Journal of Otology & RhinologyISSN: 2324-8785

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Case Report, J Sleep Disor Treat Care Vol: 2 Issue: 4

Combined Treatment of a Severe OSAS Patient Planned after a Sleep Endoscopy Performed with and without a Mandibular Protrusion Simulator. A Case Report

Milano Francesca1*, Gobbi Riccardo2, Scaramuzzino Giuseppe2, Marra Francesca2, Billi Maria Celeste1, Antonio Gracco3 and Sorrenti Giovanni2
1Private Practice, Bologna, Italy
2Department of Otolaryngology Head and Neck Surgery, S. Orsola-Malpighi Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
3Assistant Professor, School of Dentistry, University of Padova, Padova, Italy
Corresponding author : Francesca Milano
Private Practice, Via Clavature 1, 40124 Bologna, Italy
Tel: +39051228084; Fax: +39051239889
Received: September 02, 2013 Accepted: November 08, 2013 Published: November 11, 2013
Citation: Milano F, Gobbi R, Scaramuzzino G, Marra F, Billi MC, et al. (2013) Combined Treatment of a Severe OSAS Patient Planned after a Sleep Endoscopy Performed with and without a Mandibular Protrusion Simulator. A Case Report. J Sleep Disor: Treat Care 2:4. doi:10.4172/2325-9639.1000123


Combined Treatment of a Severe OSAS Patient Planned after a Sleep Endoscopy Performed with and without a Mandibular Protrusion Simulator. A Case Report

Objective: The case report aim was to show the effectiveness of a combined treatment, to treat a severe OSAS patient.b Study design: A severe OSAS patient (AHI=51.1) was evaluated during sleep endoscopy with and without a mandibular advancing simulator. A combined treatment plan was performed and he underwent to a pharyngeal surgery followed by the delivery of an individual oral device. Results: We attained an AHI of 0.7 events per hour. Conclusions: The combined treatment was effective and the patient achieved a complete recovery.


Obstructive sleep apnea syndrome (OSAS) is a sleep respiratory disorder, characterized by snoring and partial (hypopnea) or complete (apnea) obstructions of airflow. Oxygen desaturation and sleep fragmentation, caused by the airflow limitations, can lead to an excessive daytime sleepiness and an increased risk of cardiovascular, cerebrovascular and metabolic diseases [1]. Mandibular advancing oral devices (MADs) are indicated in subjects affected by mild to moderate OSAS or in severe OSAS patients who refuse or are not tolerant to Continue positive airway pressure (CPAP). Especially in these cases, an otolaryngological evaluation can provide a comprehensive diagnostic analysis of airway collapse, helping to perform an individualized treatment plan, which can include MAD, pharyngeal surgery or the combination of MAD and upper airway surgery therapy [2]. Drug induced sleep endoscopy (DISE) is a topodiagnostic endoscopic procedure of obstructive sites, described by Croft and Pringle in 1991, which is performed during propofol’s pharmacologic induction of sleep [3]. DISE allows to evaluate the collapse of retropalatal (palate and oropharynx) and retrolingual (tongue base and epiglottis) region and to determine the pattern of obstruction (concentric, anteroposterior or lateral) [4,5]. Here is presented the case report of a combined treatment, consisting in a modified expansion sphincter pharyngoplasty (MESP) [6] plus MAD therapy, after an evaluation of the levels and of the patterns of obstruction during DISE with a mandibular protrusion simulator [2].

