The Upper Airway Evaluation of Habitual Snorers and Obstructive Sleep Apnea Patients

8/18/2019 The Upper Airway Evaluation of Habitual Snorers and Obstructive Sleep Apnea Patients

1/6

Fax +41 61 306 12 34E-Mail [email protected]

Original Paper

ORL 2012;74:136–140

DOI: 10.1159/000337134

The Upper Airway Evaluation of Habitual Snorers and Obstructive SleepApnea Patients

Omer Karakoca Timur Akcama Mustafa Gereka Hakan Genca Fuat Ozgenb

Departments of a Otolaryngology, Head and Neck Surgery, and b Psychiatry, Gulhane Military Medical Academy,

Ankara, Turkey

Fujita classification (all p ! 0.001). There were significant re-

lationships between tonsil size, Fujita classification, Mallam-

pati classification, collapse ratios and AHI. Conclusion: We

saw that hypopharyngeal area often contributes to obstruc-

tion and some examination methods correlate more with

AHI. This can aid sleep physicians in the evaluation of OSA

patients. Copyright © 2012 S. Karger AG, Basel

Introduction

The upper airway is obstructed with both snoring andobstructive sleep apnea (OSA). This varies from a partialobstruction causing habitual snoring to complete ob-

struction causing OSA. The cause of the upper airwayobstruction in sleep is an imbalance of the forces thatkeep the airway open and closed. Evaluation of the upperairway is very important for the success of surgical pro-cedures performed in snoring and OSA. Even thoughthere is not a standard way to evaluate of snoring andOSA patients, the challenge of the examination is to de-termine the cause that increases the upper airway resis-tance. Therefore, the aim of this study was to determine

Key Words

Sleep apnea Snoring Upper airway obstruction

Abstract

Objective: To investigate the relationship between the Ap-

nea Hypopnea Index (AHI) and upper airway examination

findings of habitual snorers and obstructive sleep apnea

(OSA) patients. Materials and Methods: This study included

264 patients whose tonsils were evaluated in 4 grades. The

Mallampati classification was used to determine the rela-

tionship between tongue and palate. All patients performed

the Müller maneuver in a sitting position. The Fujita classifi-

cation was used to define the type of obstruction. All pa-

tients had polysomnography and were divided into 4 groups

according to AHI. Statistical analysis was performed to evalu-ate the relationship between examination findings and AHI.

Results: Of the patients, 133 (50.4%) were habitual snorers,

66 (25%) were mild OSA, 40 (15.2%) were moderate OSA and

25 (9.5%) were severe OSA patients. There was a positive cor-

relation between neck circumference, BMI and AHI in males

(p ! 0.001). There was a significant difference between pa-

tient groups according to Mallampati classification, collapse

at the velopharyngeal level and hypopharyngeal level and

Received: August 12, 2011

Accepted after revision: January 31, 2012

Published online: April 5, 2012

Dr. Omer KarakocGulhane Military Medical AcademyDepartment of Otolaryngology, Head and Neck SurgeryTR–06018 Etlik, Ankara (Turkey)E-Mail omerkarakoc @ hotmail.com

© 2012 S. Karger AG, Basel0301–1569/12/0743–0136$38.00/0

Accessible online at:www.karger.com/orl


2/6

Upper Airway Evaluation of Habitual

Snorers and OSA Patients

ORL 2012;74:136–140 137

the relationship between the results of upper airway ex-amination findings and the Apnea Hypopnea Index(AHI) which designates the severity of OSA.

Materials and Methods

The ethics committee of the Gulhane Mil itary Medical Acad-emy approved the study, which included 264 patients (213 menand 51 women) who applied to the Otolaryngology, Head andNeck Surgery Department complaining of snoring and or sleep-disordered breathing (SDB). Patients were included who snoredevery night, either the whole night long or from time to time;those who snore only some nights were excluded.

