- Email: [email protected]
Response to Michael Friedman re: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey”
Letters to the editor
FINANCIAL DISCLOSURE None.
REFERENCES 1. Khalid AN, Quraishi SA, Kennedy DW. Long-term quality of life measures after functional endoscopic sinus surgery. Am J Rhinol 2004; 18:131– 6. 2. Metson R, Glicklich RE. Clinical outcome of endoscopic surgery for frontal sinusitis. Arch Otolaryngol Head Neck Surg 1998;124:1090 – 6. 3. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: Effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;136:261–7.
doi:10.1016/j.otohns.2007.05.052
Response to: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey”
527 the position the Friedman Tongue Position as opposed to a Mallampati scale. The modifications are significant enough that the term Mallampati is incorrect and does not represent an assessment that is valuable for obstructive sleep apnea. I agree completely, however, with the authors that the Friedman Tongue Position is an important prognostic indicator that the patient will likely have recurrence or persistence of obstructive sleep apnea after the initial benefit of adenotonsillectomy. Michael Friedman, MD Professor of Otolaryngology Rush University Medical Center Chicago, IL E-mail [email protected]
FINANCIAL DISCLOSURE None.
The recently published article by Dr Christian Guilleminault et al, entitled “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey,” is an extremely important contribution to the medical literature and to our understanding of obstructive sleep apnea. We have long been aware that many adults who have had adenotonsillectomy as a child present with obstructive sleep apnea. In fact, it is also well known to an otolaryngologist that these are the most difficult patients to treat. It is therefore logical to assume that adenotonsillectomy does not cure all patients with obstructive sleep apnea. I would like to comment on the author’s use of the term “Mallampati scale” for determining the tongue position. Dr Mallampati originally described a palate-position scoring system to predict difficult intubation. Dr Mallampati never studied the relevance of this position to obstructive sleep apnea. In his paper quoted by Dr Guilleminault, the evaluation is done with the patient protruding his or her tongue. In addition, he only has three levels of palate position. The concept of using a similar but modified assessment for evaluating sleep apnea was based on a study that I performed in 1999. At that time, I modified the assessment by having the patients open their mouth without protruding their tongue. This is an important modification in the assessment of obstructive sleep apnea since we do not protrude our tongue when we are asleep. The position often changes significantly whether this procedure is done with the tongue protruded or not. Over the course of the last 8 years, I have incorporated the tongue position utilizing this modified assessment and studied it with relationship to obstructive sleep apnea in 12 published articles. During the course of this time, the modifications not only included the change in tongue protrusion, but also the number of positions was initially changed from three to four, and currently it is being assessed to include five levels. Because of these modifications, I have renamed
doi:10.1016/j.otohns.2007.06.721
Response to Michael Friedman re: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey” We thank Dr Friedman for his comments. We are aware of Dr Friedman’s investigations and his description of the tongue maneuver; in fact, we systematically ask our adult patients to perform maneuvers while pulling their tongue forward and while keeping their tongue inside the mouth. In young children, we have found that it was much easier to obtain subject collaboration when asking them to pull their tongue forward than to keep their tongue inside the mouth. We tried the 2 different approaches during a test period and the results were overwhelming in young individuals: we obtained much greater positive results with pulling tongue forward (often young children found the maneuver a great thing to do); after 7 years of age and older there was no difference in response rate. As a large number of our subjects are in the younger age range, we prefer to have a positive response than no response at all. We acknowledge that Dr Mallampati described his maneuver in relation to ease of intubation, which is also affected by airway size, jaw size, and jaw positions. The term “Mallampati maneuver” has been used in the sleep medicine field for over 20 years, as the idea to use an equivalent maneuver to evaluate upper airway in OSA patients was derived from the article of Mallampati and colleagues. Usage of tongue maneuvers is important; such maneuvers are helpful clinical tools to investigate the presence of anatomic risks of airway narrowing during sleep. The Friedman tongue maneuver is an approach that should be used by all involved in the investigation of patients suspected of sleep-disordered breathing.
528
Otolaryngology–Head and Neck Surgery, Vol 137, No 3, September 2007 Christian Guilleminault Allison Chan Kasey Li Stanford University Sleep Medicine Program, Stanford, CA E-mail: [email protected]
FINANCIAL DISCLOSURE None.
doi:10.1016/j.otohns.2007.06.722
FINANCIAL DISCLOSURE None.
