Anteroposterior and Lateral Epiglottis-Related Obstruction in Adult Obstructive Sleep Apnea

Epiglottis-related airway obstruction in obstructive sleep apnea is uniquely identified during drug-induced sleep endoscopy (DISE) and may be associated with poorer treatment outcomes. To determine whether specific demographic factors, awake physical examination, and DISE findings are associated with anteroposterior and/or lateral configurations of epiglottis-related airway obstruction during DISE. This cross-sectional study including adults with obstructive sleep apnea undergoing DISE with prospective data collection from 2015 to 2025 was performed at 2 academic medical centers. Statistical analyses were performed in November 2024 and May 2025. Demographic (age, sex), awake physical examination (body mass index, Modified Mallampati Position, tonsil size, posterior displacement of the epiglottis off the tongue base during awake upright fiberoptic endoscopy), and DISE findings. Presence and degree of anteroposterior or lateral epiglottis-related obstruction in the supine body position during DISE. Among 708 study participants, the mean (SD) age was 52.5 (13.5) years, and 109 were female individuals (15%). Epiglottis-related obstruction occurred in 103 (16%), including 100 (14%) and 13 (1.8%) with anteroposterior and lateral configurations, respectively. Multivariable analysis showed that anteroposterior epiglottis-related obstruction was strongly associated with male sex (odds ratio [OR], 2.84; 95% CI, 1.20-6.73), lesser degree of velum-related obstruction (OR, 0.50; 95% CI, 0.29-0.84), and posterior epiglottis displacement (OR, 2.94; 95% CI, 1.73-4.99), and weakly associated with older age (OR, 1.04; 95% CI, 1.01-1.06). Lateral epiglottis-related obstruction was only seen in male individuals and the presence of oropharyngeal lateral-wall related obstruction; it was also associated with posterior epiglottis displacement. This study found that anteroposterior and lateral epiglottis-related obstruction are distinct, having many different risk factors. However, both configurations were associated with posterior epiglottis displacement during awake examination.