Sleep and Breathing

, Volume 23, Issue 1, pp 311–317 | Cite as

Epiglottis shape as a predictor of obstruction level in patients with sleep apnea

  • Matej DelakordaEmail author
  • Nina Ovsenik
ENT • Original Article



Despite a broad range of diagnostic methods, identifying the site of obstruction in the upper respiratory tract in patients with obstructive sleep apnea is not always simple and straightforward. With regard to this problem, we present our observations about the specific shape of the epiglottis in patients with obstruction at the level of the tongue base and/or epiglottis.


One hundred and forty consecutive drug-induced sleep endoscopy (DISE) video recordings of patients with polygraphy-verified obstructive sleep apnea were analyzed by three independent observers. We compared the levels of obstruction using the VOTE classification and the shape of the epiglottis, both as seen during the DISE investigation and in the awake state. We have calculated the interrater reliability for VOTE classification results and epiglottis shape evaluation by three different observers.


Out of 140 patients, there were 52 (37.1%) with a flat epiglottis. Within this group, there were only 3 (6%) cases in which obstructions at the tongue base and/or epiglottis level were not found. In the group with normally convex and omega-shaped epiglottis, obstruction at the tongue base level was observed in 28 patients (31.8%); obstruction at the epiglottis level was observed in 5 patients (5.7%); and obstruction at both the epiglottis and tongue base level was observed in 3 patients (3.4%). Interrater reliability for VOTE classification was poor for V (ICC = 0.414) and good for O (ICC = 0.824), T (ICC = 0.775), and E (ICC = 0.852). Additionally, interrater reliability was excellent for epiglottis shape (ICC = 0.912).


In patients with obstructive sleep apnea, examinations in the awake state and drug-induced sleep endoscopy both showed that in most cases of obstruction at epiglottis and/or tongue base, the epiglottis was flat, i.e., lacking the typical anterior convexity in its upper part. We assume that the change of its shape is a result of degeneration of suspensory apparatus that maintains the shape of the epiglottis and holds it in its position. This could contribute to the better identification of patients with a narrowing at this level, and in turn to better decisions regarding the choice of the most suitable treatment.


Sleep apnea Diagnosis Site of obstruction Epiglottis shape 



The authors wish to acknowledge Prof. Dr. Irena Hočevar Boltežar for her contribution to the article and Dr. Andrej Florjan for his evaluation of DISE recordings.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of study, formal consent is not required.


