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ObjectiveThe epiglottis plays an integral role in the swallowing mechanism and is also implicated as an obstruction site in obstructive sleep apnea (OSA). The underlying causes of epiglottic collapse during sleep remain unclear. This study aimed to investigate the cognitive functions using the Loewenstein Occupational Therapy Cognitive Assessment (LOTCA) and the neurophysiological and anatomical factors using videofluoroscopic swallowing studies (VFSS). We compared patients with OSA exhibiting epiglottic collapse to those without, assessing differences in anatomical or neurophysiological characteristics.MethodsThe study included 12 patients with epiglottic collapse (Epi-group) and 68 without (non-Epi group), all undergoing overnight polysomnography (PSG), drug-induced sleep endoscopy (DISE), LOTCA, and VFSS. Oral transit time (OTT), pharyngeal delay time (PDT), and pharyngeal transit time (PTT) were considered as neurophysiological traits, and laryngeal elevation length (LE) as anatomical trait, and were measured across various test diets (10 ml of liquid, soft, or solid).ResultsThe study comprised 80 individuals, 57 men and 23 women, with no significant age, sex, body mass index or PSG parameters between groups, or DISE findings, with the exception of epiglottic collapse. Swallowing metrics from VFSS were normal, with no differences in OTT, PDT, PTT, or LOTCA scores. Notably, patients with epiglottic collapse showed a greater laryngeal elevation when swallowing soft and solid foods (p = 0.025 and p = 0.048, respectively).ConclusionsPatients with epiglottic collapse do not exhibit neurophysiological or cognitive impairments when compared to non-Epi group. However, the Epi-group displayed a significantly increased laryngeal elevation length. This suggests that anatomical factors may have a more substantial role in the development of epiglottic collapse than neurophysiological factors.

In den letzten Jahrzehnten hat sich die Kieferorthopädie kontinuierlich weiterentwickelt. Neueste Technologien ermöglichen hochpräzise und schonende Zahnregulierungen. Dennoch bleiben Kieferform und Zahnstellung lebenslang in der funktionellen Matrix eingebunden. Ein kieferorthopädisches Präventionsprogramm gibt es bisher nicht. Der vorliegende Beitrag geht der Frage nach, welche Merkmale kieferorthopädische Risikokinder in bestimmten Altersgruppen aufweisen. Was kann bereits vor der Geburt, im Säuglingsalter, in der Milchgebissphase, in der ersten Phase des Zahnwechsels und beim späten Wechselgebiss erkannt und unternommen werden, damit Kinder früher und besser ihr naturgegebenes Potenzial entfalten können. Ein kieferorthopädisches Präventionskonzept wird vorgestellt, das die Säulen Information, Aufklärung, Förderung der Entwicklung der Kiefer, begleitete Anleitung zur Verhaltensänderung und Ernährung beinhaltet.

BackgroundNon-invasive ventilation is sometimes unable to provide the respiratory needs of very premature infants in the delivery room. While airway obstruction is thought to be the main problem, the site of obstruction is unknown. We investigated whether closure of the larynx and epiglottis is a major site of airway obstruction.MethodsWe used phase contrast X-ray imaging to visualise laryngeal function in spontaneously breathing premature rabbits immediately after birth and at approximately 1 hour after birth. Non-invasive respiratory support was applied via a facemask and images were analysed to determine the percentage of the time the glottis and the epiglottis were open.HypothesisImmediately after birth, the larynx is predominantly closed, only opening briefly during a breath, making non-invasive intermittent positive pressure ventilation (iPPV) ineffective, whereas after lung aeration, the larynx is predominantly open allowing non-invasive iPPV to ventilate the lung.ResultsThe larynx and epiglottis were predominantly closed (open 25.5%±1.1% and 17.1%±1.6% of the time, respectively) in pups with unaerated lungs and unstable breathing patterns immediately after birth. In contrast, the larynx and the epiglottis were mostly open (90.5%±1.9% and 72.3%±2.3% of the time, respectively) in pups with aerated lungs and stable breathing patterns irrespective of time after birth.ConclusionLaryngeal closure impedes non-invasive iPPV at birth and may reduce the effectiveness of non-invasive respiratory support in premature infants immediately after birth.

