OBSTRUCTIVE SLEEP APNEA

DIAGNOSIS AND MANAGEMENT

AAMIR YOUSUF
PG ENT AND HNS
HISTORIC ASPECTS
The first description of an obstructive sleep apnea
(OSA) sufferer is generally attributed to the well
known novelist Charles Dickens, who described
Joe in The Posthumous Papers of the
Pickwick Club, published in 1836. Joe was an
excessively sleepy, obese boy who snored loudly and
had possible right-sided heart failure that led to his
being called young dropsy
The first physician to describe the clinical features of
OSA was Broadbent in 1877
In 1898 Wells reported curing of several
patients of sleepiness by treating their upper
airway obstruction.
In 1965, Gastaut et al in France and Jung
and Kuhlo in Germany described sleep
apnea and its associated polysomnographic
findings.

Guilleminault et al coined the terms sleep
apnea syndrome and obstructive sleep
apnea syndrome in 1976 to emphasize the
occurrence of this syndrome in nonobese
patients. In the same year, they reported the
existence of this syndrome in children.
In 1982 Guilleminault et al reported the presence
of abnormal respiratory efforts during sleep
without apneas in children and gave the name
upper airway resistance syndrome (UARS) in
1993 after a similar description in adults.

Although Ikematsu popularized uvulopalato-
pharyngoplasty (UPPP) for the treatment of snoring in
1964, it was not until 1981 that Fujita performed the
first UPPP as a treatment for OSA .

Sullivan et al devised the first nasal continuous
positive airway pressure (CPAP) machine and in 1981
reported its efficacy in the treatmentof sleep apnea .

Riley et al developed new Maxillomandibular
procedures in the 1980s for subjects intolerant to nasal
CPAP.
Understanding the problem
Sleep disorders are very common and up to
20% of adult population have some form of sleep
disorder.
According to widely used International
Classification of Sleep Disorders produced by
the American Sleep Disorder Association at least
90 different sleep disorders have been described.
Sleep Is A Reward For Some, A Punishment For
Others
I ssador
Ducasse
Obstructive sleep disordered breathing,is a
common form of SDB.
It is very common and greatly underestimated
disorder. It occurs in all age groups,from newborn
to old age and is common in middle-aged
overweight men and women(4% men and 2%
women).
It is estimated 2-5% of the population suffers from
obstructive sleep apnea .
The incidence of OSA is reportedly increased in
Pacific Islanders, Mexican-Americans, and blacks.

PREVALENCE OF OSA
Approximately 42 million American adults have
SDB (Young et al 1993).
Obstructive sleep apnea (OSA),affects an
estimated 15 million Americans, with a
prevalence that is probably also rising as a
consequence of increasing obesity.
1 in 5 adults has mild OSA (Young 2004) 1 in
15 has moderate to severe OSA
Young et al estimated that among middle-aged
adults, 93% of women and 82% of men with
OSA have not been clinically diagnosed.



Prevalence similar to asthma (20 million) and
diabetes(23 million) (Am Academy of Allergy,
Asthma & Immunology 2005; Am Diabetes
Assoc 2007)
In 2006, a population-based survey from
north India had estimated the prevalence of
OSAS at 3.6 per cent (males and females being
4.9 and 2.1% respectively) Sharma et al
2006, India.





Risk factors

People who are overweight (Body Mass Index of 25 to 29.9) and
obese (Body Mass index of 30 and above)
Men and women with large neck sizes: 17 inches or more for men,
15 inches or more for women
Middle-aged and older men, and post-menopausal women
Ethnic minorities
People with abnormalities of the bony and soft tissue structure of
the head and neck
Adults and children with Down Syndrome
Children with large tonsils and adenoids
Anyone who has a family member with OSA
People with endocrine disorders such as Acromegaly and
Hypothyroidism
Smokers
Those suffering from nocturnal nasal congestion due to abnormal
morphology, rhinitis or both.


