for presenting in ENT department

1. Obstructive sleep apnea
Ammarin wichitpan
5th year medical student
23 August 2018

2. Outline
• CASE
• Definition
• Pathophysiology
• Approach to the patient

3. CASE
A 67-year-old man with a long-standing
history of snoring noted that, in recent
years, the snoring had worsened so much
that his wife banned him from their
bedroom. Since his retirement, he gained
20 pounds, and knee problems reduced his
physical activity. His nasal allergies also
had worsened. He noted increased fatigue,
daytime sleepiness, and some trouble
concentrating. He reported following a
medication regimen as treatment for
hypertension, but he otherwise denied
having any medical problems. He had a

4. Physical examination showed nasal
congestion with moderately swollen, pale
turbinates and no purulent discharge. The
septum was midline. Oropharyngeal
examination showed no tonsils and a low
soft palate with elongated uvula that tended
to collapse against the posterior aspect of
the pharynx and abutted the base of tongue.
Fiberoptic laryngeal examination showed a
normal larynx with moderate collapse of the
lateral pharyngeal walls in “blocked”
inspiration (a reverse Müller's maneuver
whereby the patient holds his nose, closes his
mouth, and attempts to breathe inward). He
had a short, thick neck and was overweight.

5. Definition
Obstructive sleep apnea (OSA) is
complete upper airway obstruction for at
least 10 seconds with preserve respiratory
effort
SLEEP-DISORDERED BREATHING
Apnea—is define by AASM as The complete
cessation of airflow for at least 10 seconds.
Apneas may be central, obstructive, or
mixed.
Hypopnea—definition is variable
—The airflow reduction of at least
30% that lasts for 10 seconds or longer
associated with a 3% decrease in oxygen
saturation

6. Risk Factors
Obesity (BMI > 30 kg/m
2
)
Neck size (collar size >17 inches in males, >16 inches in females)
Gender (male/female 2–3:1)
Genetic factors/family history
Upper airway and craniofacial anatomy
Macroglossia
Lateral peritonsillar narrowing
Elongation/enlargement of the soft palate
Tonsillar hypertrophy
Nasal septal deviation
Retrognathia, micrognathia
Narrowing of the hard palate
Class III/IV modified Mallampati airway
Specific genetic disorders, e.g., Treacher Collins, Down syndrome,
syndrome, etc.
Endocrine disorders, i.e., hypothyroidism, polycystic ovarian

7. Retrognathia Elongated uvula Tonsillar hypertrophy

8. Pathophysiology
Sleep
Obstructive
apnea
ChemoreceptorSleep arousal
Upper airway
tone
Upper airway
tone
Resumption of
airflow
Upper airway
resistance/collap
sibility
Hypoxia,
Hypercapnia,
Acidosis

10. Consequences of obstructive sleep
apnea
Obstructive apnea
Intermittent hypoxia Sleep fragmentation
Inflammation
Sympathetic activation
Oxidative stress
Endothelial dysfunction
Metabolic dysregulation
Insulin resistance
B cell function
Type 2 DM
Excessive daytime
sleepiness
- Neurocognitive function
- Behavioral change
- Personality change
Cardiovascular disease
- Hypertension
- CAD
- CHF
- Pulmonary
hypertension
- Arrhythmia

12. APPROACH TO THE PATIENT
•HISTORY
•PHYSICAL FINDINGS
•LABORATORY INVESTIGATION
•DIAGNOSTIC TESTING

13. Clinical feature
Nocturnal symptoms
• Snoring
• Witnessed apneas
• Nocturnal choking or
gasping
• Restless sleep

14. Clinical feature
Daytime symptoms
• Excessive daytime sleepiness
• Unrefreshing sleep, morning
headaches
• Irritability, memory loss,
personality change
• Decreased libido
• Impotence

15. Questionnaire
• STOP-BANG
• Epworth Sleepiness Scale
• Berlin questionnaire
STOP-BANG

17. Physical examination
• Vital signs
• General appearance
• Body habitus
• BMI
• Neck circumference
• Head and neck
• Craniofacial structure
• Nasal and oral cavity
• Systemic examination
• CVS
• RS
• Neurological

