C H A P T E R 3 
Airway Evaluation
1  Methods of Airway Evaluation
As the interest in sleep-disordered breathing (SDB) has
increased, various attempts have been made to assess upper
airway anatomy in patients with this relatively frequent
disorder. From the very beginning, researchers and clinicians
used a multitude of different techniques not only to reveal
potential differences in upper airway anatomy to better
understand the origin and the pathophysiology of the disease,
but also to improve patient management and treatment
success. Whereas the value of thorough clinical assessment
remains indubitable, the value of the Mueller maneuver has
been questioned from the beginning. Static radiologic imaging
techniques such as x-ray cephalometry, computed tomography
(CT) scanning, and magnetic resonance imaging (MRI) have
been used mostly to detect differences in airway anatomy.
Dynamic scanning protocols (e.g. ultrafast CT or cine MRI)
and multiple pressure recordings have been used to gain
insights into the mechanism and level of airway obstruction.
Upper airway endoscopy has been inaugurated during sleep
and sedated sleep to directly visualize airway obstruction,
and the assessment of critical closing pressures has been
used to quantify upper airway collapsibility.
2  Clinical Examination and
Clinical Scores
A clinical examination, including an endoscopy of the upper
airway during wakefulness, still constitutes the basis of every
airway evaluation in snorers and obstructive sleep apnea
(OSA) patients. Anatomic and static clinical findings were
the first parameters to be evaluated to improve treatment
success. The impact of enlarged palatine tonsils became
evident in the surgical experiences with children. If performed
simultaneously, tonsillectomy was described by most authors
as a positive predictive factor for a successful uvulopalato-
pharyngoplasty (UPPP). All the other anatomic parameters
such as the size of the uvula, the existence of longitudinal
pharyngeal folds, and so forth did not show any relationship
to the success rate of UPPP if evaluated separately. In contrast
to the significant influence of enlarged tonsils in palatal
obstruction, equivalent clinical finding for tongue base
obstructions could not be detected. Woodson and Wooten
in Obstructive
Sleep Apnea
Boris A. Stuck, MD
Joachim T. Maurer, MD
only found hints that the oropharynx was normal in cases
with retrolingual obstruction.1
Aware of this dilemma, Friedman et al. developed a clinical
four-degree staging system incorporating the tonsil size, the
position of the soft palate, the tongue size, and the body
mass index (BMI).2 This anatomic staging system predicted
the success rate better than OSA severity only for classic
UPPP.3 One may argue that the staging system merely reflects
the clinical examination of an experienced sleep physician;
nevertheless, such a system may be particularly helpful for
less experienced observers.
Whether there are further predictive anatomic parameters
for other surgical strategies has not been evaluated to date.
The subjectivity of the assessment and the variability of the
nomenclature of the clinical findings are significant limitations
in this context.
3  The Mueller Maneuver
Snoring as well as apneas can be simulated by most people,
and a direct effect of the Mueller maneuver may be seen
during wakefulness. Thus snoring simulation and the effects
of the Mueller maneuver have been used in upper airway
evaluation before surgical intervention in patients to predict
surgical outcome and to improve patient selection. Neverthe-
less, the value of this relatively simple examination has been
questioned repeatedly in the past.
3.1  Techniques of the Maneuver
To be able to compare results between different investigators
and patients, as well as before and after an intervention, the
maneuver should be performed and documented in a standard-
ized fashion. Because of its simplicity, according to Sher
et al., the classification has been widely used to describe the
finding obtained during the maneuver.3 In this classification,
four degrees of airway obstruction at the different levels are
defined, ranging from minimal to complete occlusion. Fur-
thermore, any visible obstruction linked to the epiglottis is
described. The reproducibility and inter-rater reliability of
the results remain problematic. Taking all the available data
into account, the reliability of the Mueller maneuver remains
highly questionable, and the evaluation of the maneuver
seems highly subjective and hard to reproduce.
13
14 Section B Diagnosis

3.2  Predicting Airway Obstruction During
Sleep and Surgical Success
There is some evidence that the sites of obstruction detected
with the Mueller maneuver do not reliably reflect the sites
of obstruction during sleep. This could be demonstrated
through a comparison with videoendoscopy, multichannel
pressure recordings, and dynamic MRI during sleep. Table
3.1 shows the different sites of airway obstruction detected
with the different methods of airway evaluation according
to selected examples from the literature.
The impact of body position on the significance of the
Mueller maneuver remains unclear. During the Mueller
maneuver, healthy subjects may produce extreme negative
pressures of 280 mbar without any signs of pharyngeal
collapse.4 This clearly demonstrates the significant differences
in upper airway collapsibility during wakefulness and sleep.
All the data given do not support the idea that the results
obtained by the Mueller maneuver may be transferred to
natural sleep.
Various research groups were not able to better predict the
success rates obtained with UPPP when using the Mueller
maneuver. Some authors considered an additional retrolin-
gual collapse during the Mueller maneuver as an exclusion
criterion for a UPPP or performed a partial resection of the
epiglottis in UPPP failure patients with laryngeal obstruction
during the Mueller maneuver by partial resection of the
epiglottis.
3.3  Significance of the Mueller Maneuver
The Mueller maneuver is a safe and simple examination
that does not exert relevant strain on the patient. The
reliability of the maneuver is insufficient, and the results
cannot be transferred to natural sleep. A hypopharyngeal
collapse may indicate the exclusion of patients from UPPP.
Altogether, the Mueller maneuver does not facilitate patient
selection for the varying surgical interventions used in
OSA patients.