Occipitocervical fusion (OCF) and upper cervical posterior fixation can be performed to resolve occipitocervical or upper cervical instability. The cervical vertebral realignment following these procedures can result in dysphagia, which can decline patients' postoperative status. Several radiological parameters on cervical lateral X-ray images were proposed to predict and avoid this postoperative dysphagia. However, previous parameters principally focus on cervical alignment and do not include the hyoid bone, which is an essential anatomical structure related to the swallowing mechanism. In this case-series study, we enrolled a total of 14 patients (male: female = 10:4) with a mean age of 66.4 years who underwent OCF or upper cervical posterior fixation. We measured the following parameters on cervical lateral X-ray images: T1 slope, pharyngeal airway space, and O-C2, C1-C2, C2-C7, and pharyngeal tilt angles. In addition to these parameters, we also defined and measured a hard palate-C2-hyoid bone (H2H) angle, which reflects the anatomical relationship among the cervical vertebrae, palate, and hyoid bone. We compared pre- and postoperative changes of all the parameters between those patients with postoperative dysphagia after OCF and upper cervical posterior fixation and those without. Dysphagia occurred in two cases treated with OCF. A chronological change of the H2H angle in a case with postoperative dysphagia was plotted as an outlier on box-and-whisker plots, while any chronological changes of the other parameters in cases with dysphagia were not plotted as outliers. The H2H angle could be related to the occurrence of postoperative dysphagia after OCF and upper cervical posterior fixation. This parameter should be evaluated with further studies.

PurposeDespite a broad range of diagnostic methods, identifying the site of obstruction in the upper respiratory tract in patients with obstructive sleep apnea is not always simple and straightforward. With regard to this problem, we present our observations about the specific shape of the epiglottis in patients with obstruction at the level of the tongue base and/or epiglottis.MethodsOne hundred and forty consecutive drug-induced sleep endoscopy (DISE) video recordings of patients with polygraphy-verified obstructive sleep apnea were analyzed by three independent observers. We compared the levels of obstruction using the VOTE classification and the shape of the epiglottis, both as seen during the DISE investigation and in the awake state. We have calculated the interrater reliability for VOTE classification results and epiglottis shape evaluation by three different observers.ResultsOut of 140 patients, there were 52 (37.1%) with a flat epiglottis. Within this group, there were only 3 (6%) cases in which obstructions at the tongue base and/or epiglottis level were not found. In the group with normally convex and omega-shaped epiglottis, obstruction at the tongue base level was observed in 28 patients (31.8%); obstruction at the epiglottis level was observed in 5 patients (5.7%); and obstruction at both the epiglottis and tongue base level was observed in 3 patients (3.4%). Interrater reliability for VOTE classification was poor for V (ICC = 0.414) and good for O (ICC = 0.824), T (ICC = 0.775), and E (ICC = 0.852). Additionally, interrater reliability was excellent for epiglottis shape (ICC = 0.912).ConclusionIn patients with obstructive sleep apnea, examinations in the awake state and drug-induced sleep endoscopy both showed that in most cases of obstruction at epiglottis and/or tongue base, the epiglottis was flat, i.e., lacking the typical anterior convexity in its upper part. We assume that the change of its shape is a result of degeneration of suspensory apparatus that maintains the shape of the epiglottis and holds it in its position. This could contribute to the better identification of patients with a narrowing at this level, and in turn to better decisions regarding the choice of the most suitable treatment.

Introduction Sleep endoscopy during natural sleep will be ideal, to evaluate the upper airway during episodes of obstructive sleep apnea, but quite difficult to achieve. Drug-induced sleep endoscopy is an alternative standard of care to document the level and severity of the collapse of the upper airway. It is especially of benefit for patients who are intolerant to positive airway pressure and is used as a part of a work-up for alternative therapy for treating sleep apnea. Using propofol infusion and a Bi-spectral index of 50-70, to monitor the depth of sedation, the upper airway collapse can be determined with sleep endoscopy, conducted initially without CPAP and then with a CPAP ranging from 10 cmH2O to 20 cm H2O in patients who failed PAP therapy. Methods Drug-induced sleep endoscopy (DISE) was carried out in the bronchoscopy suite by the same Pulmonologist with an anesthesiologist to manage sedation using Propofol. Adequate depth of sedation was confirmed by the presence of snoring, and a BIS. The patient underwent the entire procedure while supine. The severity of obstructions followed the velum/oropharynx/tongue base/epiglottis and was recorded as patent/partial/complete. The obstruction pattern was classified into circumferential, anteroposterior, or lateral. Tongue base obstruction was identified when the tongue base pushed the epiglottis causing lumen obstruction. The DISE was conducted initially without CPAP followed by DISE with CPAP. Results Out of a total of 80 patients, upon application of the CPAP, 3 patients (4%) had patent velum and the base of the tongue. 3 (4%) with partial collapse of the velum and complete collapse of the base of the tongue. One (1%) had persistent anterior-posterior and lateral wall collapse of the velum, but the base of the tongue was patent. 68 (85%) had improved lateral wall collapse and obstruction of the velum improved from complete to partial anteroposterior collapse. Five patients (6%) continued to have persistent circumferential collapse of the velum. Conclusion Drug-induced sleep endoscopy performed in combination with various pressures of CPAP allows real-time visualization of the impact of these pressures on the upper airway. It allows us to provide alternative treatment options sooner than later. Support (if any)