Professional Documents
Culture Documents
2. Small amounts of nitric oxide are made by the nose and sinus mucous
membranes. Nitric oxide is lethal to bacteria and viruses and is also
known to increase oxygen absorption in the lungs from 10% to 25%.
3.
The muscles surrounding the airway that actively constrict and dilate the UA
lumen interact in a complex fashion to determine the patency of the airway.
They can be classified into four groups:
1. Muscles regulating the position of the soft palate: ala nasi, tensor palatini,
and levator palatine
2. Tongue: genioglossus, geniohyoid, hyoglossus, and styloglossus
3. Hyoid apparatus: hyoglossus, genioglossus, digastric, genio hyoid, and
sternohyoid
4. Posterolateral
constrictors
pharyngeal
walls:
palatoglossus
and
pharyngeal
Soft tissue structures form the walls of the UA and include the tonsils, soft palate,
uvula, tongue, and lateral pharyngeal walls
Pharyngeal soft tissues exhibited two periods of accelerated change
The increase in airway size that occurs from ages 6 to 9 years is thought to occur
because of
These three mechanisms are suspected to play a role in the increase of the
airway during the 12- to 15-year-old period.
The primary craniofacial bony structures that determine the airway size are the
mandible and the hyoid bone ; these presumably act by providing the anchoring
structures to which muscles and soft tissue attach.
Acoustic Rhinometry
This technique is based on the principle that a sound pulse propagating in the
nasal cavity is reflected by local changes in acoustic impedance.
AR is a simple, fast (approximately 30 seconds), and noninvasive technique that
became widely accepted in a short period.
Most previous investigations of living human subjects have demonstrated
reasonably good agreement between the cross-sectional areas in the anterior
part of the nasal cavity determined by AR and those determined by imaging
techniques such as MRI and CT.
However, this does not hold true for the posterior part of the nasal cavity and the
epipharynx, in which AR significantly overestimates cross-sectional areas
compared with MRI and CT scans.
Pharyngometry
The acoustic reflection technique may also assess the pharyngeal crosssectional area.
Unlike the nose, the oropharyngeal airway is geometrically more complex and
variable and includes mobile structures (soft palate and tongue); therefore
establishing a standard operating protocol and an understanding of the possible
sources of artifacts is of great importance in obtaining reliable results.
Pharyngometry provides a noninvasive assessment of the dimensions, structure,
and physiologic behavior of the UA from the oral cavity to the hypopharnyx while
the patient breathes.
Computer processing of the incident and reflected sound waves from the airways
provide an area distance curve that represents the lumen from which minimal
cross-sectional area and volume can be derived. This dynamic test measures the
dimensions of the airway through the oral cavity and 25 cm down the pharynx.
When attempting to maintain good reliability and obtain accurate results, posture
may play an important role in determining the pharyngeal area. Flexion of the
neck and back, as well as raising the shoulders (which occurs near residual
volume), may compress the pharynx and decrease its cross-sectional area.
Pharyngometry is often marketed as a screening method to assess quickly a
patient for potential sites of sleep-related UA obstruction and to better determine
whether an OA or continuous positive airway pressure (CPAP) device may be
appropriate for the patient.
Research have shown twofold increase in the nasal passage volume of patients
who underwent RME treatment compared with controls even at the end of
approximately a 2-year treatment.
Functional Orthopedic Appliances
The position of the mandible, relative to the anterior cranial base and mandibular
length, seems to have an impact over the oropharyngeal airway.
Several studies have shown weak negative correlation between oropharyngeal
dimensions and the skeletal configuration according to the A point nasionB
point (ANB) angle. In addition, mandibular corpus length and oropharyngeal
airway volume, along with minimum axial area, have shown a positive
correlation.
When the mandible is protruded, a different posture of the tongue caused by
increased genioglossus muscle activity and/or other soft tissue activity may play
an important role over airway dimensions. The majority of the airway
enlargement occurs in the mediolateral dimensionin other words, in the width
of the airway.
On the other hand, when fixed functional appliances are used in the later stages
of growth, when most dental changes take place, no significant posterior airway
changes are usually seen after treatment is completed.
Other extensively used orthopedic appliances are headgears, to inhibit the
forward maxillary growth, and the facemask for maxillary protraction.
Cervical headgear treatment increased the velopharyngeal airway space but did
not significantly affect the rest of the oropharynx or hypopharynx.
