Dr. Somasekhar Reddy (DLO DNB ENT ) Dr. Preeti (DLO DNB ENT )

1. Etiopathology & Evaluation
Obstructive Sleep Apnoea
Syndrome (OSAS )
PRESENTED BY : DR.SOMASEKHAR
MODERATED BY : DR. R.R.BARLE
DEPT. OF ENT , JLNRC , BHILAI.

2. OBSTRUCTIVE SLEEP APNOEA SYNDROME
• Prevalence in India 7.5 %
• Tip of Iceberg phenomenon
• Undiagnosed OSAS – Hidden health crisis.
• Misconception - Snoring or Sleepiness is Normal.
• Snoring - Indication of the airway narrowing & “warning sign
of OSA”

3. OBSTRUCTIVE SLEEP APNOEA SYNDROME
SLEEP APNOEA
Cessation of airflow > 10 seconds.
1. Obstructive
2. Central
3. Mixed

4. DEFINATION : OBSTRUCTIVE SLEEP APNOEA SYNDROME
Unexplained excessive daytime sleepiness with at least five
obstructed breathing events (apnea or hypopnea) per hour
of sleep.
Cessation of airflow - Presence of breathing effort
Collapse and obstruction in upper airway
Recurrent Hemoglobin desaturation
Frequent Arousals during sleep
OBSTRUCTIVE SLEEP APNOEA SYNDROME

5. HYPOAPNOEA:
Nasal Pressure 30% ( > 10 Sec)
Oxygen Saturation 3%
Electroencephalography “Arousal”
RESPIRATORY EFFORT–RELATED AROUSAL (RERA):
Respiratory effort for >10 seconds Arousal from sleep.
OBSTRUCTIVE SLEEP APNOEA SYNDROME

6. Nose and Nasopharynx Septal deviation
Nasal valve collapse
Adenoid hypertrophy
Nasal polyposis
Oral cavity and Oropharynx Elongated soft palate-uvula.
Enlarged tonsils
Macroglossia
Enlarged Base of Tongue
Lingual thyroid
Larynx and Laryngopharynx Laryngeal stenosis
Laryngocele
ETIOLOGY OBSTRUCTIVE SLEEP APNOEA SYNDROME
OSA is a Multilevel airway disorder .

7. Craniofacial syndromes Pierre Robin syndrome
Beckwith Weidman syndrome
Crouzon’s syndrome
Goldenhar syndrome
Teacher collin’s syndrome
ETIOLOGY OBSTRUCTIVE SLEEP APNOEA SYNDROME

8. RISK FACTORS
• Obesity
• Elderly
• Alcoholics
• Hypnotics & Sedatives

9. AWAKE
Sleep onset
SLEEP
Narrow upper airway Upper airway collapse
Apnoea
Hypoapnoea
Hypoxia
Hypercapnia
Respiratory center &
Sleep center
Chemoreceptor’s
ArousalUpper airway opening
Compensatory
hyperventilation
Corrected
Hypoxia &
Hypercapnia
PATHOGENESIS OF OBSTRUCTIVE SLEEP APNOEA SYNDROME
Muscle tone
Muscle tone

10. SYMPTOMATOLOGY OF OSAS
• Witnessed choking spells
• Snoring
• Nocturnal restlessness
• Insomnia with awakenings
• Gastro esophageal reflux disease
• Nocturia
• Bedwetting ( children)
• Excessive daytime sleepiness
• Lack of concentration
• Morning headaches
• Cognitive deficits
• Mood changes
• Impotence
• Aggression
• Hyperactive behavior
• Inattention
• Poor school performance

11. A . Unexplained Excessive Daytime Sleepiness
B. Witnessed choking spell
Recurrent awakening
Non-refreshing sleep
Impaired concentration.
C. PSG > 5 Obstructed breathing events per hour
A + C or B + C
Minimum 2
DIAGNOSTIC CRITERIA – OBSTRUCTIVE SLEEP APNOEA
SYNDROME

12. INDICES - OBSTRUCTIVE SLEEP APNOEA SYNDROME
1. APNOEA HYPOAPNOEA INDEX (AHI)
AHI = ( Apneas + Hypoapneas )
2. RESPIRATORY DISTURBANCE INDEX (RDI)
RDI = ( Apneas + Hypoapneas + RERAs )
TST ( Total Sleep Time)
TST ( Total Sleep Time)

13. OSA severity Adult Pediatric
Normal <5 <1
Mild 5-14 1-5
Moderate 15-29 5-10
Severe >30 >10

14. EVALUATION

15. HISTORY EPWORTH SLEEPINESS SCALE
< 10 Normal
11-14 Mild EDS
15-18 Mod. EDS
18-23 Severe EDS

16. PHYSICAL EXAMINATION :
BMI > 30 kg/m2
NECK CIRCUMFERENCE /COLLAR SIZE: > 42 Cms Men
> 37.5Cms Women
LABORATORY INVESTIGATIONS :
Complete Blood count, Biochemistry, Lipid profile,
Thyroid Hormone Assay.
ENT EXAMINATION :

17. UPPER AIRWAY EVALUATION :
1.Fujita classification
2.Moore tongue classification
3.Müller’s maneuver
4.Friedman staging

18. Fujita classification
Type 1 Type 2 Type 3

19. Moore Tongue classification
Combined and Retroepiglottic.Proximal Retroepiglottic

20. Müller’s maneuver
• Reverse Valsalva maneuver
• Attempt to duplicate negative pressure during sleep.
• Fiberoptic scope – upper airway – amount of collapse
• Uvulopalatopharyngoplasty success.
Awake
Effort dependent
Interpretations - Subjective
Drawbacks :

21. Friedman staging system :
Three stages based on
1. Tonsil size (1 to 4+)
2. Modified Mallampati classification (1 to 4+)
3. Severe obesity (Body mass index of > 40 kg/m2)
4. Craniofacial abnormalities.

