Clinical examination

This can be quite easily conducted in out patient setting and addresses the patency of the nasal passage as well as the assessment of different segments of the pharynx. Anterior rhinoscopy using a simple nasal speculum allows visualisation of the anterior aspect of the nasal cavity and helps in identifying problems of caudal dislocation of the septum and if the nasal valve area is compromised. However, a rigid endoscope is more useful in a more comprehensive evaluation of the nasal passage and will identify problems such as deviated nasal septum, nasal polyps (fig. 1) and rhinosinusitis. The identification of these pathological features is important as they may be a cause of failed compliance and efficacy in the nCPAP patients.

Simple oropharyngeal cavity examination provides the clinician with useful information and of note would be the size and grading of palatine tonsils, the length of the soft palate and uvula and more subtle features such as redundant pharyngeal folds. Friedman tongue position1 and Mallampati2 grading are also utilised by many clinicians in order to select patients who may be suitable for palatal surgery. For example in patients with Friedman tongue position 3 or 4 (figs. 2 & 3) palatal surgery is unlikely to be successful. In contrast Friedman tongue position 1(fig. 4) would yield better results following palatal surgery. One must however take in to account that as this assessment is done during wakefulness it may not truly reflect what happens to the upper airway during sleep as there must undoubtedly be some variation in the muscle tone in the state of wakefulness and different stages of sleep.

Fig. 2. Friedman tongue position 3
Fig. 3. Friedman tongue position 4
Fig. 4. Friedman tongue position 1

Probably the most useful equipment in assessing the upper airway is the flexible fibreoptic nasopharyngoscope which is widely available and allows brilliant visualisation of all aspects of the naso, oro and hypopharynx. Local anaesthesia in the form of a nasal spray can be used in allowing an easier and tolerable insertion of the scope and the different segments of the pharynx are carefully assessed. The patient could be asked to simulate a snoring sound to try and ascertain the level responsible for causing the turbulent airflow resulting in the snoring sound. Herzog3 has reported a study based on simulating snoring sound in order to establish a model of grading upper airway obstruction. However, not all patients can simulate snoring and some may do this with mouth open or closed and these patients are usually sitting up whilst during sleep patients may be supine, prone or in lateral positions. In any case the fact that the muscle tone variation in sleep and wakefulness must also be borne in mind. Another commonly used technique during the flexible endoscopic assessment is the Mullers4 manoeuvre. This essentially is a reversed Valsalva procedure which some patients do find difficult to perform. Furthermore, there is subjective variation in the assessment of the degree of collapse noted in different segments of the pharynx and thus the reliability of this technique may be questioned.

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