Although this finding is not unusual, I still find it remarkable, particularly because we were unaware of it until we began performing Drug Induced Sleep Endoscopy (DISE).
In patients with Obstructive Sleep Apnea (OSA), the upper airway collapses during sleep, leading to apnea episodes. It was previously thought that the only collapsible area in the upper airway was the oropharynx, which is also the usual anatomic origin of snoring, primarily involving the soft palate. Consequently, treatments were focused on the oropharynx, with numerous techniques developed for pharyngoplasty. We know that the base of tongue can also drop back while lying supine closing the posterior air space (PAS). This was the other anatomical area of therapeutic interest. But the larynx was not involved.
The primary function of the larynx is to protect the airway during swallowing. The larynx contains several sphincter systems and undergoes a complex physiological movement during swallowing to ensure the airway is sealed. One of these systems is the epiglottis, which acts as a cover over the glottis during swallowing.
This mechanism is clearly demonstrated in barium swallow videofluoroscopy. This dynamic examination underscores the importance of a sound understanding of the physiology of the upper airway, involved in a number of critical functions, most importantly breathing, swallowing, and speech.
However, in some patients, the epiglottis completely collapses the airway during sleep, and snoring actually originates from the epiglottis.
Usually, manoeuvrers that push the base of the tongue forward solve this problem. We can demonstrate this during DISE with chin lift or mandibular advancement manoeuvrers. Depending on the case, treatment options to reproduce this effect might include maxillo-mandibular advancement or orthodontic mandibular advancement appliances. A more direct treatment option would be epiglotoplasty.
Though we call it epiglottoplasty, the usual surgical technique involves resecting the upper two-thirds of the suprahyoid epiglottis. There are several techniques, but typically, no matter the approach, you will end up loosing sight of the suprahyoid epiglottis, resulting in an epiglottectomy.
As for the surgical tools to perform this, it depends on your preference: Transoral Laser Microsurgery (TLM), Transoral Robotic Surgery (TORS), or my favourite, Transoral Microsurgery with Micro-Electrodes (Basterra).
J Granell. 24 de julio de 2024.