Classification Of Sleep - Related Breathing
Disorders


The first organized effort for the classification of sleep disorders was
published in Sleep in 1999 under the title
Diagnostic Classification of Sleep and Arousal Disorders.
This classification was further improved and revised with the
collaboration of major international sleep societies. The most
recent classification was published in 2005 and was entitled
International Classification of Sleep Disorders:
Diagnostic and Coding Manual (ICSD-2).
It aimed at introducing a common terminology to everyone related to
the field of sleep medicine, thereby improving communication and
promoting clinical practice as well as research. According to the
current classification, there are four major types of sleep-related
breathing disorders.
Classification
1. Central apnea syndromes
1.1. Primary central apnea
1.2. Cheyne - Stokes respiration
1.3. Periodic respiration of high altitude
1.4. Central apneas without Cheyne-Stokes respiration
secondary to other disorders (vascular, malignant,
degenerative or traumatic disorders of the central
nervous system, cardiac/renal disorders)
1.5. Central apneas caused by medicine or other
substances
1.6. Primary sleep apnea of newborn
Classification
2. Hypoventilation/ hypoxemia syndromes
associated with sleep
3.1. Non-obstructive alveolar hypoventilation,
idiopathic
3.2. Congenital central hypoventilation
3.3. Hypoventilation/hypoxemia secondary to other
disorders:lung parenchymal, airway (e.g. COPD),
orvasculardisorders(e.g.pulmonaryhypertension)
neuromuscular disorders; thoracic wall
abnormalities; obesity.
Classification
3. Obstructive apnea syndromes
2.1. Obstructive apnea in adults
2.2. Obstructive apnea in children
4. Undefined/non-specific sleep disorders
Disorders without specific characteristics to
allow their classification in any of the previous
categories. Further investigation is required
Obstructive sleep apnea syndromes
Guilleminault et al coined the terms obstructive
sleep apnea syndrome in1976.Obstructive sleep
apnoea(OSA)is increasingly being recognised as an
important health issue in adults and is increasingly
recognised in children over the past two decades.

OSAS is characterised by repetitive episodes of
complete or partial upper airway obstruction that
occur during sleep, usually associated with a
reduction in blood oxygen saturation(hypoxemia)
and unconscious(EEG) arousals


As upper airway is involved this condition is
seen most commonly by otolaryngologists.
Spectrum of OSD

Severe




Mild








Upper airway resistance syndrome
Obstructive sleep apnea syndrome
Obesity hypoventilation syndrome
Asymptomatic snorer

Definitions

Apnea is defined as:
1. Reduction in airflow 90% of baseline, recorded by
or oronasal thermistors or nasal pressure cannulas.
2. Duration 10 sec.
3. Aforementioned reduction in airflow at least 90% of the event.
Classification of apneas based on respiratory effort:
1. Obstructive apnea: respiratory effort is recorded throughout
the event.
2. Central apnea: absence of respiratory effort throughout the
event.
3. Mixed apnea: there is absence of respiratory effort at the
beginning of the event followed by increasing respiratory effort
during the second half.
Defnitions
Hypopnea is defined as:
1. Reduction in airflow 30% from baseline, recorded
by nasal pressure cannulas or oronasal thermistors.
2. Duration 10 sec..
3. Reduction in saturation at least 4% from baseline
SpO2% prior to the event.
Alternatively: Hypopnea can be defined as a
respiratory event that meets the following criteria:
1. Reduction in airflow 50% from baseline, recorded
by nasal pressure cannulas or oronasal thermistors.
2. Duration 10 sec.
4. Reduction in saturation 3% from baseline prior to
the event or appearance of an arousal.




Defnitions
Respiratory effort- related arousal (RERA)
It is a breathing disorder characterized by obstructive
upper airway airflow reduction (which does not meet
the criteria of apnea or hypopnea), associated with
increased respiratory effort that resolves with the
appearance of arousals (RERAs). It is preferably
recorded with esophageal manometry, although nasal
manometry is also appropriate
Diagnostic criteria are:
1. A series of respiratory cycles of increasing/
decreasing effort or flattening, recorded by nasal
manometry and leading to an arousal that cannot be
defined as apnea or hypopnea.
2. Duration 10 sec.