Facemask with or without RME seems not to create a significant change for the
oropharyngeal or nasopharyngeal sagittal airway dimensions when compared
with subjects with untreated Class III malocclusions.
Orthognathic Surgery
When mandibular setback osteotomy is performed, the hyoid bone tends to move
to a more posterior and inferior position, and the tongue is carried to a more
posterior position, regardless of whether using bilateral intraoral vertical ramus
osteotomy or sagittal split ramus osteotomy.
As a result, narrowing in the width and depth of the hypopharyngeal and
oropharyngeal areas has been reported. However, there seems to be an
adaptation of the airway in the oropharyngeal and hypopharyngeal levels after
surgery.
On the contrary, mandibular advancement surgery results in an increase in the
dimensions of the oropharyngeal airway. Maxillary advancement, on the other
hand, creates a significant increase in the nasopharyngeal and oropharyngeal
airway dimensions.
Therefore performing bimaxillary orthognathic surgery rather than only
mandibular setback surgery would be advisable, even if the patient exhibits
mandibular prognathia.
Additionally, when maxillomandibular advancement surgery is performed in
conjunction with genial tubercle advancement, which pulls the geniohyoid and
genioglossus muscles forward, the gain in the UA is even better.
Craniofacial anomalies involving the midface (Crouzon, Apert, and Pfeiffer
syndromes), the ones primarily involving the mandible (Nager and Stickler
syndromes and Pierre Robin sequence), and those affecting the midface along
with the mandible (Treacher Collins syndrome and hemifacial microsomia) can
lead to a decrease in the size of the oropharyngeal and nasopharyngeal airways.
In these disorders, the reduced size of the mandible and its retruded position
cause retrodisplacement of the tongue and concomitant reduction of the
oropharyngeal airway, which may lead to UA obstruction. Distraction
osteogenesis (DO) has become an accepted method of treatment for patients
requiring reconstruction of a hypoplastic mandible and a severely retruded
maxilla to increase airway dimensions.
Different types of distraction devices are used for the treatment of craniofacial
anomalies. These are primarily classified as external and internal distraction
devices.
External distractors, although bulky and having a negative impact on a patients
psychosocial life, appear to provide more extended bone osteogenesis
advancement when compared with internal devices. Therefore a greater gain is
obtained in the UA
Similarly, mandibular DO has been proposed as a useful method to resolve
oropharynx airway obstruction. This effect is primarily due to the displacement of
the hyoid bone away from the posterior pharyngeal wall. Furthermore, the small
size of the mandible and its retruded position causes a corresponding
retrodisplacement of the tongue, which also contributes to a reduction in the
airway. Mandibular DO also creates a change in the position of the tongue and is
believed to aid in increasing the airway
Extraction treatment does not seem to affect the airways size, but caution
may be taken in patients who have respiratory problems or already
constricted airways, possibly avoiding maximum anchorage approaches, if
possible.
RME may be able to help solve the nasal resistance to air- flow if the
problem originates from the anterior nasal cavity. Therefore in a possible
relationship with an ear, nose, and throat (ENT) specialist, the clinician
must be aware of the limitations of the procedure.
SLEEP-DISORDERED
MANAGEMENT
BREATHING:
AIRWAY
DISORDERS
AND
Getting enough quality sleep can help protect mental health, physical health,
quality of life, and safety.
Inadequate sleep contributes to
Heart disease,
Diabetes, depression,
Falls,
Accidents,
Impaired cognition, and
A poor quality of life.
In children and teenagers, sleep also supports growth and development.
OSA, which the orthodontist will most frequently encounter, is considered part of
a group of disorders called sleep- disordered breathing (SDB). This class of
disorders refers to abnormal respiratory patterning during sleep; but ironically its
presence or a suspicion of disease is made when the patient is awake.
It can result in decrease in oxygen and increase in carbon dioxide levels, and
arousals during sleep. Sleepiness by itself is not specific for SDB.
OSA is estimated to affect approximately 8% of men and 2% of women,
averaging 5% of the general population.
The orthodontist who treats many patients a day probably encounters several
people daily with OSA. Although the role of the orthodontist is not to diagnose
SDB, an opportunity to screen for SDB exists. It is important for the orthodontist
to recognize the signs and symptoms of SDB and refer the patient to a sleep
medicine physician for proper diagnosis. An otorhinolaryngologist (also known as
ENT physician) may also be consulted in suspected cases of chronic nasal
obstruction or adenotonsillar hypertrophy.
Proper diagnosis can only be done through polysomnography (PSG) or home
testing with portable monitors, with PSG being the gold standard.
