Oblika poklopca kot napovedni dejavnik za obstrukcijo na nivoju poklopca pri odraslih bolnikih z obstruktivnimi motnjami dihanja med spanjem

Delakorda, Matej (author), Hočevar Boltežar, Irena (mentor)

Izhodišča Ocena nivoja v zgornjih dihalih, na katerem pri bolniku z obstruktivnimi motnjami dihanja med spanjem (OSA) prihaja do obstrukcij, je pomembna, saj lahko vpliva na odločitev o najprimernejšem zdravljenju. Kljub številnim diagnostičnim možnostim to ni vedno enostavno, kar še posebej velja za bolnike, pri katerih prihaja do obstrukcij na nivoju korena jezika in/ali poklopca. Za to skupino bolnikov je dolgo veljalo, da pri njih med kliničnim pregledom v področju ust, žrela in grla ni videti sprememb, ki so sicer značilne za bolnike z OSA. Ob velikem naboru preiskav ima pri tem odločilno vlogo pregled zgornjih dihal v kratki sedaciji (DISE), pri katerem lahko s fleksibilnim endoskopom spremljamo statične in dinamične obstrukcije. Kljub temu lahko bolezenski proces ostane podcenjen, kakšno od mest zožitve pa spregledano. Klinični pregled v budnosti je še vedno temelj vsake obravnave, zato bi bila vsaka značilnost teh bolnikov, po kateri se razlikujejo od ostalih, zelo dobrodošla. Namen naloge Namen raziskave je bil ugotoviti, če se pri bolnikih z OSA, ki imajo poravnan poklopec, obstrukcije na nivoju korena jezika in/ali poklopca, ki jih ugotovimo med DISE, pojavljajo pogosteje kot pri tistih, pri katerih poklopec ni takšne oblike. Spoznanje, da se določena oblika poklopca pogosteje pojavlja pri obstrukcijah na navedenih nivojih, bi prispevalo k lažji prepoznavi teh bolnikov in služilo kot pomoč pri izbiri najustreznejšega načina zdravljenja. Metode V raziskavo smo vključili 105 zaporednih odraslih bolnikov s klinično in poligrafsko potrjenimi OSA. Pri vseh smo zbrali demografske (spol, starost) in nekatere antropometrične podatke (telesna višina, telesna teža, obseg vratu). Oblika poklopca je bila ocenjena med otorinolaringološkim pregledom v budnem stanju, nato pa še med DISE. Različne oblike poklopca smo razvrstili v tri skupine glede na izraženosti ukrivljenosti v anteroposteriorni smeri: tip 1 - omegast, tip 2 - običajno ukrivljen in tip 3 - poravnan poklopec. Navedene oblike smo med seboj primerjali glede na nivoje obstrukcij v zgornjih dihalih, ki smo jih opredelili med DISE. Oceno oblike poklopca in nivoja obstrukcije sta s pomočjo shranjenih posnetkov DISE dodatno opravila še dva neodvisna ocenjevalca. S primerjavo ocen vseh treh ocenjevalcev smo izračunali ujemanje med ocenami nivojev obstrukcij in oblike poklopca. Skupino bolnikov s poravnanim poklopcem smo s preostalimi primerjali tudi glede na zbrane demografske, antropometrične in podatke, pridobljene z respiratorno poligrafijo med spanjem (PG). Rezultati S kliničnim pregledom smo od 105 bolnikov, vključenih v raziskavo, zaznali 36, z DISE pa 40 takšnih s poklopcem tip 3. Skladnost pri ocenjevanju oblike poklopca med obema pregledoma je bila ocenjena kot dobra s koeficientom skladnosti (?) 0,62. Skladnost pri oceni oblike poklopca med vsemi tremi ocenjevalci je bila prav tako dobra (?