2. Physiology of sleep
• Normal healthy adult sleeps for about 7-8hrs
• There are two phases:
*NON-REM SLEEP
*REM SLEEP
• Occur in semi regular cycles, each cycle lasts for 90-120mins(3/4cycles)
• Non-REM sleep:( forms 75-80% of sleep)
4 stages:
Stage 1- Transition from wakefulness to sleep
Stage 2- Decrease in musle tone
Stage 3- Deep sleep
Stage 4- Deep and most restful sleep
3. REM Sleep:(20–25% of total sleep)
*Characterized by rapid eye
movements
*Increased autonomic activity with
erratic cardiac and respiratory
movements.
*Dreaming occurs in this stage but
muscular activity is decreased so
that dreams are not enacted
4. Apnoea:
• Means no breathing at all.
• There is no movement of air at the level of nose
and mouth.
• 3 types:
*Obstructive(collapse of upper airway
resulting in cessation of airflow)
*Central(brainstem fail to send signal to
muscles to breath)
*Mixed(combination of both)
6. Definition:
• Obstructive sleep apnea occurs when the muscles that
support the soft tissues in your throat, such as your tongue
and soft palate, temporarily relax.
• When these muscles relax, your airway is narrowed or
closed, and breathing is momentarily cut off.
7. Etiology
Anatomic factors:
• Enlarged tonsils (children)
• volume of the tongue soft tissue
• lateral pharyngeal walls
• length of the soft palate
• abnormal positioning of the maxilla and mandible
Neuromuscular factors:
• Decreased Neuromuscular activity in the upper
airway including reflex activity
• Reduced ventilatory motor output to upperairway
muscles
8. Structural factors:
• Innate anatomic variations (facial elongation, posterior facial
compression)
• Retrognathia and micrognathia
• Mandibular Hypoplasia
• Brachycephalic head form
• inferior displacement or the Hyoid
• Adenotonsilar hypertrophy( particularly in chldren and young)
• Pierre Robin syndrome
• Down syndrome
• Marfan syndrome
• Prader-Willi syndrome
• High arched palate (particularly in women)
9. Non structural factors:
• Obesity
• Central fat distribution
• Male sex (male/female 2:1)
• Postmenopausal state
• Alcohol use
• Sedative use
• Smoking
• Habitual snoring with daytime somnolence
• Supine sleep position
• Rapid eye movement (REM) sleep
10. Other factors:
• Nasal obstruction -polyps,
septaldeviation, tumors, trauma, and
stenosis.
• Retropalatal obstruction, posteriorly
placed palate and uvula, tonsil
hypertrophy
• Retroglossal obstruction -macroglossia
and tumor.
12. Clinical features
Night time symptoms:
• Snoring usually loud
• Witnessed apnoea
• Gasping and choking
sensations
• Nocturia
• Insomnia
• Restless Sleep
Daytime symptoms:
• Nonrestorative sleep
• Morning headache, dry or sore
throat
• Excessive daytime sleepiness (EDS)
• Daytime fatigue/tiredness
• Cognitive deficits
• Decreased vigilance
• Morning confusion
• Personality and mood changes
• Sexual dysfunction (including
impotence anddecreased libido)
• Gastroesophageal reflux
• Hypertension
• Depression
13. Clinical evaluation
History:
• Ask patients bed partner about h/o snoring,restless
disturbed sleep,gasping,choking/apnoeic events &
sweating
• Obtain day time history like excessive daytime
sleepiness,fatigue,irritability, morning headache,memory
loss,impotence
• Also obtain h/o position during sleep, use of alcohol,
sedatives, caffeine, mouth breathing and HRT
14. 1.) Physical examination:
• BMI
• Collar size(neck circumference at cricothyroid memb
level)
• Complete head and neck examination
• Nasopharynx
• Larynx
15. 2.) Systemic examination
3.) Cephalometric radiographs(craniofacial
anomalies and tongue base tumors)
4.) Polysomnography(Gold standard test for
diagnosis)
* It can differentiate b/w primary snoring,
OSA and central sleep apnoea.
* It records:
EEG(electroencephalography), ECG,
EOM(electroculogram), EMG
(electromyography), Pulse oximetry, Nasal and
oral airflow, Sleep position, Blood pressure,
Oesophageal pressure.
16. 5.) Split night polysomnography:
1st part of night –
used in usual polysomnography.
2nd part of night –
used in continuous postive
airway pressure(CPAP)
17. Diagnostic criteria for OSA
• Individuals must fulfill criterion A or B, plus criterion C to be
diagnosed with OSA:
A. Excessive daytime sleepiness that is not explained by other
factors
B. Two or more of the following that are not explained by other
factors:
* Choking or gasping during sleep
* Recurrent awakenings from sleep
* Unrefreshing sleep
* Daytime fatigue
* Impaired concentration
18. C. Overnight monitoring demonstrates 5 to 10 or
more obstructed breathing events per hour during
sleep
or
greater than 30 events per 6 hours of sleep.
• These events may include any combination of
obstructive apnea, hypopnea, or respiratory effort-
related arousals.
19. Epworth sleepiness scale (for
Excessive Daytime Sleepiness)
Situation
*Sitting and reading
*Watching TV
*Sitting inactive in a public place (e.g. theatre
or in a meeting)
*Being a passenger in a car for 1 h without
break
*Lying down to rest in the afternoon when
circumstances permit
*Sitting and talking to someone
*Sitting quietly after a lunch without alcohol
*Sitting in a car while stopped in traffic for a few minutes
SCORE : 0-3
0 = never dozing off; 1 = slight chance of dozing off; 2 = moderate
chance of dozing off; 3 = high chance of dozing off.
20. Treatment
• Non- surgical:
* Change in life style( weight loss, dietary modification, cessation of alcohol and
smoking)
* Positional therapy( Patient should sleep on the side not in supine position)
* Intraoral devices( alter position of mandible/tongue to open retropalatal airway
and relieve snorting & apnoea)
* Continuous positive airway pressure
• Surgical:
* Nasal surgery
. * Oropharyngeal surgery
* Tonsillectomy and/or adenoidectomy
* Advanced genioplasty with hyiod suspension
. * Tongue base radio-frequency
. * Maxillomandibular advancement osteotomy
