Muller’s Maneuver in Patients with Obstructive Sleep Apnea
Background and Objective: Numerous anatomical abnormalities or pathological conditions can cause upper airway obstruction in obstructive sleep apnea syndrome (OSAS). Muller’s maneuver (MM) is one of diagnostic modalities investigating the obstruction site in patients with OSAS. This study aimed to investigate the obstruction sites of patients with OSAS based on MM.
Materials and Methods: This was a case-series study. A total of 145 patients were enrolled in this study. The awake MM (a flexible fiberoptic endoscopy of the upper airway while patients perform forced inspiration against a closed oral and nasal airway) was performed by a single surgeon with the patient in a supine position. Endoscopic findings were classified using the modified velum, oropharyngeal lateral walls, tongue base, and epiglottis (VOTE) classification criteria.
Results: Mean ± standard deviation age of patients was 41.5 ± 10.1 years old. Mean respiratory disturbance index was 29.7 ± 24.3/hours. The most common site of obstruction in all patients was velum. About 72% of the patients had more than 75% obstruction in the velum area while most patients had < 50% obstruction in oropharyngeal lateral walls (41.4%) and tongue base (55.2%). 69% of the patients had no obstruction in epiglottis according to the modified VOTE classification.
Conclusion: Simple awake diagnostic test before surgery would help physicians to identify obstruction sites of OSAS patients.
Fusetti M, Fioretti AB, Valenti M, et al. Cardio- vascular and metabolic comorbidities in patients with obstructive sleep apnoea syndrome. Acta Otorhino- laryngol Ital 2012; 32: 320-5.
Kim HC, Young T, Matthews CG, et al. Sleep- disordered breathing and neuropsychological deficits. A population-based study. Am J Respir Crit Care Med 1997; 156: 1813-9.
Shahar E, Whitney CW, Redline S, et al. Sleep- disordered breathing and cardiovascular disease: cross- sectional results of the Sleep Heart Health Study. Am J Respir Crit Care Med 2001; 163: 19-25.
Young T, Evans L, Finn L, et al. Estimation of the clinically diagnosed proportion of sleep apnea syn- drome in middle-aged men and women. Sleep 1997;20: 705-6.
Hudgel DW. The role of upper airway anatomy and physiology in obstructive sleep apnea. Clin Chest Med 1992; 13: 383-98.
Badr MS. Pathophysiology of upper airway ob- struction during sleep. Clin Chest Med 1998; 19:21-32.
Sher AE, Schechtman KB, Piccirillo JF. The ef- ficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996; 19: 156-77.
Faber CE, Grymer L. Available techniques for objective assessment of upper airway narrowing in snoring and sleep apnea. Sleep Breath 2003; 7: 77-86.
Kezirian EJ, Hohenhorst W, de Vries N. Drug- induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol 2011; 268: 1233-6.
Weitzman ED, Pollak C, Borowiecki B, et al. The hypersomnia sleep-apnea syndrome: site and mechanism of upper airway obstruction. Trans Am Neurol Assoc 1977; 102: 150-3.
Cavaliere M, Russo F, Iemma M. Awake versus drug-induced sleep endoscopy: Evaluation of airway obstruction in obstructive sleep apnea/hypopnoea syn- drome. Laryngoscope 2013; 123: 2315-8.
Campanini A, Canzi P, De Vito A, et al.Awake versus sleep endoscopy: Personal experience in 250 OSAHS patients. Acta Otorhinolaryngol Ital 2010; 30:73-7.
Soares D, Folbe AJ, Yoo G, et al. Drug-induced sleep endoscopy vs awake Muller's maneuver in the diagnosis of severe upper airway obstruction. Oto- laryngol Head Neck Surg 2013; 148: 151-6.