=0,66), pri oceni nivoja obstrukcij med DISE pa se je razlikovala glede na nivo. Najvišja - dobra je bila pri obstrukciji na nivoju poklopca (?=0,63), najnižja - zmerna pa pri mehkem nebu (?=0,32). Pri ustnem žrelu in korenu jezika je ? znašala 0,46 in 0,42, kar velja za srednje dobro skladnost. Pri ocenjevanju ujemanja ocen nivojev obstrukcij in oblike poklopca med posameznimi ocenjevalci smo ugotovili, da izkušenost zdravnika ni bila statistično pomembna. Oblika poklopca, ocenjena med kliničnim pregledom, je statistično značilno povezana z med DISE ugotovljenimi obstrukcijami na korenu jezika (p=0,003), poklopcu (p=0,001) ter jeziku in/ali poklopcu (p<0.001). V skupini bolnikov s poklopcem tip 3 so bile obstrukcije na nivoju korena jezika in/ali poklopca statistično pomembno pogostejše kot v skupini bolnikov s poklopcem tip 1 ali 2. Bolnikov, ki so med kliničnim pregledom imeli poklopec tip 3, je bilo 36/105 (34 %), med njimi 23 (64 %) bolnikov z obstrukcijo na nivoju korena jezika, 13 (36 %) z obstrukcijo na nivoju poklopca in 29 (81 %) bolnikov z obstrukcijo na kateremkoli od obeh nivojev. V tej skupini obstrukcije na nobenem od obeh nivojev nismo zaznali le pri 7 (19 %) bolnikih. Poklopca tip 1 in 2 sta bila prisotna pri 69 (66 %) bolnikov. Med njimi smo obstrukcijo na nivoju poklopca med DISE zaznali le v 7 (10 %) primerih. Dodatno multivariatno testiranje je pokazalo, da je oblika poklopca, ocenjena med kliničnim pregledom, statistično značilno povezana z obstrukcijo na jeziku (p=0,010), poklopcu (p=0,008) ter jeziku in/ali poklopcu (p=0,002) ne glede na starost, obseg vratu in indeks respiratornih dogodkov. Bolniki z ravno obliko poklopca imajo 3,5-krat večje obete za obstrukcijo na jeziku kot tisti, pri katerih poklopec ni takšne oblike. Prav tako so obeti večji za obstrukcijo na nivoju poklopca, za približno 5-krat. Če združimo oba nivoja, razmerje obetov znaša 5,4.Bolniki s poklopcem tip 3 so bili od ostalih v povprečju starejši 6 let in so imeli v povprečju za 3,5 dogodka/h nižji indeks respiratotnih dogodkov. Pri primerjavi oblike poklopca z ostalimi demografskimi in antropometričnimi lastnostmi statistično pomembnih razlik nismo ugotovili. Zaključki Pri bolnikih z OSA, ki imajo poravnano obliko poklopca (tip 3), se med DISE določene obstrukcije na nivoju korena jezika in/ali poklopca pojavljajo pogosteje kot pri tistih, ki takšnega poklopca nimajo. Za odrasle bolnike z OSA, pri katerih med kliničnim pregledom ugotovimo poklopec tip 3, lahko glede na naše rezultate z 80 % verjetnostjo napovemo prisotnost obstrukcije na nivoju korena jezika in/ali poklopca. Rezultati kažejo tudi na to, da na takšno obliko poklopca ostali spremljani parametri ne vplivajo. V skupini bolnikov s poklopcem tip 1 ali 2 se obstrukcije na nivoju poklopca pojavljajo zelo redko. Menimo, da rezultati naše raziskave lahko pomembno pripomorejo k prepoznavi bolnikov z obstrukcijo na teh nivojih in odločanju za morebitne dodatne diagnostične postopke ter najustreznejši način zdravljenja. Opisana razdelitev oblik poklopca lahko služi tudi kot osnova za razvrščanje najdb ob kliničnem pregledu v tem področju.

