Abstract
Laryngomalacia occurs in some brain injury patients secondary to global muscle hypotonia. Surgical therapies for epiglottis prolapse have centered around removal or reshaping of the epiglottis. This approach has brought mixed success and frequent complications. We present a case that demonstrates successful nonsurgical treatment of a 33-year-old male brain injury patient with moderate obstructive sleep apnea that is believed to be a consequence of post-brain injury nocturnal epiglottis prolapse. The presence of a tracheostomy performed at the time of emergency surgery had become an emotional and physical barrier to our patient’s recovery. The tracheostomy could only be reversed if the obstructive sleep apnea disorder could be managed in an alternative fashion. A titratable mandibular repositioning appliance was prescribed and its effectiveness was demonstrated with nasolaryngoscopy and polysomnography.
After initially fitting the oral appliance, a period of accommodation and gradual protrusive adjustments was allowed. Subsequent confirmation polysomnography demonstrated improvement, but not suitable resolution, of disordered breathing events. However, an additional 1.25-mm protrusive titration of the oral appliance during the course of the confirmation polysomnogram led to therapeutic success. The patient’s tracheostomy was subsequently reversed with significant quality of life benefits.
This is a preview of subscription content, log in via an institution to check access.
References
Lowe AA, Sjoholm TT, Ryan CF, Fleetham JA, Ferguson KA, Remmers JE. Treatment, airway, and compliance effects of a titratable oral appliance. Sleep 2000;23(suppl 4):S172–S178
Pancer J, Al-Faifi S, Al-Faifi M, Hoffstein V. Evaluation of variable mandibular advancement for treatment of snoring and sleep apnea. Chest 1999;116:1511–1518
Randerath W, Heise M, Hinz R, Ruchle K. An individually adjustable oral appliance vs. continuous positive airway pressure in mild-to-moderate obstructive sleep apnea syndrome. Chest 2002;122:569–575
Furguson KA, Ono T, Lowe AA et al. A randomized cross-over study of an oral appliance vs. nasal CPAP in the treatment of mild-moderate OSA. Chest 1996;109:1269–1275
Clark GT, Blumenfeld I, Yoffe N et al. A crossover study comparing the efficacy of CPAP with anteriorly mandibular repositioning devices on patients with OSA. Chest 1996;109:1477–1483
Smith S. A three-dimensional airway assessment for the treatment of snoring and/or sleep apnea with jaw positioning intra-oral appliances: a case study. Cranio 1996;14:332–343
Fransson AM, Svenson BA, Isacsson G. The effect of posture and a mandibular protruding device on pharyngeal dimensions: a cephalometric study. Sleep Breath 2002;6:55–68
Liu Y, Park Y-C, Lowe A, Fleetham J. Supine cephalometric analysis of an adjustable oral appliance used in the treatment of obstructive sleep apnea. Sleep Breath 2000;4:59–66
Yoshida K. Effect of a prosthetic appliance for treatment of sleep apnea syndrome on masticatory and tongue muscle activity. J Prosthet Dent 1998;79:537–544
Skinner M, Robertson C, Kingshott R, Jones D, Taylor DR. The efficacy of a mandibular advancement splint in relation to cephalometric variables. Sleep Breath 2002;6:115–124
Tsuiki S, Hiyama S, Ono T et al. Effects of a titratable oral appliance on supine airway size in awake non-apneic individuals. Sleep 2001;24:554–560
George P. Selecting sleep-disordered-breathing appliances. Biomechanical considerations. J Am Dent Assoc 2001;132:339–347
Tufik S. Effects of mandibular posture on obstructive sleep apnea severity and the temporomandibular joint in patients fitted with an oral appliance. Sleep 2002;25:507–513
Kat J, Isono S, Tanaka A et al. Dose-dependent effects of mandibular advancement on pharyngeal mechanics and nocturnal oxygenation in patients with sleep disordered breathing. Chest 2000;117:1065–1072
Roberts D, Becker P, Jamieson A. Determination of a split night oral appliance and CPAP protocol using polysomnography. Paper presented at: Associated Professional Sleep Societies June 1998 New Orleans, LA
Thornton WK. Combined CPAP-oral appliance therapy. Sleep Rev 2002;3:16–21
Isono S, Tanaka A, Sho Y, Konno A, Nishino T. Advancement of the mandible improves velopharyngeal airway patency. J Appl Physiol 1995;79:2132–2138
Raphaelson M, Alpher E, Bakker K, Perlstrom J. Oral appliance therapy for obstructive v sleep apnea syndrome: progressive mandibular advancement during polysomnography. Cranio 1998;16:44–50
Fakhry S, Trask A, Waller M, Watts D. Management of brain-injured patients by an evidence-based medicine protocol improves outcomes and decreases hospital charges. J Trauma 2004;56:492–500
Webster J, Bell K, Hussey J, Natale T, Lakshminarayan S. Sleep apnea in adults with traumatic brain injury: a preliminary investigation. Arch Phys Med Rehabil 2001;82:316–321
Catalfumo F, Golz A, Westerman S, Gilbert L, Joachims H, Goldenberg D. The epiglottis and obstructive sleep apnoea syndrome. J Laryngol Otol 1998;112:940–943
Woo P. Acquired laryngomalacia: epiglottis prolapse as a cause of airway obstruction. Ann Otol Rhinol Laryngol 1992;101:314–320
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Conaway, J.R., Scherr, S.C. Multidisciplinary Management of the Airway in a Trauma-Induced Brain Injury Patient. Sleep Breath 8, 165–170 (2004). https://doi.org/10.1007/s11325-004-0165-5
Issue Date:
DOI: https://doi.org/10.1007/s11325-004-0165-5