Case Study: A Physical Examination of the Upper Airway by an Ear, Nose, and Throat Physician

An examination of nasal turbinates for a patient shows the septum to be primarily in the midline with only a mild posterior deformity to the right. Examination of the teeth shows decay near the gum line on several of the teeth, but no active infection. The examination of the oral cavity is normal. There is minimal laxity of the soft palate, the tongue position is a Friedman Class II to III, and the oropharynx shows tonsils to be 0+. The Friedman classification system is similar to the Mallampati classification except that the tongue remains in a natural or neutral position when the oral cavity is examined. There are 4 grades with 4 being the most severe.1

Procedure

Flexible fiberoptic laryngoscopy was performed through the right nostril after application of topical decongestant/anesthetic. The study was done with the patient in the supine position to try to mimic his position during sleep. The examination of the right nasal passage shows normal mucosa and turbinates with a very mild septal deformity to the right. The nasopharynx shows normal mucosa and Eustachian tubes. The hypopharynx shows normal pharyngeal walls and piriform sinuses. An examination of the larynx shows normal epiglottis, false cords, true cords, and both true cords move well. The tongue base has a posterior position, and on a Mueller maneuver the maximum obstruction was noted at the level of the hypopharynx/tongue base rather than in the soft palate. The Mueller maneuver is considered the opposite or inverse of the Valsalva maneuver. It is performed by inhaling against a closed glottis. The force of the inspiration is then measured for 30 seconds with a manometer.²

Ear, Nose, and Throat Analysis

This patient would benefit from a procedure to address the tongue base.