Table 3.1  Distribution of the Sites of Obstruction Detected by Different Methods of Airway Evaluation
(Selected Literature)
Method Author Diagnosis n Palatal Retrolingual Combined Epiglottis No Result
Mueller Petri et al. OSAS 30 8 0 22 n.d. 0/30
maneuver Sher et al. OSAS 171 101 56 14 2/101 0/171
Skatvedt SBAS 20 4 0 4 n.d. 0/20
Sum (mean value %) 221 113 (51%) 56 (25%) 40 (18%) 2 (1%) 0/221 (0%)
Endoscopy Launois et al. OSAS 18 11 2 5 n.d. 8/26
during sleep Woodson and OSAS 11 5 6 n.d. n.d. n.d.
Wooten
Sum (mean value %) 29 16 (55%) 8 (28%) 5 (17%) 8/26 (31%)
Endoscopy Croft and Pringle SBAS 56 25 n.d. 31 0 15/71
under Pringle and Croft SBAS 70 33 9 28 0 20/90
sedation Camilleri et al. SBAS 25 17 0 8 0 2/27
Hessel et al. SBAS 340 111 8 221 n.d. n.d.
Steinhart et al. SBAS 306 139 23 134 10 16/322
Den Herder et al. SBAS 127 65 15 47 n.d. n.d.
Quinn et al. Snoring 50 35 4 5 6 4/54
Marais Snoring 168 101 52 13 2 37/205
El Badawey et al. Snoring 46 8 2 36 n.d. 5/55
Abdullah et al. Snoring 30 12 0 18 0 n.d.
Abdullah et al. OSAS 89 12 4 71 2 4/93
Sum (mean value %) 1307 558 (43%) 117 (9%) 612 (47%) 20 (1.5%) 103/917 (11%)
Pressure Hudgel OSAS 9 4 5 0 n.d. 0/9
recordings Chaban et al. OSAS 10 5 5 0 n.d. n.d.
during Metes et al. SBAS 51 30 7 n.d. n.d. 13/51
sleep
Tvinnereim and OSAS 12 6 2 n.d. 4 (?) 0/12
Miljeteig
Skatvedt SBAS 20 2 5 10 n.d. 0/20
Katsantonis et al. OSAS 20 5 4 9 2 (?) 0/20
Woodson and OSAS 11 8 3 n.d. n.d. n.d.
Wooten
Sum (mean value %) 133 60 (47%) 31 (23%) 19 (14%) 6 (4,5%?) 13/112 (12%)

SBAS, patients with primary snoring or OSAS; OSAS, only patients with OSAS; Palatal, nasopharynx, tonsils, soft palate and/or lateral pharyngeal
wall; Retrolingual, tongue base and/or hypopharynx; Epiglottis, exclusively epiglottis; No result, either the method was not tolerated or the result
was not utilizable, n.d.: not detected.

