Multidisciplinary Management of the Airway in a Trauma-Induced Brain Injury Patient

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.

KEYWORDS

Sleep apnea - oral appliance therapy - epiglottis prolapse - brain injury - laryngomalacia

REFERENCES

• 1 Lowe A A, Sjoholm T T, Ryan C F, Fleetham J A, Ferguson K A, Remmers J E. Treatment, airway, and compliance effects of a titratable oral appliance.  Sleep. 2000;  23(suppl 4) S172-S178
• 2 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
• 3 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
• 4 Furguson K A, Ono T, Lowe A A 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
• 5 Clark G T, 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
• 6 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
• 7 Fransson A M, Svenson B A, Isacsson G. The effect of posture and a mandibular protruding device on pharyngeal dimensions: a cephalometric study.  Sleep Breath. 2002;  6 55-68
• 8 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
• 9 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
• 10 Skinner M, Robertson C, Kingshott R, Jones D, Taylor D R. The efficacy of a mandibular advancement splint in relation to cephalometric variables.  Sleep Breath. 2002;  6 115-124
• 11 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
• 12 George P. Selecting sleep-disordered-breathing appliances. Biomechanical considerations.  J Am Dent Assoc. 2001;  132 339-347
• 13 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
• 14 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
• 15 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;
• 16 Thornton W K. Combined CPAP-oral appliance therapy.  Sleep Rev. 2002;  3 16-21
• 17 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
• 18 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
• 19 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
• 20 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
• 21 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
• 22 Woo P. Acquired laryngomalacia: epiglottis prolapse as a cause of airway obstruction.  Ann Otol Rhinol Laryngol. 1992;  101 314-320