How many mysteries do our patients present us with as we seek to resolve their symptoms? We talk, we listen, we interpret, and we use diagnostic tools to help us prescribe a course of treatment that we hope will result in the preferred outcome.
Such is the nature of medicine. To aid us in our pursuit of better odds, there is constant improvement in diagnostic aids. One set of such tools involves imaging – developing a rendering of our patient’s anatomy so we can predict what might happen to those body parts and allow us to make a connection between those events and the symptoms. We want something concrete to pin the diagnosis to. We want something to blame. A dragon to fight.
Too bad for us that the oropharynx lends itself poorly to observation. Especially when our patient is asleep. We know it differs in parts of sleep, in varying parts of the night. We can measure with great skill and reliability the response of the body to narrowing or closure of the airway, but actually observing the apneas and hypopneas is pretty much impossible in normal sleep. Certainly not in the patient’s natural state, unsullied by observer effect.
We are, of course, dealing with a fairly simple mechanical problem. We can use physics to describe the challenge, with terms like Bernoulli, Starling, and Poiseuille. Without looking back to your high-school physics class, think of the mandible and the tongue falling into the airway, the palate flopping over the nasopharynx, and you can build a 3-D picture in your mind about what goes on during a disordered-breathing event.
What would we all like? To show that 3-D image on a screen so that we can understand it ourselves, manipulate the virtual tissue to effect a desired change, and enable our patient to ‘own the problem’ as they see themselves on our monitors.
Recently I enjoyed a pinch-me, career-highlight event having dinner with the engineer whose group developed CBCT for the head and neck. He’s (my guess) younger than me and working very hard to give his medical colleagues more and better tools to help us treat patients. There is no such thing as ‘mature technology’ in medical imaging. The innovations he shared, both real today and just at the edge of imagining, are nothing short of awe-inspiring. OK, maybe I’m a little geeky, but who will say that moving a virtual jaw exactly like the actual person that stood there in the scanner isn’t pretty cool?
There is also technology that’s not changed much in a long time that also shows airway anatomy well. Dr. Dan Taché, one of the most respected teachers in sleep, leaped at the invitation to share how he uses a pharyngometer to help his patients. His commitment to the best outcome includes using every tool he has to inform his treatment strategies.
There are dots still to be connected. We cannot know with precision, no matter what imaging system we use, what happens to the soft tissue during sleep. Stay tuned. Very smart people are working day and night to help us clinicians with this mystery.
This issue showcases what we know about imaging today. I present it to you knowing that by the time you read this, we will know more, be able to do more, and move closer to our wish to predict, exactly, how we can help. Many fear moving into this exciting world of imaging technology because of what’s around the corner. How long do we wait, guessing about anatomy, hoping our clinical judgement alone is enough?