More than 5 apneas, hypopneas, or RERAs per hour of sleep (i.e., an AHI
or RDI >5 events per hour) in a patient with symptoms (e.g., sleepiness,
fatigue, inattention) or signs of disturbed sleep (e.g., snoring, restless
sleep, respiratory pauses).
OSA syndrome applies only to the latter definition. In both situations, more than
75% of the apneas or hypopneas must have an obstructive pattern.
Epidemiologic Factors
In OSA, the most common form of sleep apnea, episodes of apnea occur during
sleep as a result of airway obstruction at the level of the oropharynx and
velopharynx
OSA in children is a special case for several reasons. The presenting symptoms
are more likely to be behavioral problems during the day and below expected
performance in school.
Sleepiness during the day is less common than hyperactivity, and a
consideration of OSA is warranted in those with ADHD.
Adenotonsillar hypertrophy by itself or in the presence of obesity, the prevalence
of which is increasing, is a major cause for OSA in children.
The scoring rules for diagnosis are different in children, with less emphasis on
the number of apnea episodes or hypoxemia and more emphasis on the number
of hypopneas, RERAs, and arousals from sleep
Adenotonsillary surgery plays a greater role in children
In young women and in women before menopause, OSA is accompanied with
more complaints of fatigue and depression than with snoring or sleepiness, and a
workup for hypothyroidism is more often negative. The results of a PSG may be
dominated by arousals, RERAs, and hypopneas.
The special case of pregnancy is also a time when a woman is more vulnerable
to OSA because of edema, nasal congestion, progesterone and small lung
volumes, resulting in increased oscillation from hyperventilation to apnea
Pathophysiologic Factors
Pharynx is abnormal in size and/or is capable of collapsing or being collapsed in
patients with OSA.
The pharynx must be collapsible because, as an organ for speech and
deglutition, it must be able to change shape and close. However, as a conduit for
airflow, it must also resist collapsing. The solution to this design problem involves
a group of muscles that can alter the shape of the pharynx when an individual
swallows or speaks but will hold it open when he or she inhales.
With sleep,
Clinical Presentation
The most recognized manifestations of the OSA are
Loud snoring
Severe sleepiness;
Insomnia or
Fatigue or
Inattention.
Physical Characteristics
The patient with OSA exhibits
1. Hypertension,
2. Obesity,
3. Large neck, neck size is an important predictor of sleep apnea and, in
some cases, is a better predictor than body mass index (BMI), and
4. Structurally abnormal or crowded UA.
The orthodontist can detect
5. Nasal obstruction,
6. Low hanging soft palate and
7. Large uvula,
8. Enlarged tonsils and adenoids, and
9. Retrognathia or micrognathia.
10. Nasopharyngeal tumors are rare but must be ruled out.
Other disorders that can crowd or affect the pharynx include
11. Hypothyroidism,
12. Acromegaly,
13. Amyloidosis,
14. Neuromuscular disease, and
15. Vocal cord paralysis.
Clinical examination,
Daytime sleepiness, and
Overnight PSG.
Other clinical tools that are more time efficient and clinically feasible are available
and include
Screening questionnaires,
Indexes, and
Cephalometric analyses.
Berlin Questionnaire,
The Epworth Sleepiness Scale (ESS),
The Sleep Disorders Questionnaire (SDQ),
The STOP Bang Questionnaire,
The Kushida Index,
Apnea prediction score, and
The Friedman classification that includes the modified Mallampati (MMP)
score.
Friedman Classification
Friedman showed that the combination of many factors such as tonsil size, MMP
score, and BMI plays an important role in clinically predicting OSA
The tonsil size can be graded from 0 to 4
MMP scoring was initially developed to help clinically predict the ease versus
difficulty of laryngeal intubation.
This scoring system is based on the direct visualization of the soft palate, uvula,
faucial pillar, and hard palate and on the concept of examining the tongue size
relative to the oral cavity.
Because measuring the size of the tongue relative to the oropharyngeal cavity is
not possible, the MMP score is considered an indirect way of assessing the size
3
Tonsils are beyond the pillars
337
4
Tonsils extend to midline
FIGURE 12-10 Tonsil classification. 0: surgically removed tonsils; 1: tonsils hidden within pillars;
2: tonsils extended to the pillars; 3: tonsils beyond the pillars; 4: tonsils extended to the midline.