4  X-Ray Cephalometry
Over the years, lateral x-ray cephalometry has become
one of the standard diagnostic tools in patients with SDB,
especially with regard to the evaluation of the skeletal
craniofacial morphology. Although not specifically developed
for the fields of SDB, imaging techniques and standards
for data analysis have been incorporated from the field of
maxillofacial surgery, where it has already been used for
decades.
4.1  Providing Insights Into the
Pathophysiology of SDB
Extensive literature is available comparing upper airway
anatomy and dentofacial structures using x-ray cephalometry
between OSA patients and healthy controls. In siblings, a
significantly longer distance from the hyoid bone to the
mandibular plane has been documented in those affected
by SDB.5 Further differences were described by different
working groups. The concrete results are often difficult to
compare, as the authors not only use different landmarks
and parameters, but also sometimes rather complex cal-
culated indices and ratios to describe the differences they
found. Therefore the following findings in OSA patients
can only be a selection: longer soft palates, reduced mini­
mum palatal airway widths, increased thickness of the soft
palate, differences in calculated craniofacial scores, increased
pharyngeal lengths, retroposition of the mandible or the
maxilla, micrognathia, increased midfacial heights, and dif-
ferences in hyoid bone position. In general, the differences
are more pronounced in nonobese patients, suggesting that
craniofacial changes play a dominant role in this sub-
group. Furthermore, substantial differences in maxillofacial
appearance of different ethnic groups need to be taken
into account.
Various authors could demonstrate that the aberrations
in craniofacial morphology they found in OSA patients
were more pronounced in patients with severe OSA. Dempsey
et al. demonstrated that in nonobese patients and in patients
with narrow upper airway dimensions, four cephalometric
dimensions were the dominant predictors of Apnea/Hypopnea
Index (AHI) level, accounting for 50% of the variance.6
Rose et al. questioned the diagnostic relevance of x-ray
cephalometry for OSA, as they found no direct correlation
between skeletal cephalometric findings and OSA severity;
nevertheless, they also reported a correlation with hyoid
bone position.7
4.2  X-Ray Cephalometry and
Therapeutic Interventions
One of the dominant indications for performing x-ray
cephalometry has been treatment with oral appliances.
Especially with regard to the evaluation of potential predictive
parameters for treatment success and dental side effects,
x-ray cephalometry has been the standard diagnostic tool.
As early as 1995, Mayer and Meier-Ewert, two of the fathers
of treatment with oral appliances in Europe, looked for
cephalometric predictors of treatment success8 and reported
that specific cephalometric variables were indeed predictive
for the therapeutic effect. Other authors have confirmed
CHAPTER 3  Airway Evaluation in Obstructive Sleep Apnea 15
the existence of predictive cephalometric parameters,
especially in relation to hyoid bone position and oropharyngeal
airway dimension. Nevertheless, the problems related to
different nomenclature and selection of airway parameters
described earlier remain.
X-ray cephalometry has also been evaluated with regard
to potential predictive parameters for postoperative results
of UPPP alone or in combination with other approaches.
To date, there is no convincing evidence that skeletal
measurements obtained with x-ray cephalometry could
predict the outcome of UPPP. Nevertheless, lateral x-ray
cephalometry is the standard tool in the preoperative
evaluation of the craniofacial skeletal anatomy before
maxillomandibular advancement surgery. Its value is not
questioned.9
4.3  X-Ray Cephalometry in Patient
Management
X-ray cephalometry has provided substantial insights into
the pathophysiology of OSA, demonstrating significant
craniofacial characteristics associated with this disease.
Although the results are not easy to compare, specific
cephalometric characteristics have been repeatedly men-
tioned as a risk factor for OSA and correlate with the
severity of the disease. Selected cephalometric parameters
indicate favorable results of mandibular advancement by
oral appliances. Nevertheless, no cephalometric param-
eter exists that would reliably rule out treatment success
with an oral appliance, and surgical outcome cannot be
predicted. This may explain why x-ray cephalometry
has not become a routine procedure in the diagnostic
workup of OSA as long as maxillomandibular surgery is
not planned.
5  CT Scanning
Compared with lateral x-ray cephalometry, CT scanning
significantly improves soft tissue contrast and allows precise
measurements of cross-sectional areas at different levels as
well as three-dimensional reconstruction and volumetric
assessment. Fast scanning times and relatively quiet scanning
conditions even allow a dynamic assessment of the airway
during a respiratory cycle, as well as measurements during
natural sleep. Nevertheless, ionizing radiation remains
problematic.
5.1  Techniques and Standards
Despite its widespread use in airway assessment in patients
with SDB, no standardized scanning protocol exists for this
indication, and the nomenclature of the soft tissue structures
is not uniform. In addition to a two-dimensional assessment
of the upper airway, three-dimensional techniques were used
to assess volumes of soft tissue structures and airway spaces.
As early as 1987, ultrafast or dynamic CT was inaugurated
in this field to evaluate dynamic changes of the upper airway
dimensions during respiratory cycles. Whereas the vast