Defnitions
Apnea-Hypopnea index (AHI):
The number of apneas and hypopneas per hour
of sleep, confirmed by electroencephalogram
(EEG).
Respiratory Disturbance Index (RDI):
The number of apneas, hypopneas and RERAs
per hour of sleep, confirmed by EEG.
Note: Both indexes of sleep-related breathing disorderscan be used in
full polysomnography. In limited sleep studies (which does not
include EEG), RDI is defined as the number of apneas and hypopneas
per hour of sleep recorded.
OSAS
Severity of OSA Adult AHI Pediatric AHI
None 05 0
Mild OSA 615 15
Moderate OSA 1630 610
Severe OSA >30 >10
AHI apnea-hypopnea index, the number of episodes of sleep disordered breathing
per hour
Defnitions
Arousal:
It is defined as a sudden change of EEG frequency
consisting of alpha and theta activity or waveforms
with frequency greater than 16 Hz (but not sleep
spindles) and duration 3-15 sec. Normal sleep is
recorded for at least 10 seconds before and after the
event. Anarousal is not considered wakefulness in the
sense that the patient is unconscious of the event.
1: Baseline is considered the moderate of steady respiration and ventilation
during the last 2 minutes prior to the event for patients with fixedrespiration
pattern, or the moderate of the 3 longest respirations during the last 2
minutes prior to the event for patients with variable respiration pattern



Defnitions
Upper Airway Resistance Syndrome (UARS):
It is a clinical term diagnostic of patients with
RERAs and symptoms of OSAS. RERAs are similar
to true obstructive apneas and hypopneas in
terms of the pathophysiology their complications.
Therefore, UARS is not considered as an
independent disorder rather than one aspect of
the spectrum of obstructive sleep disorders and
should be diagnosed and treated in this context.
Pathophysiology
Airway patency maintained by Pharyngeal Dilator
Muscles which stiffen during inspiration to
prevent lateral pharyngeal wall collapse
By Contracting And Stiffening Lateral Pharyngeal
Walls, And Pulling Base of the Tongue Forward
(Ventrally), air is able to pass through the
retropharyngeal area into the trachea.
These muscles act opposite the inspiratory forces
generated by diaphragm and muscles of
inspiration to allow air entry into trachea


Pathophysiology
OSA is common in obesity due the increased
fat deposition in nasopharynx, laryngo
pharynx, uvula, tonsils, tonsillar pillars,
tongue, aryepiglottic folds, and the lateral
pharyngeal walls, all result in narrowing of the
pharynx and the increased likelihood that
relaxation of the pharyngeal dilator muscles
will result in collapse of the soft-walled
pharyngeal airway.

Pathophysiology
Mechanical
Short, thick
neck
Neck flexion,
supine position
Nasal
obstruction,
congestion,
polyps
Surface tension
of upper
airway lining
fluid


Anatomic
Enlarged tonsils and
adenoids (esp. ages 3-5),
enlarged uvula
Macroglossia
Retrognathia, craniofacial
abnormalities
Compliant (floppy)
pharynx, especially soft
palate
Fat deposition in lateral
walls of pharynx, pharyngeal
dilator muscles (obesity)
Submucosal edema in
lateral walls of pharynx

Physiologic
Decreased function of
upper airway dilator
muscles (more than 20
skeletal muscles normally
involved)
Decreased pharyngeal
dilator reflex response
Decreased
chemoreceptor
drive/central drive (mixed
with central sleep apnea)
Impaired arousal
response
Alcohol, depressant drugs

Pathophysiology
Pathophysiology
CLINICAL PRESENTATION
Daytime
Excessive daytime Sleepiness(EDS)
Fatigue
Impaired memory
Symptoms of gastroesophageal reflux
Morning headache
Mood and personality changes
(Depression,anxiety,irritablity)
Sexual dysfunction
(impotence or decreased libido,abnormal menses)


The subjective symptoms associated with OSAS are
Symptoms
Night Time
Snoring
Observed apneas and
gasping
Frequent awakenings
Choking
Sweating
Palpitations
Nocturia
Restless sleep/frequent
arousals
Drooling /bruxism
Dry mouth

Children
Snoring
Agitated arousal
Unusuall sleep postures(sleeping on
hands and knees)
Nocturnal enuresis
Daytime mouth breathing
Swallowing difficulty
Poor speech articulation

Symptoms
Snoring:
It is the most frequent symptom in OSAHS and is found in
70-95% of such patients.

The snoring may have been present for many years but
the typical increase in intensity over time is noticed and
further exacerbated by nighttime alcohol
consumption,weight gain,sedative medication,sleep
position (supine position).

Snoring becomes so loud as to be greatly disruptive to
the bedpartner and is source of relationship discord.
Symptoms
Apneas :
Witnessed apneas are observed by up to 75% of
bedpartners and are second most common
nocturnal symptom reported in OSAHS.

