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This document provides a historical overview and definitions related to obstructive sleep apnea (OSA). It discusses how OSA was first described in the 1800s and key developments in its diagnosis and treatment over time. These include the coining of the term "sleep apnea syndrome" in 1976 to describe the condition in non-obese patients, and the development of treatments like CPAP in the 1980s. The document also defines OSA and classifies sleep-related breathing disorders, noting that OSA is characterized by repetitive upper airway obstruction during sleep associated with oxygen desaturation and arousals. Risk factors and prevalence are discussed.
This document provides a historical overview and definitions related to obstructive sleep apnea (OSA). It discusses how OSA was first described in the 1800s and key developments in its diagnosis and treatment over time. These include the coining of the term "sleep apnea syndrome" in 1976 to describe the condition in non-obese patients, and the development of treatments like CPAP in the 1980s. The document also defines OSA and classifies sleep-related breathing disorders, noting that OSA is characterized by repetitive upper airway obstruction during sleep associated with oxygen desaturation and arousals. Risk factors and prevalence are discussed.
This document provides a historical overview and definitions related to obstructive sleep apnea (OSA). It discusses how OSA was first described in the 1800s and key developments in its diagnosis and treatment over time. These include the coining of the term "sleep apnea syndrome" in 1976 to describe the condition in non-obese patients, and the development of treatments like CPAP in the 1980s. The document also defines OSA and classifies sleep-related breathing disorders, noting that OSA is characterized by repetitive upper airway obstruction during sleep associated with oxygen desaturation and arousals. Risk factors and prevalence are discussed.
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
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.
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.