Management of the Epiglottis

This chapter reviews the role of the epiglottis in obstructive sleep apnea (OSA) and surgical management of its obstructive capacity. Although it has been well recognized for years that multiple levels of obstruction are responsible for OSA, most authors focus on nasal, retropalatal, and retroglossal obstruction as the three major sites of collapse. Relatively little literature has been devoted to the role of the epiglottis in contributing to OSA. With the advent of more widespread use of drug-induced sleep endoscopy (DISE), this anatomic site has begun to receive more attention ( Fig. 54.1 ).

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Isolated epiglottic collapse.

Catalfumo et al. published an early study regarding the role of the epiglottis in OSA, based upon awake endoscopy. In their study, epiglottic collapse was estimated to be involved in 12% of patients with OSA. Using DISE, many subsequent studies have demonstrated an increased incidence of epiglottic involvement in OSA. Torre et al. have done a thorough review of this literature and cite studies identifying percentage of epiglottic collapse ranging from 15% to 73.5%. Authors defined epiglottic collapse in various ways. For example, Woodson found an incidence of 15% isolated epiglottic collapse on DISE, whereas Golz et al. found an incidence of 14.4% isolated epiglottic collapse and 11.3% multiple-level collapse (including epiglottis). Other authors defined anteroposterior collapse and lateral collapse as relevant in determining success of surgical outcome.

There is evidence that epiglottic collapse may be a determinant of continuous positive airway pressure (CPAP) failure, as the positive pressure may force the collapsing epiglottis further into the laryngeal airway. For example, Dedhia et al. demonstrated that 15% of adult patients unable to tolerate CPAP had primary epiglottic obstruction of the hypopharynx. Particularly in the circumstance of isolated collapse, the epiglottis must be considered as an independent variable in determining the proper surgical strategy to manage OSA patients. Several surgical strategies are discussed next: epiglottopexy with or without lingual tonsillectomy and partial laser epiglottectomy.

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Alternative Treatment Options

Patients with true epiglottic prolapse will likely not respond well to CPAP, as positive pressure ventilation will force the epiglottis farther down into the airway. If the sleep apnea is relatively mild, a dental repositioning device may be sufficient to overcome partial collapse ( Fig. 54.2 ).