In OSAHS of milder severity,the apneic episodes
are usually associated with maintanance of
respiratory movements and are terminated by
loud snorts,gasps,and sometimes with brief
awakenings and body movements.

Symptoms
In more severe disease,cyanosis can occur
along with cessation of respiratory
movements during the apnea
Body movement at the time of arousals in
severe OSAHS can be frequent and
sometimes violent.
Symptoms
Nocturnal sweating:
50% of the patients with OSAHS report nocturnal sweating typically
occurs in neck and upper chest areas.
This can be attributed to autonomic instablity .
Gerd:
Ger occurs in high frequency in patients with osahs (64-73%)
Mechanism UAO results in in increased intraabdomen pressure
combined with more negative intrathoracic pressure resulting in
increased intra diapharagmatic pressure gradient there by promoting
reflux of gastric contents into esophagus.
Nocturia :
Reported in 28% of OSAHS experience increased frequency 4-7
episodes pr nt
Due to ANP secretion /increased abdominal pressure





Symptoms
EDS
Excessive day time sleepiness is the most
common daytime symptom in OSAHS
patients(30-50%)
EDS is caused by sleep fragmentation leading to
frequent arousal and insufficient sleep.
Manifested by inappropriate urge to sleep during
relaxing sedentary activities (watching tv,reading)
When severe it can lead to motor vehcle
accidents machinery accidents poor school/job
performance,relation ship discord

Symptoms
Morning headache:
Reported in about half of the patients of
OSAS.
Typically dull or generalised,lasts 1-2 hrs.
Non specific symptom
Sexual dysfunction:
Manifests as erectile dysfunction and
decreased libido
Reversible corrects with treatment of osas

Symptoms
Neurocognitive impairment:
The processes most commonly affected are
vigilance,executive function,motor
coordination.
Decreased vigilance and poor memory(short
and long term) are result of sleep
fragmentation
Psychomotor impairment appears to be due
to hypoxemia seen in severe
OSAHS(irreversible anoxic brain damage)


Physical examination of patient
General examination..
Patient is usually obese male above 50 yrs.
Note weigt and height and calculate BMI.
Grunstein et al demonstrated that BMI
of >25kg/m2 was associated with 93%
sensitivity and 74% specificity for OSAHS.
Recording of blood pressure both
hypertension or hypotension can be seen.

Short and bulky neck.
measurement of neck at level of cricothyroid
membrane is taken.
For males >17 inch and females >15 inch is
significant predictor of OSAS.
Kushida et al found that neck cicumference
of 40cm was asssociated with a sensitivity of
61% and specificity of 93%.
Facial morphology.
Observation of the patients facial
profile was performed to recognize
developmental disorders of the
mandible and maxilla.
The Mandible Retrognathism
was investigated by placing the patient
seated in the Frankfort horizontal
position with a virtual vertical line
dropped from the vermilion border of
the lower lip to the chin. If the anterior
prominence of the chin (soft tissue
pogonion) is great than 2 mm
behind this line, mandibular
retrodisplacement may be present.
Vertical line is drawn from
soft tissue nasion to
subnasale (junction of
columella and upper lip) for
maxillary assessment.
if f subnasale is posterior to
a vertical line maxillary
retrusion may be present.
( two points are in vertical
allignment)


Dental occlusion :
Class I occlusion :normal one
when buccal cuspsof the maxillary
first molar fits into the buccal
groove of the mandibular first
molar.
Class II: if frst mandibular molar
is posterior to first maxillary molar
.(suspect retrognathism)
Class III:if buccal groove of
mandibular first molar is anterior to
the mesial buccal cusp of maxillary
first molar (prognathism suspected)


TONGUE: Patient sitting, mouth
closed(FOE)
1: vallecula open
2:Vallecula filled with tongue base
3:epiglottis pushed posteriorly
4:Epiglottis touching posterior
pharyngeal wall secondarily to tongue
base pressure
LARYNX:(FOE)
0: normal
1: any airway obstruction or
deformed epigllotis not covered
above
TONSIL:

0: post tonsillectomy
1:Inside the pillars
2:outside the pillars,25%of
airway
3: 25-75% of airway
4: 75% or more of airway
ADENOIDS :
0:post op
1:,10% obstruction
2:10-50% obs
3:50-90%obs
4:>90%
NOSE :
0: POST OPERATIVE STRAIGHT
1:STRAIGHT WITH NORMAL CARTILAGE
/BONE AT FLOOR,10%OF OBSTRUCTION
2:10-50% OBSTRUCTION ON WORST SIDE
3: 50-90% OBSTRUCTION ON WORST
SIDE
4: 90-100% OBSTRUCTION ON WORST
SIDE OR NASAL POLYPS ALLERGIC
RHINITS ADD ON
Staging
Friedman staging system
Palate
Position
Tonsil size
Body mass
index
The Friedman Palate Position is
based on visualization of
structures in the mouth with the
mouth open widely without
protrusion of the tongue.
Palate grade I allows the
observer to visualize the
entire uvula and tonsils.
Palate Grade II allows
visualization of the uvula but
not the tonsils.
Palate Grade III allows
visualization of the soft palate but
not the uvula.
Palate Grade IV allows
visualization of the hard palate
only.
FRIEDMANN STAGING SYSTEM
FPP
1
2
Tonsil size
3,4
3,4
BMI KG/M2
<40
<40
1,2
3,4
0,1,2
3,4
<40
<40
)
3
4
Any
0,1,2
0,1,2
Any
ANY
ANY
>40
Some categorise >40 and all patents with
skeletal deformity such as micrognathia or mid
face hypoplasia stage IV


DIAGNOSIS
Early identification of OSA relies on a high level of
suspicion of primary care physician.A carefull sleep
history and physical examination are necesssry in
patients with high risk for OSA.
Patients at high risk for OSA need to have objective
testing to confirm the diagnosis and to determine
the severity of disease.
The standard for the diagnosis of OSAHS is
Polysomnography.it helps in identfying patients
who have osa but does not identify the sie of
obstruction.
Upper airway imaging is a powerful technique to
determine the site of obstruction.




HISTORY/EXAMINATION
Polysomnoggraphy
Imaging Modalities
Nasopharyngoscopy
Cephalometrics
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)

OSAS
Diagnostic criteria: A, B plus D or C plus D
A. At least one of the following:
1. Sleepiness, hypersomnolence, exhaustion or insomnia.
2. Arousals with feeling of asphyxiation/ suffocation.
3. Snoring, breathing pauses witnessed by sleep partner.
B. Polysomnography findings:
1. Apnea, hypopnea or RERAs 5 per hour of sleep.
2. Recording of respiratory effort during part or the whole event.
C. Polysomnography findings:
1. Apnea, hypopnea or RERAs 15 per hour of sleep.
2. Recording of respiratory effort during part or the whole event.
D. The disorder cannot be attributed to other conditions,use of
medicines or other substances.


Severity criteria: The criteria of the severity of OSAS are a
combination of the severity of daytime sleepiness and the value of
apnea-hypopnea index (AHI)
Severity assessment of daytime sleepiness can be subjective and
objective. Subjective assessment is obtained with questionnaires.
Epworth Sleepiness Scale
(ESS) is the most commonly used, which has a range of
0-24 and a minimum normal value of 10.
Apnea - Hypopnea Index (AHI) or Respiratory Disturbance Index (RDI)
1.1. Mild: 5-15 events per hour.
1.2. Moderate: 15-30 events per hour.
1.3. Severe: more than 30 events per hour.
Epworth Sleepiness Scale

Name: Date:
Your age: (Yr) Your sex: Male Female
Use the following scale to choose the most appropriate number for each situation:-
0 = would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing
Situation Chance of dozing
Sitting and reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Watching TV . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sitting, inactive in a public place (e.g. a theatre or a meeting) . . . . . . .
As a passenger in a car for an hour without a break . . . . . . . . . . . . . . .
Lying down to rest in the afternoon when circumstances permit . . . . .
Sitting and talking to someone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Sitting quietly after a lunch without alcohol . . . . . . . . . . . . . . . . . . . . . .
In a car, while stopped for a few minutes in the traffic . . . . . . . . . . . . .
Total . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Score:
0-10 Normal range 10-12 Borderline 12-24 Abnormal


Severity criteria of OSAS
M
I
L
D


5-15/H
Unwanted
sleepiness or
involuntary
sleep episodes
during activity
requiring
little
attention(e.g.,
watching TV,
reading)
M
O
D
E
R
A
T
E