18. Laboratory investigation
• CBC
• TFT
• Arterial blood gas
• CXR
• Cephalometric study

19. Diagnostic Testing Options for Sleep-Disordered
Breathing
Polysomnography
• Full-night
study
• Split-night

20. Polysomnography
LEVELS Parameters Measured
I [Standard attend in-lab PSG] EEG, EOG, EMG, ECG, airflow,
respiratory effort, O2 saturation, usually
video (all conducted in a sleep
laboratory with a sleep professional
present)
II [Comprehensive portable Minimum of seven channels including
EEG, EOG, chin EMG, ECG/HR,
respiratory effort, and O2 saturation
III [Modified portable sleep
apnea testing]
Minimum of four channels including
ECG/HR, O2 saturation and at least
The American Academy of Sleep medicine [AASM] has defined four levels of sleep studies.

21. Standard attended PSG
o Total sleep time
o Sleep efficiency
o Sleep stage
percentage
o Sleep latency
o Arousals
o Apnea
o Hypopnea
o Respiratory effort
related
arousal[RERA]

22. Diagnostic criteria for OSA in adults
The combination of either (A + B) or of (C) satisfies the criteria for OSA
A. At least one of the following applies:
1.Patient complains of unintentional sleep episodes, daytime sleepiness,
unrefreshing sleep, fatigue, or insomnia.
2.Patient awakens with breath-holding, gasping, or choking.
3.Bed partner reports loud snoring, interrupted breathing, or both as patient
sleeps.
B. Polysomnography recording shows the following:
1.≥5 scoreable respiratory events (apneas, hypopneas, or RERAs) per hour of sleep.
C. Polysomnography recording shows the following:
1.≥15 scoreable respiratory events (apneas, hypopneas, RERAs) per hour of sleep.
Apnea-hypopnea index (AHI): Number of apneas plus hypopneas per

23. Obstructive Sleep Apnea/Hypopnea Syndrome
(OSAHS): Quantification and Severity Scale

24. TREATMENT
• The decision to treat OSA should be based on its severity, related
symptoms, and medical comorbidities. Treating moderate-to-severe
disease (defined as AHI ≥15)
Behaviora
l
modificati
ons
Continuous
Positive
Airway
Pressure
Surgery

25. Behavioral modifications
• Weight reduction
• Positional therapy
• Sleep hygiene
• Oral appliance

26. Oral appliance

27. Continuous Positive Airway Pressure
• CPAP is the gold standard treatment for OSAS

28. Improved sleep quality:
↓ Arousal index, ↑ sleep efficiency
↓ Stage 1 sleep, ↑ stages 3 & 4 sleep
Improved neurocognitive function:
↑ Driving simulator performance
↑ Vigilance
Decreased daytime somnolence
Improved cardiovascular function:
↑ Left ventricular function
↓ Systemic & pulmonary
hypertension
↑ Exercise performance
↓ Endothelial dysfunction
↑ Transplant-free survival time (?)
Improved subjective work
performance
Improved self-reported health status
Improved glycemic control, insulin
sensitivity
Reversed deficiencies in:
Plasma IGF-1, SHBG
Serum testosterone
Multisystem benefits of CPAP therapy
for OSAS

29. Complications Associated with CPAP
Nasal congestion
Aerophagia
Mask and mouth leaks (dry mouth in morning)
Facial rash or irritation
Difficulty with exhalation
Claustrophobia

30. Surgery
• Nasal surgery (septoplasty, sinus surgery, and others)
• Tonsillectomy ± adenoidectomy
• Uvulopalatopharyngoplasty(UPPP)
• Laser-assisted uvulopalatopharyngoplasty(LAUP)
• Hyoid myotomy and suspension
• Tongue suspension
• maxillomandibular advancement : MMA
• Tracheostomy
• Radiofrequency volumetric tissue reduction

31. Uvulopalatopharyngoplasty(UPPP)

32. Hyoid myotomy and suspension

33. Maxillomandibular advancement

34. Radiofrequency tissue volume reduction :
RFTVR
Thermal injury to specific
submucosal sites in the soft
palate resulting in fibrosis of
the muscular layer and
volumetric tissue reduction

36. TAKE HOME MESSAGE
Snoring and
excessive
daytime
sleepiness
History and
physical
examination
Polysomno
graphy
Many options
treatment
multidiscipl
inary team

37. References