The Value of the Muller maneuver during endoscopic evaluation of OSAS patients

The Muller maneuver is a forced inspiration with both the nose pinched and mouth closed, after a forced expiration, so as to simulate the colapse of pharyngeal walls, similar to what happens at night during deep sleep (atonia of the pharyngeal muscles during REM sleep). When diagnosing patients with obstructive sleep apnea syndrome (OSAS) the nasofibroscopy-assisted Muller maneuver (NMM) is indispensable to identifying the site of obstruction[1] and thus properly establishing the surgical indication [2]. This patient was overweight (BMI of 29.4) and had documented severe OSAS with 4 channel ambulatory polygraphy and the apnea-hypopnea index (AHI) of 83.7 events\hour. Objective E.N.T. assessment shown Mallampati 3 with moderate-severe (Brodsky 3+) palatine tonsil hypertrophy. The images show (clockwise) the initial aspect ("helicopter view") of the oropharynx as seen from the rhinopharynx, the beginning of the Muller maneuver and the total closure of the oropharynx during the maneuver. Thus the patient was classified in the Fujita I class of OSAS, and was later operated, by way of tonsillectomy and modified uvulo-palatal-pharyngoplasty (UPPP) with expansion-sphincter construction. The NMM is a easy-to-use technique that provides valuable information in patients with OSAS and thus help establish the proper surgical indication.