15-30/H
Unwanted
sleepiness or
involuntary
sleep episodes
during activity
requiring
some
attention(e.g.,
meetings,
concerts)
S
E
V
E
R
E


>30/H
Unwanted
sleepiness or
involuntary
sleep episodes
during activity
requiring
active
attention(e.g.,
eating during
conversation,
operating a
motor vehicle)
Polysomnography requires three
necessary types of measurement to
reliably determine sleep stages

EEG (Electroencephalogram) measures continuous variance
in voltage (from the 5 200 microvolts range) and is in the
lower portion of the EEG spectrum (0.5 to 14Hz).
EOG (Electro-oculogram) to detect the slow-rolling
eyemovements (SEM) associated with sleep onset and the
cardinal rapid eye movements in REM sleep.
EMG (electromyogram) to measure changes in muscle tone
that may occur during sleep onset but more importantly to
detect the skeletal muscle atonia during REM sleep.

Additional Measures in PSG

EKG (electrocardiogram) measures cardiac function.
Leg EMG measures limb movements by placing EMG sensors on
both right and left tibialis muscles.
Respiratory function (to detect sleep disordered breathing
phenomenon
1.) Airflow measured by thermally-sensitive devices detecting
both oral and nasal airflow
2.) Respiratory effort strain belts often using Piezo Electrodes to
measure abdominal and thoracic effort
3.) Oximetry a photosensitive sensor is placed on the finger or
earlobe (highl vascularized areas) to detect blood oxygenation levels.
[All three of these previous respiratory measures use the Principle of
Transduction a way to represent physiological phenomena and how
they change over time in terms of varying voltages.]
4.) Snoring either decibel meter or movement detector
5.) Position sensor first calibrated than placed over chest plate to
measure position in ambulatory studies.
Sleep study
Sleep study classification: recording montage
Level I Level II Level III Level IV
EEG + + - -
EOG + + - -
Chin EMG + + - -
EKG + + + -
Airflow + + + -
Respiratory effort + + + -
SpO2 + + + +
Body position + Optional Optional
Anterior tibialis EMG + + - -
Attended setting + - - -
Level I, attended comprehensive polysomnography.
Level II, comprehensive portable polysomnography.
Level III, modified portable sleep apnea testing.
Level IV, continuous bioparameter recording
This is what it looks like after applying all the
sensors and electrodes!
Polysomnographic records in a patient with obstructive sleep apnea syndrome. The top eight channels including chin EMG, EEG, EOG, and
EKG represent 30 s of data; the bottom five channels represent 5 min of data. There are nine obstructive apneic episodes with significant drop of
SpO2, which are associated with respiratory efforts. The channel of nasal airflow shows intermittent cessation of airflow (apnea). Heart rate
variability is noted in the pulse channel. EMG, electromyogram; EEG, electroencephalogram; EOG, electrooculogram; EKG, electrocardiogram;
SpO2, arterial oxygen saturation.
Polysomnography
Multiple sleep latency test (MSLT)
- provides an objective assessment of the tendency to
sleep
- correlates well with the subjective feelings of
excessive daytime sleepiness
- measures the amount of time required for a patient
to fall asleep
- The mean sleep onset latency in normal persons : 10 -
15 min
- OSA patients : have a much reduced sleep onset
time


Cephalometry
Use of very accurately taken lateral head and
neck radiograph has become very standard
diagnostic tool in patients of osas.
To evaluate skeletal and soft tissue
abnormalities contributing to obstruction.
Most siginificant when used MMA surgery is
planned

LIMITATIONS:
Two dimentional picture of three dimentional
structure
Done in sitting position .