It is important to note that the MMP score increases in certain conditions such as pregnancy; therefore it is important
that clinicians not confuse high scores when they are caused by
pathologic versus physiologic reasons.186
Mallampati Score Method
Three steps are followed to determine the MMP score:
338
STOPBang Questionnaire
The STOPBang questionnaire was developed
on the Berlin Questionnaire by anesthetist Ch
sleep specialists in Canada to screen patients
OSA preoperatively. It was first identified as
tionnaire, which stands for yes or no question
tiredness (T), observed events (O), and blood
was later modified to STOPBang, adding BMI (
circumference (N), and gender (G) (Table 12
ification improved the questionnaires sensit
study reports that the STOPBang Questionnair
sensitivity to diagnose the patient with modera
when compared with other screening tests su
Questionnaire, the original STOP questionna
Their result showed that with AHI of 5 even
of 15 events per hour, and AHI 30 events per
the sensitivities of the STOPBang Questionna
92.9%, and 100%, and the specificities were 5
37%, respectively.192
Cephalometric Analysis
Although cephalometrics has an inherent lim
a 2D representation of a 3D structure, cephal
FIGURE 12-11 The modified Mallampati test (MMT) classificais still common in orthodontic offices. The sa
tions. I: Soft palate, fauces, uvula, and pillars are visible. II: Soft
cal position of different structures such as sof
palate, fauces, and uvula are visible. III: Soft palate and base of
airway, and hyoid position measurements cou
uvula are visible. IV: Soft palate is not visible.
airway problem. In 1984, McNamara describ
metric technique,195 which included assessmen
suggested taking two measurements, one for
Kushida Index
ynx and the other for the lower pharynx dimen
Mallampati Score Method
The Kushida index was developed in 1997 through a mathematpharynx dimension was described as the mi
ical formula and is considered to have high levels of sensitivity
between the upper soft palate and the nearest
188,189
Three steps and
arespecificity.
followed
to determine
the MMP
score: with
It combines different
measurements
terior pharynx wall. This distance was determ
BMI and neck circumference, creating a morphometric mathewith age, with its norm established at 17.4 3.4
matical
model
to
predict
OSA.
After
the
calculations
are
made,
dimension
is the minimum distance b
Step 1. Patients are asked to take a seated or supine position.pharynx
A study
showed
if the result is 70 or above, then it indicates a high risk of OSA.
terior wall of the pharynx and a point seen in t
that the accuracy
of predicting
the intubation
observed
more
The Kushida
index is calculated
as follows: using the MMT was
as the
intersection
between the posterior conto
with
the
lower
border
in the sitting position; however, both positions are reliable. If seated in an upright of the mandible. The
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dimension was not seen to change with age, a
position, the{1head
is in neutral position.
determined to be 11.3 3.3 mm for females an
where P, palatal height; Mx, maxillary intermolar distance; Mn,
for males (Fig. 12-12).195 The anteroposterior a
Step 2. Patients
are intermolar
asked todistance;
protrude
their tongue
asmass
far forward
mandibular
OJ, overjet;
BMI, body
tions ofas
the they
hyoid can
bone can also be seen in th
index;
and
NC,
neck
circumference.
but
a
3D
modality
such
without emitting a sound. In the Friedman classification, the patient opens his or as the CBCT allows a fa
The first part of the formula reflects the contribution of the
hensive analysis, including axial and mediolate
her mouth wide
without
protruding
tongue.
craniofacial
dysmorphism
to the
predict
OSA through measureSleep Disorders Questionnaire
ments from the oral cavity, whereas the second part reflects the
contribution
of obesity.
SDQ was
developed
Step 3. Through
visual
observation, a Class I to Class IVTheMMP
score
is from the sleep qu
assessment of wakefulness in 1993 by retrievin
determined. Berlin Questionnaire
tions, creating a multivariate scoring scale (T
The Berlin questionnaire was developed in 1996 at the Conferfour clinical diagnostic scales are sleep apnea
ence on Sleep in Primary Care that took place in Berlin, Ger(NAR), psychiatric sleep disorder (PSY), an
many. This 10-question questionnaire is considered to be a very
movement (PLM) disorder.196 In a 2003 study
accurate method of predicting OSA.190 The complete method is
questions proved to be valid and useful in scre
explained in Table 12-1.
