AAO-HNSF Primary Care Otolaryngology Handbook

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CHAPTER 1

protruding. If the entire posterior pharyngeal wall, including tonsils, uvula, and soft palate, can be seen, the grade is 1. Grade 2 is recorded if the top of the tonsils or base of the uvula is seen. Grade 3 is noted if the soft palate without tonsils or uvula is seen. If only the hard palate can be seen because of an elevated tongue, the grade is 4 (Figure 18.2). The combination of tonsil size and tongue position has been studied and correlates to outcomes of surgical intervention. Finally, a flexible fiberoptic laryngoscope can be used to examine the patient’s airway. This can give a sense of the retropalatal airway and the angulation of the palate. Retrolingual and epiglottic obstructions can be noted as well. Diagnosis of Obstructive Sleep Apnea If after a thorough history and physical exam are completed, there is a question of OSA, a sleep test (polysomnogram, or PSG) is needed. A history and phys- ical can increase suspicion for OSA, but OSA can only truly be diagnosed with testing. There are two main sleep tests: polysomnography and home sleep testing (HST). Polysomnography A PSG is the gold standard in sleep testing. Components of a PSG include: • EEG—electroencephalography • EOG—electrooculography • EMG of chin and limbs—electromyography

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Figure 18.1. Tonsil grading scale.

Figure 18.2. Modified Malampati scale (Friedman tongue position).

Primary Care Otolaryngology