Diagnosis and Treatment Plan

A 45-year-old man presented complaining of loud snoring and nasal congestion. The patient presented a dental Class II Division 1 malocclusion, a posterior crossbite, a deep overbite, an increased overjet, an upper anterior crowding and an high palatal vault. The cephalometric analysis revealed a skeletal Class II jaw relationship, a bimaxillary retrusion), a normodivergent pattern and an increased distance between hyoid bone and mandibular plane (Figure 1). A clinical otolaryngological examination was performed to evaluate both sites and dynamics of obstruction, showed a Mallampati score of 3 (Mallampati score is a classification used in anesthesia to predict the difficulty of intubation: it is showed in Table 1), a tonsillar grade of 1 (tonsillar grading is showed in Table 2) and the evidence of a previous septoplasty with hypertrophy of the bilateral inferior turbinates. The flexible endoscopic evaluation with Müller maneuver (inspiration against the closed glottis, with closed mouth and nostrils, which is performed to estimate the grade and the pattern of obstruction) was negative both at the retropalatal and at the retrolingual level (Muller maneuver grade is showed in Table 3. The Epworth Sleepiness Scale (ESS) administration revealed a score of 12, confirming daytime sleepiness reported by the patient. The Epworth Sleepiness Scale is a subjective measure of sleepiness: the patient has to self-rate if he has no chance or high chances (0 to 3) of dozing in eight different situations [7]. The total score is the sum of the eight item-scores and the normal range is 0 to 10 (ESS is shown in Table 4). At the polysomnographic evaluation (PSG) he was diagnosed with severe OSAS. He presented an apnea/hypopnea index (AHI) of 51.8 events per hour, an AHI in supine position of 51.1 events per hour, an oxygen desaturation index (ODI) of 50.5 events per hour; a lowest minimum oxygen saturation recorded during sleep (O2Sa) of 78% and the cumulative percentage of time spent at saturations below 90% (CT<90%) was 14%. His body mass index (BMI) was 26.2 Kg/m2. The collected data are summarized in Table 5. The treatment plane provided a Continue positive airway pressure (CPAP) titration, but the patient refused to try it. The ear, nose and throat (ENT) specialist decided to candidate the patient to a DISE to plan the best therapeutic alternative choice; so the patient was referred to the orthodontist for a dental, periodontal and functional evaluation to verify the possibility to wear a MAD and in case to construct an advancement simulator to wear during the exam. The orthodontist performed a comprehensive assessment of the patient and used a 5mm George Gauge bite-fork (Figure 2) to set for the ENT the anterior bite opening and the initial therapeutic protrusion of a possible MAD. The construction bite was executed with a hard putty silicone to provide a complete covering of the fork and to prevent its breakage during the sleependoscopy procedure. The silicone was finished to achieve the minimum encumbrance for the tongue. A vertically opening of 5 mm and a sagittal advancement of 7 mm (75% of the maximum protrusion) were determined [8,9]. The patient was queried about the jaw comfort of the selected protrusion. The day after, DISE was initially performed with bitefork in situ, to avoid to force the mandible to insert it when patient was asleep. During the exam, the mandible was gently held against the bite fork, to prevent bite fork loss. When the evaluation of the pharyngeal collapse with the mandibular advancement was over, the simulator was gently pulled out and a new assessment was performed. During DISE with MAD simulator were noticed a complete anteroposterior obstruction at retropalatal level and the absence of collapse and the pharyngeal stability at retrolingual level. After the removal of the simulator, were noticed the same pattern and grade of retropalatal obstruction, but were present a retroposition of the base of the tongue and the occurrence of collapse at retrolingual level. The patient treatment plan consisted of a combined therapy by oropharyngeal surgery and MAD. The first step consisted of a surgical intervention of tonsillectomy and lateral pharyngoplasty. Two weeks after the surgery, the patient underwent to impression take over, and the construction bite used for DISE was sent to the technician to realize a Somnodent® MAS oral device (Figure 3).
Figure 1: a-b )Frontal and lateral intraoral view in centric occlusion; c) Lateral teleradiography.
Figure 2: a) 5 mm George Gauge™ bite fork; b) Mandibular advancing simulator performed with George Gauge™ bite fork and putty silicon.
Figure 3: a-b) Frontal and lateral intraoral view with Somnodent® MAS in situ.
Table 1: Modified Mallampati Score: evaluation of the anatomy of the oral cavity when the patient open his mouth. It describes the encumbrance of the tongue.
Table 2: Tonsillar grading: evaluation of the anatomy of the oral cavity when the patient open his mouth. It describes the encumbrance of the tonsils.
Table 3: Müller maneuver grading: it describes the grade and the pattern of obstruction, during a forced inspiration against the closed glottis (with closed mouth and nostrils). It is evaluated during fiberoptic nasal endoscopy and it’s performed at retropalatale and at retrolingual site.
Table 4: Epworth Sleepiness Scale.
Table 5: Polysomnografic records, BMI and ESS.

Treatment Progress

After the delivery of the appliance, the patient was monitored every two weeks. The advancement was not increased during followups and no short-term side effects were reported by the patient. Three months after the delivery of the appliance, a PSG without and with the MAD was performed; the results are illustrated in Table 1. The patient was motivated to wear the MAD, because despite he felt a subjective satisfactory improvement of the snoring loudness and of the daytime sleepiness (EES=3), the PSG showed the persistence of apnea and hypopnea episodes (AHI=29.4 events per hour) without the appliance. This partial success was due to the persistence of 53.1 events per hours in supine position. With MAD, after the surgical resolution of the retropalatal obstruction, a complete recovery was achieved (AHI=0.7 events per hours).


The upper airway evaluation in patients affected by OSAS represents a fundamental step to improve treatment success rate [10,11]. In fact, most of the OSAS patients present a multilevel obstruction and the combination of specific techniques has been showed effective and allows to reach the aim to treat a large number of patients with an high success rate [12]. The main action mechanisms of MAD are to directly increase the dimensions of the pharyngeal airway whilst reducing the airway collapsibility [13]. This is effected by drawing the tongue forward, through its muscular attachments to the mandible [14]. As the tongue is brought forwards, the soft palate will tend to follow to maintain a posterior oral seal, providing variable improvement in subjects with multilevel involvement [15]. DISE allows to determine the sites and the pattern of collapse during sleep and to mimic mandibular protrusion performing a gentle mandibular pull-up (Esmarch maneuver) to verify airway response to MAD treatment. The limits of Esmarch maneuver are that it’s not reproducible in terms of the degree of mandibular advancement and that it’s doesn’t consider the vertical opening. The George Gauge bite fork, normally used to transfer the therapeutic position for the MAD construction, can be an easy and inexpensive advancement simulator and it can be used, if it is effective, to construct the appliance, replicating the same condition performed during DISE.
It can be concluded that:
1. MESP plus MAD may offer benefits in patient with combined retropalatal obstruction and retrolingual obstruction after a complete diagnostic assessment including DISE with custom made mandibular advancement simulator.
2. Further studies are needed to demonstrate that this diagnostic technique has a positive predictive value of non ventilatory treatments success rate.


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