REFERENCES 1. Khalid AN, Quraishi SA, Kennedy DW. Long-term quality of life measures after functional endoscopic sinus surgery. Am J Rhinol 2004; 18:131– 6. 2. Metson R, Glicklich RE. Clinical outcome of endoscopic surgery for frontal sinusitis. Arch Otolaryngol Head Neck Surg 1998;124:1090 – 6. 3. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: Effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;136:261–7.
doi:10.1016/j.otohns.2007.05.052
Response to: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey”
527 the position the Friedman Tongue Position as opposed to a Mallampati scale. The modifications are significant enough that the term Mallampati is incorrect and does not represent an assessment that is valuable for obstructive sleep apnea. I agree completely, however, with the authors that the Friedman Tongue Position is an important prognostic indicator that the patient will likely have recurrence or persistence of obstructive sleep apnea after the initial benefit of adenotonsillectomy. Michael Friedman, MD Professor of Otolaryngology Rush University Medical Center Chicago, IL E-mail [email protected]
FINANCIAL DISCLOSURE None.
The recently published article by Dr Christian Guilleminault et al, entitled “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey,” is an extremely important contribution to the medical literature and to our understanding of obstructive sleep apnea. We have long been aware that many adults who have had adenotonsillectomy as a child present with obstructive sleep apnea. In fact, it is also well known to an otolaryngologist that these are the most difficult patients to treat. It is therefore logical to assume that adenotonsillectomy does not cure all patients with obstructive sleep apnea. I would like to comment on the author’s use of the term “Mallampati scale” for determining the tongue position. Dr Mallampati originally described a palate-position scoring system to predict difficult intubation. Dr Mallampati never studied the relevance of this position to obstructive sleep apnea. In his paper quoted by Dr Guilleminault, the evaluation is done with the patient protruding his or her tongue. In addition, he only has three levels of palate position. The concept of using a similar but modified assessment for evaluating sleep apnea was based on a study that I performed in 1999. At that time, I modified the assessment by having the patients open their mouth without protruding their tongue. This is an important modification in the assessment of obstructive sleep apnea since we do not protrude our tongue when we are asleep. The position often changes significantly whether this procedure is done with the tongue protruded or not. Over the course of the last 8 years, I have incorporated the tongue position utilizing this modified assessment and studied it with relationship to obstructive sleep apnea in 12 published articles. During the course of this time, the modifications not only included the change in tongue protrusion, but also the number of positions was initially changed from three to four, and currently it is being assessed to include five levels. Because of these modifications, I have renamed
doi:10.1016/j.otohns.2007.06.721
Response to Michael Friedman re: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey” We thank Dr Friedman for his comments. We are aware of Dr Friedman’s investigations and his description of the tongue maneuver; in fact, we systematically ask our adult patients to perform maneuvers while pulling their tongue forward and while keeping their tongue inside the mouth. In young children, we have found that it was much easier to obtain subject collaboration when asking them to pull their tongue forward than to keep their tongue inside the mouth. We tried the 2 different approaches during a test period and the results were overwhelming in young individuals: we obtained much greater positive results with pulling tongue forward (often young children found the maneuver a great thing to do); after 7 years of age and older there was no difference in response rate. As a large number of our subjects are in the younger age range, we prefer to have a positive response than no response at all. We acknowledge that Dr Mallampati described his maneuver in relation to ease of intubation, which is also affected by airway size, jaw size, and jaw positions. The term “Mallampati maneuver” has been used in the sleep medicine field for over 20 years, as the idea to use an equivalent maneuver to evaluate upper airway in OSA patients was derived from the article of Mallampati and colleagues. Usage of tongue maneuvers is important; such maneuvers are helpful clinical tools to investigate the presence of anatomic risks of airway narrowing during sleep. The Friedman tongue maneuver is an approach that should be used by all involved in the investigation of patients suspected of sleep-disordered breathing.
528
Otolaryngology–Head and Neck Surgery, Vol 137, No 3, September 2007 Christian Guilleminault Allison Chan Kasey Li Stanford University Sleep Medicine Program, Stanford, CA E-mail: [email protected]
FINANCIAL DISCLOSURE None.
doi:10.1016/j.otohns.2007.06.722