majority used CT imaging during wakefulness, several authors
also used scanning protocols under hypnotic relaxation, sleep,
and sleep during apneas, and also used direct comparisons
between wakefulness and sleep.
16 Section B Diagnosis
5.2  Providing Insights Into the
Pathophysiology of SDB
The majority of published data points to potential differences
in upper airway structures and dimensions between OSA
patients and healthy controls or snorers. In general, the upper
airway is described as smaller in apneic patients compared
with controls, especially with regard to the retropalatal region.
Cross-sectional areas were found to be significantly narrower
in affected patients. Inversely, retropalatal tissue was described
as being greater in OSA patients compared with controls,
and larger tongue and soft palate dimensions and volumes
were found. Schwab et al. have pointed out the differences
in upper airway configuration with an anterior-posterior
configuration—a result that is in line with data obtained
from MRI.10
Different authors have described anatomic conditions that
reflect the severity of the disease and have correlated their
measurements with polysomnographic data. A high apnea
index seems to be associated with large tongue and soft
palate volumes, and a significant correlation of the retropalatal
space and its lateral diameter with the Respiratory Disturbance
Index was documented. A combination of the smallest
cross-sectional area, the upper airway resistance, and the
BMI was used to predict the severity of OSA, and a narrower
cross-sectional area and a thicker soft palate were found in
severely affected patients compared with patients with only
mild to moderate OSA.
With the help of dynamic and ultrafast CT, further insights
into airway obstruction were gained. In addition to the fact
that the nasopharyngeal and oropharyngeal airways were
smaller in OSA patients compared with weight-matched
controls, an increased collapsibility in affected patients was
found. During a respiratory cycle, substantial changes in
cross-sectional areas were seen in patients with SDB, with
the velopharyngeal segment being the narrowest and most
collapsible region.11 These results were essentially confirmed
later, showing that patients with severe OSA have significantly
narrower cross-sectional areas at the velopharyngeal level12
(Fig. 3.1).
FIG. 3.1  Upper airway narrowing during tidal breathing as assessed
with CT scanning. (A) Cross-sectional image of a patient at the level
of uvula in tidal breathing. (B) The significant narrowing at the same
level in forced expiration is seen. The region of interest (white line)
was used to assess total cross-sectional areas in each image (according
to Yucel et al., 2005).12
5.3  Evaluating the Effects of Therapeutic
Intervention
Effects of therapeutic intervention have been assessed, mostly
with regard to treatment with oral appliances and surgical
intervention. Although a decrease in the diameters at the
retropalatal and retroglossal level was seen during apnea,
these cross-sectional areas were significantly enlarged with
the help of the appliance. With regard to surgical treatment
effects, it has been demonstrated that the upper airway
increases after mandibular distraction osteogenesis in children
and after maxillomandibular advancement in adults. Even
more data are available for the effects of UPPP and its
modifications, demonstrating that UPPP significantly increases
the upper airway cross-sectional area and that the oropha-
ryngeal enlargement seen in pharyngeal CT measures is
associated with a good outcome in UPPP.
5.4  CT Scanning in Patient Management
CT scanning has provided valuable insights into the patho-
physiology of SDB. In addition, it has often been stated that
CT scanning does play or will play a major role in the manage-
ment of patients with SDB. Nevertheless, CT scanning has
not become part of the routine assessment of patients with
SDB, especially not with regard to surgical treatment selec-
tion. The limited availability, associated costs, practical
considerations, and ionizing radiation remain problematic.
Beneficial effects on treatment selection and thereby treat-
ment outcome have been postulated repeatedly but could
not be demonstrated to date.
6  Magnetic Resonance Imaging
Compared with lateral x-ray cephalometry or CT scanning,
MRI offers various advantages, such as excellent soft tissue
contrast, three-dimensional assessments of tissue structures,
and lack of ionizing radiation. The latter has made MRI the
imaging technique of choice in the assessment of children
with SDB.
6.1  Techniques and Standards
Concerning their scientific or clinical use in the context
of SDB, routine imaging techniques were initially applied,
following various protocols used in everyday clinical prac-
tice. For patients suffering from SDB, it was attempted
to determine anatomic preconditions and peculiarities for
SDB. In this research, comparisons with healthy controls
have been utilized, measuring two-dimensional distances and
diameters of the upper airway or its related structures. In
addition, three-dimensional data were obtained. Volumes
were either calculated based on cross-sectional areas and slice
thickness or established by various computerized models.
Ultimately, ultrafast or dynamic imaging was used to visualize
dynamic motion of the upper airway to assess upper airway
collapse or differences in upper airway motion between
patients with SDB and healthy controls. Subjects were
either measured during wakefulness or during wakefulness
and sleep; children were routinely scanned under sedation.
Sleep in adults was either pharmacologically induced or
spontaneous.