a good degree of sensitivity and specificity.197 I
http://dentalebooks.com
Cephalometric Analysis
Although cephalometrics has an inherent lim
a 2D representation of a 3D structure, cephal
Kushida Index
FIGURE 12-11 The modified Mallampati test (MMT) classificais still common in orthodontic offices. The sa
tions. I: Soft palate, fauces, uvula, and pillars are visible. II: Soft
cal position of different structures such as sof
The Kushida
index
through
a are
mathematical
formula
andof is considered
to have
palate,
fauces,
and uvula
visible. III: Soft palate
and base
airway, and hyoid
position measurements coul
uvula
are visible. IV:
Soft
palate is not visible.
high levels of
sensitivity
and
specificity.
airway problem. In 1984, McNamara describ
metric technique,195 which included assessmen
suggested taking
two measurements,
one for
It combinesKushida
different
measurements with BMI and neck circumference,
creating
a
Index
ynx and the other for the lower pharynx dimen
morphometric
toinpredict
OSA.
The mathematical
Kushida index wasmodel
developed
1997 through
a mathematpharynx dimension was described as the min
ical formula and is considered to have high levels of sensitivity
between the upper soft palate and the nearest p
188,189 It combines different measurements with
and specificity.are
terior pharynx
wall. This
After the calculations
made, if the result is 70 or above, then
it indicates
a distance was determ
BMI
and
neck
circumference,
creating
a
morphometric
mathewith
age,
with
its
norm
established at 17.4 3.4
high risk of OSA.
matical model to predict OSA. After the calculations are made,
pharynx dimension is the minimum distance b
if the result is 70 or above, then it indicates a high risk of OSA.
terior wall of the pharynx and a point seen in th
The Kushida
is index
calculated
as follows:
Theindex
Kushida
is calculated
as follows:
as the intersection between the posterior conto
with the lower border of the mandible. The
{1 (.Y .O) 0+} [.BY (#.* , )] (/$#.*
dimension was not seen to change with age, a
determined to be 11.3 3.3 mm for females an
where P, palatal height; Mx, maxillary intermolar distance; Mn,
for males (Fig. 12-12).195 The anteroposterior a
Where P, mandibular
palatal height;
Mx,
maxillary
intermolar
distance;
Mn,
mandibular
intermolar distance; OJ, overjet; BMI, body mass
tions
of the
hyoid bone can also be seen in th
intermolar index;
distance;
overjet; BMI, body mass index;butand
NC, neck
and NC,OJ,
neck circumference.
a 3D modality
such as the CBCT allows a fa
The first part of the formula reflects the contribution of the
hensive analysis, including axial and mediolate
circumference.
craniofacial dysmorphism to predict OSA through measureSleep Disorders Questionnaire
ments from the oral cavity, whereas the second part reflects the
The first part
of
the
formula
reflects
the
contribution
of
theSDQcraniofacial
contribution of obesity.
The
was developed from the sleep qu
dysmorphism to predict OSA through measurements fromassessment
the oral
cavity, in 1993 by retrievin
of wakefulness
Questionnaire
tions, creating a multivariate scoring scale (T
whereas theBerlin
second
part reflects the contribution of obesity.
The Berlin questionnaire was developed in 1996 at the Conferfour clinical diagnostic scales are sleep apnea (
ence on Sleep in Primary Care that took place in Berlin, Ger(NAR), psychiatric sleep disorder (PSY), an
Berlin Questionnaire
many. This 10-question questionnaire is considered to be a very
movement (PLM) disorder.196 In a 2003 study
190
accurate method of predicting OSA. The complete method is
questions proved to be valid and useful in scre
explained in Table 12-1.
a good degree
The Berlin questionnaire
10-question questionnaire is considered
to beofasensitivity
very and specificity.197 I
http://dentalebooks.com
STOPBang Questionnaire
It was first identified as the STOP Questionnaire, which stands for yes or no
questions on snoring (S), tiredness (T), observed events (O), and blood pressure
(P). It was later modified to STOPBang, adding BMI (B), age (A), neck
circumference (N), and gender (G)
STOPBang Questionnaire has the highest sensitivity to diagnose the patient with
moderate to severe OSA when compared with other screening tests such as the
Berlin Questionnaire, the original STOP questionnaire, and the ESS.
Electroencephalogram,
Electrooculogram,
Chin electromyogram,
Airflow analysis,
Oxygen saturation,
Respiratory effort, and
Electrocardiogram, sometimes replaced by heart rate.
Body position and excessive movements are also observed during this
test.
Treatment Modalities
CPAP therapy
OAs
Surgery. Bariatric surgery is indicated for eligible men and women and can
reduce OSA to low levels in 85% of patients.
