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Review
. 2019 May-Jun;85(3):379-387.
doi: 10.1016/j.bjorl.2019.01.010. Epub 2019 Mar 8.

LwPTL: a novel classification for upper airway collapse in sleep endoscopies

Ahmed Elsobki  1 , Michel Burihan Cahali  2 , Mohamed Kahwagi  3
Affiliations
Review

LwPTL: a novel classification for upper airway collapse in sleep endoscopies

Ahmed Elsobki et al. Braz J Otorhinolaryngol. 2019 May-Jun.

Abstract
in English, Portuguese

Introduction: There is no consensus on a single classification system for the obstructive findings in drug-induced sleep endoscopy. Previous classification systems have neglected to address the upper retropalatal obstruction, the segmental division of the lateral pharyngeal wall and the primary or secondary nature of laryngeal collapse.

Objective: To propose, illustrate and evaluate a more comprehensive and yet simple classification for drug-induced sleep endoscopy findings.

Methods: Cross sectional study in a tertiary sleep surgery unit. A total of 30 patients with obstructive sleep apnea underwent drug-induced sleep endoscopy according to a new classification system called LwPTL, and its findings were analyzed according to obstructive sleep apnea severity and body mass index. LwPTL incorporates the description of upper retropalatal collapse, distinguishes the lateral pharyngeal wall collapse into three levels and clarify when laryngeal collapses are primary or secondary.

Results: 93.3% of the patients presented lateral pharyngeal wall collapse, usually at the level of the velum (73.3%). 80% presented multilevel collapse. Regarding the upper retropalatal region, LwPTL identified 10% of the cases presenting lateral salpingopharyngeal obstruction and 6.6% with high palatal collapse. 3.3% presented epiglottic collapse. Patients presenting lower levels of collapse, either from the lateral wall and/or tongue and/or larynx, represented 30% of the cases and had significantly more severe obstructive sleep apnea, without significant differences in body mass indexes.

Conclusion: LwPTL seems a simple and straightforward staging system for classifying drug-induced sleep endoscopy, distinguishing the important upper retopalatal obstruction and the primary and secondary laryngeal collapses, providing more information for appropriate treatment selection.

Introdução: Não há consenso sobre um sistema único de classificação para os achados obstrutivos da endoscopia do sono induzido por drogas. Os sistemas de classificação anteriores negligenciaram a abordagem da obstrução retropalatal alta, a divisão segmentar da parede lateral da faringe e a natureza primária ou secundária do colapso laríngeo.

Objetivo: Propor, ilustrar e avaliar uma classificação mais abrangente e simples para os achados da endoscopia do sono induzido por drogas.

Método: Estudo transversal em uma unidade terciária de cirurgia do sono. Foram submetidos à endoscopia do sono induzido por drogas 30 pacientes com apneia obstrutiva do sono, de acordo com um novo sistema de classificação denominado LwPTL, e seus achados foram analisados de acordo com a gravidade da apneia obstrutiva do sono e índice de massa corpórea .O LwPTL incorpora a descrição do colapso retropalatal alto, distingue o colapso da parede faríngea lateral em três níveis e esclarece quando os colapsos laríngeos são primários ou secundários.

Resultados: Apresentaram colapso da parede faríngea lateral 93,3% dos pacientes, geralmente no nível do palato mole (73,3%). Em 80% dos pacientes o colapso foi multinível. Em relação à região retropalatal alta, o LwPTL identificou 10% dos casos com obstrução salpingo-faríngea lateral e 6,6% com colapso alto do palato. Em 3,3% ocorreu colapso epiglótico. Pacientes com colapso em regiões baixas, tanto da parede lateral e/ou língua como e/ou laringe, representaram 30% dos casos e apresentaram apneia obstrutiva do sono significativamente mais grave, sem diferenças significantes no índice de massa corpórea.

Conclusão: O LwPTL parece um sistema de estadiamento simples e direto para classificar os achados da endoscopia do sono induzido por drogas, distingue a importante obstrução retropalatal alta e os colapsos laríngeos primários e secundários, fornece mais informações para uma seleção adequada do tratamento.

Keywords: Endoscopia; Endoscopy; Epiglote; Epiglottis; Faringe; Língua; Pharynx; Tongue.

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Figures

Figure 1
Figure 1
Fiberoptic view of LS collapse, Lateral pharyngeal wall collapse at the level of the salpingeopharyngeal folds.
Figure 2
Figure 2
Fiberoptic view of LV collapse, Lateral pharyngeal wall collapse at the level of the velum.
Figure 3
Figure 3
Fiberoptic view of LH collapse, Lateral pharyngeal wall collapse at the level of the hypopharynx.
Figure 4
Figure 4
Fiberoptic view of PHL collapse, High palatal collapse.
Figure 5
Figure 5
Fiberoptic view of PL collapse, Low palatal collapse.
Figure 6
Figure 6
Fiberoptic view of TH collapse, High tongue collapse.
Figure 7
Figure 7
Fiberoptic view of TL collapse, low tongue collapse causing secondary epiglottic collapse.
Figure 8
Figure 8
Fiberoptic view of Epiglottic collapse (Floppy epiglottis).
Figure 9
Figure 9
Fiberoptic view of Arytenoid collapse.
Figure 10
Figure 10
Fiberoptic view of transoral DISE showing the oral tongue not pushing the palate (negative tongue palate interaction).
Figure 11
Figure 11
Fiberoptic view of transoral DISE showing the oral tongue pushing the palate (positive tongue palate interaction).
Figure 12
Figure 12
Brief schematic presentation for surgical approach used according to classification system: (A) for Lw, lateral pharyngeal wall collapse and subdivisions; (B) for P, Palatal collapse and subdivisions; (C) for T, tongue collapse and subdivisions; (D) for L, laryngeal collapse.
Figure 13
Figure 13
Percent distribution of each level of collapse using the LwPTL classification for DISE (LS, Lateral wall collapse at the level of salpingeopharyngeal fold; LV, Lateral wall collapse at the level of the velum; LH, Lateral wall hypopharyngeal collapse; PL, Low palatal collapse; PHL, High and low palatal collapse; TL, Low tongue base collapse; TH, High tongue base collapse; L, Primary laryngeal collapse).
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