Only a small number of authors have attempted to establish
distinct protocols for MRI of the upper airway in SDB; the
results of the measurements were either validated with a
phantom or tested for variability in repeated measures
over time and with different investigators.13 Validation and
standardization of this imaging paradigm seem essential;
nevertheless, in contrast to, for example, lateral x-ray
cephalometry, hardly any consensual standards exist for this
indication.
6.2  Providing Insights Into the
Pathophysiology of SDB
6.2.1  OSA in Children
Especially in children, extensive research has been done
with regard to the pathophysiology of OSA. Children
with or without persistent OSA after tonsillectomy and
adenoidectomy were compared, and it was demonstrated
that enlarged lingual tonsils were present in those children
with persistent disease, especially in children with Down
syndrome. Further findings were an airway restriction in
the vicinity of both the adenoids and the tonsils and an
enlarged soft palate in the affected group. Nevertheless, the
airway restriction is not limited to these areas, but seems to
occur throughout the initial two-thirds of the upper airway.
Furthermore, a close dependency between the frequency
of respiratory events and the size of the tonsils and the
soft palate could be demonstrated, and the upper airway
narrowing was more pronounced in those children with
a high number of respiratory events compared with the
less affected group. With regard to dynamic airway evalu-
ation, more pronounced fluctuations in airway area during
tidal breathing14 and significant differences in airway
FIG. 3.2  Complete pharyngeal collapse as detected with dynamic MRI during natural sleep. Dynamic single-slice images of a 45-year-old
man during an apnea period. The first images show the complete nasopharyngeal, oropharyngeal, and hypopharyngeal obstruction; the
arrows mark collapse of the different pharyngeal regions (according to Schoenberg et al., 2000).17
CHAPTER 3  Airway Evaluation in Obstructive Sleep Apnea 17
motion15 were demonstrated in children with OSA compared
with controls.
6.2.2  OSA in Adults
As early as 1989, authors pointed out the significance of
pharyngeal fat deposits in adult patients with OSA.16 In this
group, more fat is present in the areas surrounding the
collapsible segment of the pharynx, and fat deposition has
been described even in nonobese patients with OSA. Some
authors could demonstrate a trend for larger tongues or a
significantly higher tongue volume in relation to the oral
cavity volume in patients with OSA compared with controls.
Other anatomic conditions associated with SDB were an
elliptic horizontal cross-sectional area of the pharynx and
large volumes of the lateral pharyngeal walls and total soft
tissue surrounding the upper airway. Nevertheless, other
authors did not find any significant differences in tongue
volume, soft palates, or pharyngeal walls, but pointed out
specific anatomic factors of the mandible in OSA patients.
Numerous authors have demonstrated that the mechanism
and level of airway obstruction can be visualized by MRI,
even under natural sleep17 (Fig. 3.2). The fact that patients
with OSA present multiple sites of pharyngeal abnormality
was demonstrated by Suto et al. as early as 199318; neverthe-
less, the authors pointed out that the levels of airway
obstruction during wakefulness did not match those levels
found during sleep. Other trials have shown that no pharyngeal
airway narrowing was seen in the healthy subjects, but a
significant narrowing was seen in the OSA patients during
wakefulness, and even more so during sleep. Moreover, it
was demonstrated that apneic patients have a more circular
occlusion, underlining the relevance of the lateral pharyngeal
walls in the pathogenesis of airway obstruction.
18 Section B Diagnosis
6.3  Evaluating the Effects of Therapeutic
Intervention
Finally, MRI has been used to assess the effects or side
effects of various therapeutic interventions, including surgical
and nonsurgical strategies. Although potential anatomic criteria
for successful treatment with mandibular advancement devices
were reported, MRI has not become a routine procedure in
the management of patients designated for treatment with
a mandibular advancement device.
With regard to surgical treatment, MRI has been used to
assess potential effects of surgery on upper airway anatomy.
In radiofrequency surgery, imaging has been used to visualize
immediate postoperative effects on the soft palate and the
tongue base, with the latter leading to concrete recommenda-
tions for the technical settings of this technique.19 A standard-
ized protocol has furthermore been used to study anatomic
changes at the upper airway after radiofrequency surgery of
the tongue base20 and after hyoid suspension.21
6.4  MRI in Patient Management
Static and dynamic MRI have substantially improved our
understanding of the pathophysiology of SDB. Significant