Treatment Options
The desired outcome of treatment includes the resolution of the clinical signs and
symptoms, and the normalization of the AHI and oxyhemoglobin saturation.
No treatment should be rendered without proper diagnosis through PSG.
Positive airway pressure (PAP) is the treatment of choice for mild, moderate, and
severe OSA and should be offered as an option to all patients; however,
depending on the severity of the OSA, the patients anatomy, risks factors, and
patient preferences, other options such as OAs and surgery may be adequate.
Oral Appliances
When the OSA is diagnosed as mild to moderate, OAs are considered a viable
option.
Patients often prefer OAs instead of a CPAP device because of their portability,
ease of use, and comfort.
OAs are also helpful with patients who snore or have UA resistance syndrome.
As a general rule, patients with severe OSA are not treated with OAs because of
the concern that failed treatment or partial treatment may lead to respiratory
failure. Overall, two-thirds of patients will experience improvement in OSA
Younger patients,
Patients with smaller neck circumferences,
Women,
Supine-dependent patients with OSA.
Longer maxilla,
Shorter facial heights and soft palate,
MAS are the predominant type of OA used in clinical practice and have shown
the best results. MAS effects include:
The use of a dental implant retained MAS and mini-implants have been
reported in edentulous and partially dentate patients.
Tongue-retaining and tongue-stabilizing devices, which protrude and hold the
tongue forward by using suction, have also been suggested as a treatment
alternative for edentulous patients.
Contraindications to the use of OA therapy include:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Excessive salivation,
Dry mouth,
Tooth discomfort,
Gingival irritation,
Masticatory muscle tenderness, and
Temporomandibular joint (TMJ) discomfort.
Increases in facial height,
Occlusal changes,
Incisor inclination, and molar positional changes.
Surgical Treatment
Surgical procedures may be considered as a secondary option when the patient
is intolerant of CPAP or OAs or when CPAP therapy is unable to eliminate OSA
Surgical treatment alternatives for OSA treatment include:
UA bypass procedure or tracheostomy: This procedure creates an opening in
the trachea to bypass the UA where obstruction is causing OSA. A tube or stoma
is placed for ventilation.
Nasal procedures: The objective of procedures such as
Septoplasty,
Functional rhinoplasty,
Inferior turbinate reduction, and
Nasal polypectomy
major weight loss and is indicated in individuals with a BMI of 40 kg/m2 or those
with a BMI of 35 kg/m2 with important comorbidities and in whom dietary
attempts at weight control have been ineffective
Oropharyngeal Exercises
A less invasive option for the treatment of snoring and/or OSA includes exercises
One of the reasons why OSA could occur in some patients is the larger size and
hypotonicity of the oropharyngeal muscles.
Oropharyngeal hypotonia may be linked to the pathogenesis of an individual and
predispose him or her to OSA.
To treat patients with OSA, the muscles responsible for blocking the UA need to
be exercised to prevent airway collapse.
The goal of the exercise is to strengthen the muscles located around the airway
and to increase their tonicity, especially during sleep when muscles tend to relax.
Oropharyngeal exercises can also improve stomatognathic function and reduce
neuromuscular impairment.
The oropharyngeal muscles are the tongue, soft palate, neck muscles, and
pharyngeal muscles. UA dilator muscles are very important to the maintenance
of the pharyngeal opening and may contribute to the beginning of OSA.
In addition, if the neck muscles are flabby and weak, then they can exert
pressure on the airway, which may lead to its collapse and obstruction of airway
flow.
The oropharyngeal exercises target the soft palate, tongue, and facial muscle, as
well as stomatognathic function. They are frequently performed during the day for
few minutes in
Patients with AHI >65 and/or BMI >32 are not good candidates for this
therapy, attributable to a decreased likelihood of response to treatment.
This therapy is also contraindicated when central and mixed apneas
represent 25% or more of the AHI and
When neurologic problems in the UA are due to a condition or previous
procedures.
The device is implanted in the chest and has a small generator, a breathing
sensor lead, and a stimulation lead. The patient can turn on the therapy before
bedtime and turn it off in the morning through a remote control. When the device
is activated, it senses the persons breathing patterns and delivers a mild
stimulation to keep the airway open, acting in a similar fashion as a pacemaker.
The hypoglossal nerve is accessed through a horizontal incision in the upper
neck at the inferior border of the submandibular gland. The median time for
surgical implantation has been reported as 140 minutes (65 to 360 minutes), with
most patients spending the night at the hospital.