ≦ AHI < 15; moderate OSA, 15 ≦ AHI < 30; severe OSA, AHI ≧ 30. Logistic regression was used to identify risk factors for OSA severity. Fifty-nine patients (24%) were simple snorers. The prevalence of sleep apnea (mild, moderate, or severe OSA) for our non-obese snoring patients was 76%. Univariate logistic analyses showed that higher BMI, male gender and retropalatal Müller grades were significantly associated with OSA severity. Multivariate logistic regression analysis identified male gender and retropalatal Müller grade as risk factors for OSA in non-obese snoring patients. Physical examination may be useful for studying the upper airway in non-obese snoring patients. Flexible nasopharyngoscopy with Müller maneuver appears to be useful for evaluating the severity of OSA in non-obese patients. Retropalatal Müller grade is highly related to both the presence and severity of OSA, particularly in males.
    Full-text · Article · Nov 2010
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