• Language: Slovenian
• Keywords: OSA, obstruktivne motnje dihanja med spanjem, diagnostika, oblika pokolopca
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2020
• PID: 20.500.12556/RUL-117340
• COBISS.SI-ID: 24215555
• Publication date in RUL: 08.07.2020

Secondary language

• Language: English
• Title: Epiglottis shape as a predictor of obstruction at epiglottis level in adult patients with obstructive sleep apnea

Abstract

Background Identifying the site of obstruction in the upper respiratory tract in patients with obstructive sleep apnea (OSA) is important since it can influence the decision on most suitable treatment. Despite a broad range of diagnostic methods, this is not always simple and straightforward particularly for the level of the tongue base and/or epiglottis. There have been few typical characteristics on physical examination in this group of patients described to date. Among expanse of diagnostic options, although not ideal, DISE continues to play an important role in the identification of both static and dynamic obstructions. Nevertheless, the disease often remains underestimated and some obstructive sites may be overlooked. Identification of specific characteristics in patients with obstruction at the level of tongue base and/or epiglottis can therefore aid in-depth consideration and greater success in final decision making about the most suitable treatment. Aim of the study We wanted to verify our observations about the specific shape of the epiglottis in OSA patients with obstruction at the level of the tongue base and/or epiglottis, specifically the lack of concavity. This could contribute to better identification of patients with a narrowing at this level, and lead to better decisions regarding the choice of surgical treatment. Methods One hundred five consecutive adult OSA patients were included in the study. We collected demographic (sex, age) and anthropometric (body height, weight and neck circumference) data. Epiglottis shape was assessed during the awake state in upright position and also during short sedation (DISE) in the supine position. Epiglottis shape was classified into three groups: type 1 - omega, type 2 - normal concave and type 3 - flat epiglottis. The DISE results, including site and rate of obstruction, were compared to the epiglottis shape determined during clinical examination and during DISE. Using these archived DISE recordings, the same comparison was done by two other otorhinolaryngologists who were otherwise blinded to the patients. We calculated the interrater reliability for obstruction site results and epiglottis shape evaluation by three different observers.   Results Among the 105 patients included in our study, we identified type 3 epiglottis in 36 cases on clinical examination and 40 cases during DISE. Epiglottis shape concordance between both examinations was good with correlation coeficient (κ) 0,62. Interrater reliability for epiglottis shape among the three observers was also good (κ=0,66). Concordance differed with regard to level of obstruction. Agreement was highest at the epiglottis (good; κ=0,63) and lowest at the soft palate level (moderate; κ=0,32). At the oropharynx and tongue base it was fair, with κ values of 0,46 and 0,42 respectively. Observer experience did not play a significant role in these results. Epiglottis shape as assessed during clinical examination significantly correlated with obstruction at the tongue base (p=0,003), epiglottis (p=0,001), individually, and combined, tongue base and/or epiglottis (p<0.001). In patients with type 3 epiglottis, obstructions at these levels occurred more often than in cases of type 1 and 2 epiglottis. Within the type 3 group among 36/105 (36 %) patients, there were 23 (64 %) patients with obstruction at the tongue base level and 13 (36 %) patients with obstruction at the epiglottis level. 29 patients (81 %) had obstruction at the tongue base and/or epiglottis level. In this group, obstructions at the tongue base and/or epiglottis level were not found in only 7 patients (19 %). Type 1 and 2 epiglottis shapes were observed in 69 (66 %) of our patients. In this cohort there were only 7 cases (10 %) with obstruction at the level of epiglottis. Multivariate analysis showed that epiglottis shape correlates significantly with obstruction at the tongue base (p=0,010), epiglottis and (p=0,008) tongue base and/or epiglottis (p=0,002) regardless of age, neck circumference and respiratory disturbance index. Patients with type 3 epiglottis have 3.5-times greater odds ratio for having obstruction at the tongue base, 5-times greater at the epiglottis and 5.4-times greater for tongue base and/or epiglottis, compared to patients who lack such epiglottis shape. On average patients with epiglottis type 3 compared to the remainder were 6 years older and had respiratory event index 3.5 higher. Regarding other variables this group did not differ substantialy from the others. Conclusions In this study, we show that assessment of epiglottis shape correlates with obstruction at the level of tongue base and/or epiglottis with considerable probability (80 %). Specifically, the epiglottis has a predominantly flat shape, without the characteristic anterior convexity in the medial part. In patients with type 1 or 2 epiglottis obstructions at epiglottis occur very rarely. This characteristic flat epiglottis shape, which can be observed on awake examination of the upper respiratory tract, can inform decision making for further diagnostic procedures and it brings to the clinician's attention the fact that extra care is required regarding the decision about the best treatment. Since the proposed epiglottis shape classification has clinical implications, it could also serve as a tool for standardisation of clinical findings in larynx.

• Keywords: OSA, obstructive sleep apnea, diagnosis, epiglottis shape