  1. 1.
    Certal V, Nishino N, Camacho M, Capasso R (2013) Reviewing the systematic reviews in OSA surgery. Otolaryngol Head Neck Surg 149:817–829CrossRefGoogle Scholar
  2. 2.
    Rotenberg BW, Vicini C, Pang EB, Pang KP (2016) Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature. J Otolaryngol Head Neck Surg 45:23CrossRefGoogle Scholar
  3. 3.
    Goldberg AN, Schwab RJ (1998) Identifying the patient with sleep apnea: upper airway assessment and physical examination. Otolaryngol Clin N Am 31(6):919–930CrossRefGoogle Scholar
  4. 4.
    Charakorn N, Kezirian EJ (2016) Drug-induced sleep endoscopy. Otolaryngol Clin N Am 49(6):1359–1372CrossRefGoogle Scholar
  5. 5.
    Woodson BT, Naganuma H (1999) Comparison of methods of airway evaluation in obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 120(4):460–463Google Scholar
  6. 6.
    Blumen MB, Latournerie V, Bequignon E, Guillere L, Chabolle F (2015) Are the obstruction sites visualized on drug-induced sleep endoscopy reliable? Sleep Breath 19(3):1021–1026CrossRefGoogle Scholar
  7. 7.
    Eichler C, Sommer JU, Stuck BA, Hörmann K, Maurer JT (2013) Does drug-induced sleep endoscopy change the treatment concept of patients with snoring and obstructive sleep apnea? Sleep Breath 17(1):63–68CrossRefGoogle Scholar
  8. 8.
    Wirth M, Schramm J, Bautz M, Hofauer B, Edenharter G, Ott A, Heiser C (2018) Reduced upper obstructions in N3 and increased lower obstructions in REM sleep stage detected with manometry. Eur Arch Otorhinolaryngol 275(1):239–245CrossRefGoogle Scholar
  9. 9.
    Altintaş A et al (2018) Interobserver consistency of drug-induced sleep endoscopy in diagnosing obstructive sleep apnea using a VOTE classification system. J Craniofac Surg 29(2):140–143Google Scholar
  10. 10.
    Carrasco-Llatas M, Zerpa-Zerpa V, Dalmau-Galofre J (2017) Reliability of drug-induced sedation endoscopy: interobserver agreement. Sleep Breath 21(1):173–179CrossRefGoogle Scholar
  11. 11.
    Tang JA, Salapatas AM, Bonzelaar LB, Friedman M (2017) Long-term incidence of velopharyngeal insufficiency and other sequelae following uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 156(4):606–610CrossRefGoogle Scholar
  12. 12.
    Oliveira MC et al (2015) Systematic evaluation of the upper airway in a sample population: factors associated with obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 153(4):663–670CrossRefGoogle Scholar
  13. 13.
    Torre C, Camacho M, Liu SY et al (2016) Epiglottis collapse in adult obstructive sleep apnea: a systematic review. Laryngoscope 126(2):515–523CrossRefGoogle Scholar
  14. 14.
    Catalfumo FJ, Golz A, Westerman ST et al (1998) The epiglottis and obstructive sleep apnoea syndrome. J Laryngol Otol 112:940–943CrossRefGoogle Scholar
  15. 15.
    Cavaliere M, Russo F, Iemma M (2013) Awake versus drug-induced sleep endoscopy: evaluation of airway obstruction in obstructive sleep apnea/hypopnoea syndrome. Laryngoscope 123:2315–2318CrossRefGoogle Scholar
  16. 16.
    Woodson BT (2015) A method to describe the pharyngeal airway. Laryngoscope 125:1233–1238CrossRefGoogle Scholar
  17. 17.
    Kezirian EJ, Hohenhorst W, De Vries N (2011) Drug-induced sleep endoscopy: the VOTE classification. Eur Arch Otorhinolaryngol 268(8):1233–1236CrossRefGoogle Scholar
  18. 18.
    Koo TK, Li MY (2016) A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 15(2):155–163CrossRefGoogle Scholar
  19. 19.
    Maurer JT, Stuck BA, Hein G, Hörmann K (2000) Videoendoscopic assessment of uncommon sites of upper airway obstruction during sleep. Sleep Breath 4(3):131–136CrossRefGoogle Scholar
  20. 20.
    Grzegorowski M, Pucher B (2000) Congenital laryngomalacia in children. Otolaryngol Pol 54:561–565Google Scholar
  21. 21.
    Hey SY, Oozeer NB, Robertson S, MacKenzie K (2014) Adult-onset laryngomalacia: case reports and review of management. Eur Arch Otorhinolaryngol 271:3127–3132CrossRefGoogle Scholar
  22. 22.
    Rowe-Jones J, Moore-Gillon V, Hamilton P (1993) Acquired laryngomalacia: epiglottis prolapse as a cause of airway obstruction. Ann Otol Rhinol Laryngol 102(6):485–486Google Scholar
  23. 23.
    Woo P (1992) Acquired laryngomalacia: epiglottis prolapse as a cause of airway obstruction. Ann Otol Rhinol Laryngol 101(4):314–320CrossRefGoogle Scholar
  24. 24.
    Woodson BT, Wooten MR (1994) Comparison of upper-airway evaluations during wakefulness and sleep. Laryngoscope 104(7):821–828CrossRefGoogle Scholar
  25. 25.
    Gazayerli M, Bleibel W, Elhorr A, Maxwell D, Seifeldin R (2006) A correlation between the shape of the epiglottis and obstructive sleep apnea. Surg Endosc 20:836–837CrossRefGoogle Scholar
  26. 26.
    Gazayerli M, Bleibel W, Elhorr A et al (2006) The shape of the epiglottis reflects improvement in upper airway obstruction after weight loss. Obes Surg 16(7):945–947CrossRefGoogle Scholar
  27. 27.
    Li S, Wu D, Jie Q, Bao J, Shi H (2014) Lingua–epiglottis position predicts glossopharyngeal obstruction in patients with obstructive sleep apnea hypopnea syndrome. Eur Arch Otorhinolaryngol 271:2737–2743CrossRefGoogle Scholar
  28. 28.
    Sawatsubashi M, Umezaki T, Kusano K, Tokunaga O, Oda M, Komune S (2010) Age-related changes in the hyoepiglottic ligament: functional implications based on histopathologic study. Am J Otolaryngol 31(6):448–452CrossRefGoogle Scholar
  29. 29.
    DI Venere D et al (2017) Obstructive site localization in patients with obstructive sleep apnea syndrome: a comparison between otolaryngologic data and cephalometric values. Oral Implantol 10(3):295–310CrossRefGoogle Scholar
  30. 30.
    Vandaele DJ, Perlman AL, Cassell MD (1995) Intrinsic fibre architecture and attachments of the human epiglottis and their contributions to the mechanism of deglutition. J Anat 186:1–15Google Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Otolaryngology–Head and Neck SurgeryGeneral Hospital CeljeCeljeSlovenia
  2. 2.Faculty of MedicineUniversity of LjubljanaLjubljanaSlovenia

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