differences in upper airway anatomy and structure have been
detected between patients with SDB and healthy subjects,
and relevant insights have been gained in terms of the
mechanisms and levels of airway obstruction. Nevertheless,
MRI has not become a standard procedure either in the
diagnostic workup for patients with SDB or in the manage-
ment of the disease in terms of surgical or nonsurgical
treatment, as a number of issues remain unresolved. MRI
during sleep (especially spontaneous sleep) is possible but
not easy to perform, and measurements during wakefulness
or induced sleep are, to a certain extent, artificial or may
simply not reflect clinical conditions. Furthermore, the results
of MRI, even when performed during sleep, can only provide
information concerning a short period and are limited to the
supine position. For routine clinical application, the limited
availability and the associated costs are additional limiting
factors.
7  Videoendoscopy During
Spontaneous Sleep
As early as 1978, the first report about videoendoscopic
recordings of the pharynx and larynx during sleep was
published. Borowiecki and colleagues described a palatopha-
ryngeal collapse at the end of expiration and directly before
inspiration in patients with OSA.22 They described different
degrees of airway obstruction, often associated with a
medialization of the lateral pharyngeal walls. As there was
no treatment other than tracheotomy available at this time
for those patients, patient selection was not an issue.
Today, videoendoscopy during spontaneous sleep is per-
formed to improve patient selection for the different
treatments available and may also be performed in combina-
tion with overnight sleep recordings. Because videoendoscopy
during spontaneous sleep allows the assessment of the upper
airway during different sleep stages and lacks the side effects
of sedating drugs, this method may be considered superior
to videoendoscopy under sedation. However, sleep video-
endoscopy is rarely performed as it usually requires nightly
measurements and puts additional strain on both patient
and doctor.
8  Videoendoscopy Under Sedation
8.1  Impact of Videoendoscopy Under Sedation
on Sleep, Breathing, and Snoring
Videoendoscopy under sedation allows the visualization of
the site and mechanism of snoring and airway obstruction
in patients with SDB. Therefore it is mandatory that snoring
and airway obstruction can be provoked in affected patients
and that neither the endoscope itself nor the drugs used for
sedation disturb or influence breathing patterns, snoring, or
airway obstruction during sedation. In this regard, statistically
significant differences were found for the longest apnea and
the portion of rapid eye movement (REM) sleep, as well as
for acoustically analyzed snoring sounds when sleep under
sedation was compared with natural sleep. Furthermore, it
has to be mentioned that videoendoscopy during sedation
is usually performed for 10 to 15 minutes due to practical
considerations, and may therefore not reflect the conditions
during an entire night of natural sleep.
Endoscopy under sedated sleep does not always succeed
in inducing existing breathing disorders, and on the other
hand, snoring may be provoked even in healthy patients. In
a cohort study using propofol, Marais detected snoring sounds
in 45% of 126 healthy, nonsnoring controls.23 When titrating
propofol with target-controlled infusion, all snorers did snore
reliably, whereas not a single control person did at the same
plasma level, amounting to a sensitivity and specificity of
100%.24 Therefore target-controlled infusion with propofol
seems superior to manual titration.
8.2  Description of Findings
The patterns of snoring and airway obstruction that can be
observed during videoendoscopy under sedation are multi-
form. Pringle and Croft were the first to standardize the
findings according to their data obtained in a large series of
patients.25 Currently, different classifications coexist and,
ultimately, none of them are feasible. They distinguish either
between an isolated or a multisegmental obstruction, or they
are modifications of existing classifications comprising the
epiglottis. The majority of authors do not classify their
findings, but enumerate the various mechanisms and anatomic
sites of snoring and obstruction. The obstructive patterns
are described as being circular, anteroposterior, and latero-
lateral at the level of the soft palate, the tonsils, the tongue
base, and the epiglottis. A combination of as many as five
different concomitant sites of obstruction in primary snorers
and even six in sleep apnea patients was described, and an
isolated site of obstruction was found in only 15% of OSA
patients.
8.3  Impact on Clinical Decision Making
In clinical routine, a large tongue—defined by a modified
Mallampati score of 3 or 4—is usually considered a negative
predictive parameter for a successful classic UPPP. However,
den Herder and coworkers could not demonstrate a