22. Stage I
Stage II
Tonsil size Palate score Body mass index
3,4
3,4
1
2
< 40
1,2
3,4
1,2
3,4
< 40
3
4
Any
1,2
1,2
Any
Any
Any
> 40
All patients with significant craniofacial
abnormalities
Friedman stage
< 40
< 40
Stage III

23. POLYSOMNOGRAPHY (PSG)

24. • TYPES OF PSG :
1. In Laboratory PSG (Gold standard )
2. In Home PSG
3. Split night PSG
USE:
• Diagnostic tool – severity
• Therapeutic tool
• Response to treatment (Medical, oral appliances)
• Titration pressure -CPAP, BIPAP & ASV.
• Differentiates obstructive from central sleep apnoea.
• Diagnosis of other sleep disorders

25. IN LABORATORY PSG
• EEG-Electroencephalographic arousals,
• EOG-Eye movements
• EMG- Muscle tone
• Nasal Airflow & Pressures,
• Respiratory efforts,
• Pulse Oximetry- O2 saturation,
• ECG – Electrocardiography ,
• Sound probe, and
• Leg movements.
• Body position,

26. In Home PSG
Advantages:
• No hospital admission
• Cost effective
• Readily available data.
Disadvantages
• Less information – Fewer
signal channels
• without EEG,EOG,EMG
Multichannel kit

27. STAGES OF SLEEP
Non Rapid Eye Movement Rapid eye movement
75-80% N1-N2-N3 20-25%
Restful sleep NOT Restful
Vital signs LOW IRREGULAR Vitals
Muscle tone well maintained Depressed
No Dreams Dreams occur
NREM REM

29. Decrease in nasal pressure by greater than 30% for at least 10 seconds
At least 3 % decrease in O2 saturation (OR) Arousal as determined by EEG.
HYPOAPNOEA

30. HYPOAPNOEA

31. APNOEA APNOEA
APNOEA

32. HOW TO EVALUATE A SLEEP STUDY REPORT ?
ADI / RDI Gives degree of OSA
ADI /RDI Disparity in Supine &
Non-supine
Consider for Positional Therapy
Total Sleep Time (TST) Sleep efficiency-how well patient has slept
Oxygen Desaturation Index (ODI) Mean Oxygen saturation
REM Latency Normal 90-110 min. Narcolepsy (< 20 min)
Percentage of REM % None or Low, AHI/RDI Underestimates the
degree of OSA
Periodic Limb Movement Index Periodic limb movement disorder
ECG summary Heart rhythm, hidden arrhythmia's

33. IMAGING

34. IMAGING
• Chest X ray
• X Ray Soft tissue neck (Lateral view)
• CEPHALOMETRY (Lateral view- Skull )
X-Ray / CT
1. Soft tissue data
2. Skeletal data
Drawbacks
• Awake
• Upright
• 2-D
• Adynamic

35. SOFT TISSUE DATA
1. Soft Palate Length
2. Soft Palate Width
3. Tongue Length
4. Tongue Width

36. UPPER AIRWAY SIZE
8. Superior Posterior airway
space
9. Inferior Posterior airway
space

37. • S.N.A angle
• Position of Maxilla in
relation to cranial base
82° -- Orthognathic
>82° -- Prognathic maxilla
< 82°– Retrognathic maxilla
S
N
A
Mean value -- 82°
SKELETAL DATA

38.  S.N.B angle
• position of the Mandible in
relation to cranial base
• > 80°- Prognathic mandible
• < 80°- Retrognathic mandible
S
N
B
Mean value-- 80°

39. • 2D Echo
• Cardiac catheterization.
• Computerized Tomography Scan (CT Scan)
Advantages
Better skeletal resolution
3D-Reconstruction of skull.
Cine CT Scan- accurate localization of obstruction.
Disadvantages
High cost
Ionizing radiation
Only axial

40. • Magnetic Resonance Imaging (MRI)
Advantages
Excellent soft tissue anatomy
Multiplanar data
No ionizing radiation
Disadvantages
High cost
Noisy
Claustrophobia

41. DYNAMIC MRI

42. DRUG-INDUCED SLEEP ENDOSCOPY (DISE)
- Sites of obstruction in awake patient do not always
correlate during sleep.
INDICATIONS :
1. Persistent OSA.
2. Patients with OSA unable to tolerate PAP Therapy.
3. Before Planning for Surgery- Oral appliances- Positional
therapy.

43. • Pharmacological agents :
1. Propofol
2. Midazolam
3. Dexmedetomedine.
• Target Depth of sedation - Natural sleep
• Endoscopic evaluation – upper airway- Flexible F.O
endoscope .
• Demonstrate- Fixed blocks & dynamic upper airway
collapses.

47. CONSEQUENCES : Increased Morbidity & Mortality
LONG-TERM
• Hypertension
• Pulmonary Hypertension
• Myocardial Infarction
• Cerebro Vascular Accidents
• Metabolic Syndrome
• Left Heart Failure
• Cardiac Arrythmia’s
• Sudden Death
• Failure To Thrive
SHORT TERM
• Impaired quality of life.
• Increased Road Traffic
Accidents
• Snoring Spouse Syndrome

48. “ In an Age Of Constant Activity, The Solution To Improving
The Nation’s Health May Lie In Helping It Sleep Better ”