Measurements

Length Of Soft Palate
Posterior Airway Space(PAS)
Position Of Hyoid Relative To
Mandibular Plane (Mph)
MPH >24mm significant
PAS < 5mm significant
cephalometry
Type 1: leaf-shaped
(lanceolate); the middle portion of
the soft palate is elevated to both
the naso- and oro-side
Cephalometry
Type 2: rat-tail shaped;
the anterior portion is inflated
and the free margin has an
obvious coarctation
Type 3: a butt-like shape; the
length of the soft palate in
this type is about a third to three-
quarters of that of the leaf shape.
The width has almost no distinct
difference from the anterior portion
Type 4: straight line
Type 5: distorted soft palate,
which presents the S-
shape
Type 6: crook-shaped appearance of
the soft palate, in which the posterior
portion of the soft palate crooks
anteriosuperiorly
Definitions of Cephalometric Landmarks,
Angles, and Measurements
Landmarks
A Subspinal: the deepest point on the premaxillary outer
contour between the anterior nasal spine and the central incisor
ANS Anterior nasal spine: the most anterior part of the nasal
floor
B Supramental: the deepest point on the outer contour of the
mandible between the point of the chin and the incisor teeth
Gn Gnathion: the most inferior point in the contour of the chin
Go Gonion: the most posterior and inferior point on the
convexity of the angle of the mandible
H Hyoid: the most anterior-superior point on the body of the
hyoid bone
N Nasion: the sagittal junction of the frontal-nasal suture line
PNS Posterior nasal spine: the most posterior part of the
contour of the hard palate
S Sella: the center of the hypophysial fossa (sella turcica)
Cephalometry

Angles
GnGoH Hyoid angle: angle formed by
the line connecting the gnathion, gonion,
and hyoid
SNA Angle from the sella to the
nasion to the subspinal point
SNB Angle from the sella to the
nasion to the supramental point
ANB Angle from the subspinal point
to the nasion to the supramental point

Cephalometry
Linear Measurements
PAS Retrolingual posterior air space:
the minimal distance (in millimeters) between
the base of the tongue and the nearest point
on the posterior pharyngeal wall.
MPH The distance between the mandibular
plane and the hyoid(>24mm sig)
GnGo The length of the mandibular plane
MPH/GnGo .Relative hyoidal distance: the
ratio between the hyoidal distance from the
mandibular plane and the length of the
mandibular plane
DTH/GnGo Relative tongue height: the
ratio between the tongue height and the
length of the mandibular plane
Mullers maneuver

Flexible
nasopharyngoscopy is done
in awake patients .
Collapse of soft palate and
hypopharyx noted by
asking the patient to inhale
with closed nostril and
mouth(reverse valsalva
maneuver)
As patient is awake
pressure generated during
maneuver cannot be
compared to that pressure
present during sleep.
Muellers maneuver
Mueller maneuver
Patients -sitting position(Sher et al Laryngoscope,
1985)
-> degree of collapse graded separately at the
retropalatal area, the lateral pharyngeal walls,
and the base of tongue as follows:
0 : no collapse
1+ : 25% reduction of cross sectional area
2+ : 50% reduction in area
3+ : 75% reduction in area
4+ : for complete obstruction

Acoustic reflection
Jackson et al and Fredberg et al first described the use of
an acoustic reflection switch that relies on the fact that sound is
reflected by changes in impedance caused by changes in the
pharyngeal cross-sectional areas.
Acoustic reflection performed through the mouth are highly
correlated with roentgenographic area. This method requires a fixed
position of the head and neck and becomes uncomfortable for
sleeping patients. However, when this technique is used with a flexible
tube placed in the nose, pharynx and oesophagus, it becomes possible
to assess the narrowing of the upper airway during sleep.
The flextube recording is accompanied by minimal discomfort in the
absence of relevant complications, it is easy to perform, and it can be
combined with PSG.
The flextube device, in contrast to the pressure catheter, provides
information regarding the length of obstruction during the entire
respiratory event. However, it is relatively invasive and can disturb
sleep.
Computerized tomography (CT)

The majority of studies using CT to investigate OSA were
published from 1980-1990.
Sagittal or crosssectional images of the retropalatal and
retrolingual regions were obtained to determine the sites
of narrowing, as well as the width of the tongue and UA
muscle.
Dynamic imaging with electron beam CT has provided
detailed information about the effects of respiration on
upper airway calibre.
Cine CT or ultra-fast CT have been used to obtain multiple
images with a lower radiation exposure than standard CT.
Due to the limitations of CT in comparison with MRI,
particularly its poor resolution in detection of airway fat, it
is not frequently used for UA evaluation of OSA patients.
MRI

MR imaging is useful for the osa
patients as it provides excellent upper
airway soft tissue resolution including
adipose tissue and accurately determine
cross section area and volumes allowing
axial sagittal and coronal planes.
Comparison of an axial magnetic
resonance image in the velopharynx
region of a normal subject showing
A) maximum and B) minimum area,
an awake apnoeic patient showing
C) maximum and D) minimum area and
a sleeping apnoeic patient showing
E) maximum and F) minimum area.