correlation between videoendoscopy under sedation (retro-
lingual obstruction) and Mallampati index (tongue size).26
Pringle and Croft compared their results of the Mueller
maneuver to those obtained by videoendoscopy under sedation
in a group of 50 patients and could demonstrate that treat-
ment recommendations were not identical based on these
two investigation, to a significant extent.25 Other authors
also reported substantial differences in treatment recom-
mendation when adding sedated endoscopy to simply using
the Mueller maneuver. Taking the limited significance of the
Mueller maneuver into account, there seems to be potential
for an improvement in treatment selection based on sedated
endoscopy.
8.4  Impact on the Success Rate
Surprisingly enough, no prospective data are available to
date comparing success rates of surgical intervention with
and without the use of videoendoscopy under sedation. This
is particularly confusing as there have been numerous
advocates of sedated endoscopy presenting data and videos
on countless patients with SDB, but they have not yet been
able to demonstrate its usefulness with regard to surgical
outcome. For example, no superiority was seen with regard
to success rates compared with historic controls, despite
using sedated endoscopy.27 Yet an improved success rate was
only found in those patients who did not even show the
slightest involvement of structures other than the palate.
Hessel and de Vries retrospectively reviewed snorers and
sleep apnea patients after UPPP. In those patients where
the soft palate was least involved in airway collapse during
preoperative sedated videoendoscopy, the outcome was
superior compared with the others.28 In another retrospective
analysis of 55 sleep apnea patients after UPPP, the same
investigators did not find significantly different success rates
for different sites of obstruction, as revealed by videoendos-
copy under sedation.
8.5  Videoendoscopy Under Sedation and the
Role of the Epiglottis
According to our own experience, videoendoscopy under
sedation or in sleep is particularly helpful in detecting or
excluding a possible glottic or supraglottic obstruction, most
often described as a posterior movement of the epiglottis
during inspiration. In those cases where an epiglottic collapse
during sleep videoendoscopy was seen, a significant reduction
of respiratory events may be achieved with partial epiglot-
tectomy. Videoendoscopy under sedation or during sleep
may be particularly helpful in cases of laryngeal collapse and
failures of standard therapy.
8.6  Significance of Videoendoscopy
During Sedation
Videoendoscopy under sedation is able to initiate snoring
and upper airway obstruction during a short period of induced
sleep, mostly restricted to the supine position. The severity
of the underlying disorder appears comparable to natural
sleep, although snoring sounds seem different and the short
examination time is a significant limitation. The classification
of findings can be reduced to isolated obstruction at the
CHAPTER 3  Airway Evaluation in Obstructive Sleep Apnea 19
palate, the tongue base, or the epiglottis, or to combinations
of these. There are subtle hints that videoendoscopy under
sedation may change the indication for a limited number of
surgical interventions. Nevertheless, there is not enough
evidence to date that this procedure improves the outcome
of snoring and sleep apnea surgery.
9  Multichannel Pressure Measurements
Changes in inspiratory pressure in the upper airway during
obstructive events can be measured with catheters. Different
measuring points meaning different pressure transducers
can be used from the nasopharynx through the orophar-
ynx and hypopharynx down to the esophagus. Initially,
pressure transducers were used mainly to investigate the
mechanisms of airway obstruction in general; nowadays,
research is focused on the diagnostic potentials compared
with standard polysomnography and on the assessment of
obstruction level and its impact on the outcome of sleep apnea
surgery.
9.1  Tolerability of the Pressure Catheters
Initially, pressure recordings in the field of SDB were per-
formed with balloon and open catheters, but esophageal
balloon catheters irritated the patients significantly. The
reliability of the results of micro-tip catheters was shown
during wakefulness and sleep for the esophagus and for the
pharynx. Well-designed studies demonstrated that catheters
with no more than 2 mm diameter did not alter the sleep
structure of patients suspected of SDB, and the results
obtained with or without catheters in place did not differ
significantly.29 In a large trial with 799 patients, only 3%
rejected the placement of the catheter, and 1% refused further
measurement during the night, whereas 96% tolerated the
procedure.30
9.2  Reliability of Measuring Points and
Assessment of Obstructive Events
Multichannel pressure catheters require a reliable positioning
of the measuring points to attribute the site of obstruction
to the anatomically defined segment of the airway. Most
investigators choose the oropharyngeal sensor as a reference
to be placed under visual control at the free edge of the soft
palate. The level of obstruction is usually described as an
“upper” or “lower” obstruction, meaning an obstruction at
the level of the soft palate or the level of the tongue base
(an isolated collapse at the level of the epiglottis cannot be
assessed with this method).
Pressure catheters also can be used to measure nasal and
pharyngeal airflow. This implies that they are suitable to
assess increased respiratory effort as well as the AHI. Tvin-
nereim et al. demonstrated that the absolute number of
obstructive and mixed apneas during sleep can be assessed
with these catheters with minimal deviation from the results
obtained by polysomnography.31 The overall sensitivity,
specificity, and negative predictive value for the detection
of the different types of apneas and hypopneas may reach
up to 100%. The data available indicate that multichannel
pressure recordings are suitable to assess the severity of
SDB.
20 Section B Diagnosis
9.3  Assessing the Sites of Airway Obstruction
When using only one measuring point placed at different
levels of the upper airway, it is difficult to identify a combined
collapse at different levels of hypopharynx and oropharynx;
therefore catheters with five to six sensors are currently
used. With those sensors a collapse extending over more
than one segment may routinely be found, the segments
may not even be adjacent, and the site of obstruction may
