Obstructive sleep apnea hypopnea syndrome is often the result of obstruction at multiple anatomic sites. Nasal, palatal and hypopharyngeal obstruction, acting alone or in concert, are frequently identified as the cause of snoring and obstructive sleep apnea hypopnea syndrome. Even in cases where a single site is primarily involved, the increase in negative pressure may induce further obstruction in other areas. When surgical management of obstructive sleep apnea hypopnea syndrome is considered, a clear understanding of the complex relationship between the sites of obstruction is essential to surgical success.
The importance of determining the sites of obstruction has led to the development of numerous methods that attempt to predict the location of the upper airway obstruction. These include snoring sound analysis, physical examination, computed tomography, magnetic resonance imaging, cephalometric studies and fluoroscopy, among others. Although these methods have demonstrated value, the number of methods described is evidence of the lack of agreement that any single method is perfect. The test is widely used and simple to perform. Despite this, its use is controversial and certainly no studies have been able to associate the maneuver as a tool for patient selection. It is within this context that the Friedman tongue positions (FTP) emerged.
The procedure for identifying Friedman tongue positions involves asking the patient to open their mouth widely without protruding the tongue. The procedure is repeated five times so that the observer can assign the most consistent position as the FTP.
Previous studies have demonstrated its ability to separate patients that will likely benefit from uvulopharyngopalatoplasty (UPPP) as a single modal treatment from those that will require multilevel surgical intervention. Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure performed by otolaryngologists for the treatment of obstructive sleep apnea hypopnea syndrome. Unfortunately, a meta-analysis of unselected patients treated with UPPP revealed that only 40.79% of patients had a successful surgery.
The failure of UPPP to cure obstructive sleep apnea hypopnea syndrome has been clearly associated with sites of obstruction in the upper airway not corrected by the procedure. It is well known that obstructive sleep apnea hypopnea syndrome involves obstruction of the airway at multiple levels. Although palatal obstruction accounts for a large portion of the obstruction, hypopharyngeal obstruction can also play a significant role. UPPP alleviates obstruction at the level of the soft palate and tonsils, but does not address obstruction at the level of the hypopharynx. This is clearly a significant cause of the failure of UPPP.
Therefore when devising a system that is intended to predict UPPP outcomes, the anatomical considerations must be incorporated. Friedman tongue position is a physical finding that can help with the diagnosis and surgical management of obstructive sleep apnea hypopnea syndrome. Friedman tongue position describes the position of the tongue relative to the tonsils/pillar, uvula, soft palate, and hard palate and is easily accessed by physical examination of the oropharynx.
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