change during the night.
Investigations concerning night-to-night variability of the
distribution of the obstructive sites showed that the pre-
dominant site of obstruction can be reproduced during the
second night in more than 70% of the cases. Rollheim et al.
compared the patterns of obstruction as obtained in the
hospital with a recording at home. Although the mean AHI
was significantly higher in the hospital than at home, the
occurrence of palatal obstructions did not differ between
both recordings.32 In patients who had less than 40% or
more than 60% palatal obstructions in the first recording,
this relationship was reproduced in 90% of the cases during
the second recording.
9.4  Impact on the Success Rate of Surgery
for SDB
Metes et al. were the first to publish data concerning the
impact of pharyngeal pressure measurements on the success
rate of surgery.33 They used a catheter with only one measuring
point that was pulled through the pharynx and placed at
several sites along the upper airway to record several obstruc-
tive events at each site. The obstruction they found in this
way persisted in 8 of 12 patients after UPPP. Nevertheless,
the success rate of UPPP did not differ between patients
with predominant palatal or tongue base obstruction. Skatvedt
et al. selected 16 patients with different degrees of SDB
and predominant palatal obstruction detected by multichannel
pressure transducers for laser-assisted uvulopalatoplasty.34
Whereas the rate of “upper” obstructions dropped from
90% to 8.8% of all apneas, the number of upper hypopneas
was reduced only minimally. Osnes et al. compared the
efficacy of UPPP in patients with predominantly transpalatal
and subpalatal obstructions.35 After UPPP, transpalatal apneas
and hypopneas were reduced by 81%, whereas subpalatal
events only dropped by 42%. The success rate in patients
with transpalatal obstruction was significantly higher than
in those with subpalatal obstruction. Multichannel pressure
recordings seem to be superior to single-channel pull-through
techniques in predicting surgical success of soft palate surgery.
9.5  Significance of Multichannel
Pressure Recordings
Pressure catheters with a small diameter of not more than
2 mm are well tolerated and have only minimal impact on
sleep quality and airway obstructions. The pressure curves
allow a reliable detection of respiratory events. Positioning
of the measuring points by means of pharyngeal inspection
seems to be sufficiently accurate for the evaluation of the
palatal airway segment. There are no data suggesting that
obstructions at the hypopharynx and the epiglottis can be
discriminated reliably. The data available support the idea
that the success rate of soft palate surgery can be improved
when using multichannel pressure recordings for patient
selection.
10  Critical Closing Pressure
The severity of SDB is usually described by the AHI,
representing the number of upper airway obstructions
during sleep. Nevertheless, it has to be kept in mind that
the AHI simply describes the frequency of upper airway
obstructions, not the severity of the pharyngeal collapse
itself. Furthermore, measuring the severity of upper airway
collapse is believed to be important when estimating the
forces needed to overcome these obstructions or to maintain
upper airway stability. Schwartz et al.36 and Smith et al.37 first
measured upper airway collapsibility. They assessed airflow
and airway pressure using a special nasal continuous positive
airway pressure device with integrated pneumotachograph
and pressure sensor, being able to produce positive as well
as negative pressure levels. A pressure flow diagram can be
drawn at different levels of airway pressure, and a regression
line can be calculated. Smith defined the critical closing
pressure (Pcrit) as being the upper airway pressure when
the regression line is crossing the zero line, indicating that
airflow completely stops (Fig. 3.3). Patients with obstructive
apneas have a Pcrit clearly above zero; in simple snorers it
drops to 23 to 212 mbar, whereas in normal controls Pcrit
is, on average, below 28 mbar.
10.1  Impact of Treatment on Pcrit
Schwartz et al.38 showed that substantial weight loss resulted
in an improvement of Pcrit and a concomitant reduction of
the AHI. They investigated the effect of UPPP on Pcrit in
13 patients and found a significant decrease for the entire
group.39 Even though a complete normalization of Pcrit could
be demonstrated in the subgroup of responders in contrast
to nonresponders, they could not find any preoperative
predictor of response. An identical operation had individually
varying effects on Pcrit.
10.2  Significance of Critical Closing Pressure
The assessment of the critical closing pressure is an important
tool in the investigation of upper airway patency. It is the
gold standard for the measurement of the overall collapsibility
of the pharynx and is especially useful in research projects.
Currently, there are no data concerning the benefit of a
preoperative assessment of Pcrit for a better prediction of
success of upper airway surgery. Together with the relatively
complex assessment of Pcrit this may explain why Pcrit measure-
ments have not become a routine procedure in clinical testing
so far.
11  Summary
The various techniques of airway evaluation presented in
this chapter have significantly increased our insight into the
pathophysiology of SDB. Nevertheless, potential benefits
with regard to patient management or the superiority over
simple clinical assessment remain under discussion, and their
significance in daily practice is limited. There is not enough
 CHAPTER 3  Airway Evaluation in Obstructive Sleep Apnea 21

500
450

400

350

300

250

200

150

100

50

0
-2 -1 0 1 2 3 4 5 6 7 8
PN (cmH2O)
Supine Side

FIG. 3.3  Representative pressure flow relationships in the lateral recumbent and supine positions for one subject in non-REM sleep. Maximal
inspiratory airflow (V1 max) vs. nasal mask pressure (PN) is illustrated for lateral recumbent (open circles) and supine (closed circles) positions
with corresponding regression lines and confidence interval. Critical closing pressure is represented by the PN at which airflow becomes zero
in each body position (according to Boudewyns et al., Chest 2000;118:1031–41).

evidence that these techniques are superior to the routine
clinical assessment.
Acknowledgments
We want to thank Mr. J. Wich-Schwarz, PhD, for his editorial
assistance.
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