After reporting their medical history, all patients underwent aphysical examination. Weight and height of patients were mea-sured, their BMI was calculated and their neck circumference wasmeasured at the cricothyroid cartilage level. Anterior rhinoscopy,cottle test and nasal endoscopy were performed to diagnose nasalpathologies. Tonsil size was graded on a 4-point scale in an oralexamination: absent (0), small within the tonsillar fossa (1+), ex-tends beyond the tonsillar pillar (2+), hypertrophic but not touch-ing in midline (3+) or hypertrophic and touching in midline (4+).

To determine the position and relationship of palate andtongue, we used Friedman’s modification of the Mallampati clas-sification [1]; this has 4 ranks.

All patients underwent fiberoptic nasopharyngeal endoscopicexamination in an upright sitting position. Modif ied Müller’s ma-neuver was done at both the retropalatal and hypopharyngeal re-gions to determine the degree of collapsibility of the pharyngealwalls. In this maneuver, patients were instructed to try to make aforced inspiration with their nose and mouth totally closed. Col-lapse was scored with a percentage and grouped by the followingclassification: 1+ (0–25%), 2+ (26–50%), 3+ (51–75%) or 4+ (76–100%).

With the data obtained from the oropharyngeal and endo-scopic examinations, the type of obstruction was classified ac-cording to the Fujita classification [2]: type 1 – upper pharyngealobstruction includes abnormalities of palate, tonsillar, nasophar-ynx or oropharynx, type 2 – oropharyngeal and hypopharyngealobstruction or type 3 – hypopharyngeal obstruction.

All patients underwent polisomnographic evaluation in thesleep laboratory. Polysomgraphies were scored according to the2007 American Academy of Sleep Medicine Manual for the Scor-ing of Sleep and Related Events [3]. Patients were divided into4 groups according to AHI: (1) habitual snorers had AHI ! 5events/h, (2) mild OSA patients 5^ AHI ̂20 events/h; (3) mod-erate OSA patients had 20! AHI ̂40 events/h or (4) severe OSAPatients had AHI 1 40 events/h.

Statistical AnalysisThe SPSS 11.5 (SPSS Inc., Chicago, Ill., USA) program was

used for data analysis. For comparison between groups, an ANO-VA test was used and an 2 test was used to determine the rela-tionships between quantitative data. Relationships between pa-rameters were investigated with a Pearson correlation coefficientor Kendall’s Tau-b correlation coefficient. To find the parametersthat contribute to AHI, linear multivariate regression analysis

was done. ROC (receiver operating characteristics) was used todetermine appropriate cut-off points. We considered = 0.005to be acceptable; p^ 0.005 was interpreted as statistically mean-ingful.

Results

The average age was 44.558 11.43 years for males and48.928 13.10 years for females. The distribution of thepatients into groups by gender and apnea severity isshown in table 1. Male patients’ average BMI was 27.548 2.83 (interval 19.37–40.67) and neck circumference 40.768 2.25 cm (interval 34–50 cm); female patients’ averageBMI was 28.618 5.00 (interval 18.44–37.2) and neck cir-cumference 38.078 4.59 cm (interval 30–45 cm). Therewas a positive correlation between neck circumference,

BMI and AHI in male patients (r = 0.371; p ! 0.001 andr = 0.367; p ! 0.001, respectively), but this correlation wasnot determined in female patients (r = 0.007; p = 0.972and r = 0.273; p = 0.073, respectively).

We determined nasal septal deviation in 72 (27.6%) pa-tients, turbinate hypertrophy in 52 (19.8%) and nasal

valve deficiency in 39 (14.8%). There was not a significantdifference between patient groups according to the re-sults of the nasal examination.

Table 1. Distribution of the patients into groups according to gen-der and apnea severity

Male Female Total

Habitual snorers 102 (47.9%) 31 (60.8%) 133 (50.4%)Mild OSA 55 (25.8%) 11 (21.6%) 66 (25%)Moderate OSA 34 (16.0%) 6 (11.8%) 40 (15.2%)Severe OSA 22 (10.3%) 3 (5.9%) 25 (9.5%)

Table 2. The relationship between AHI and the physical examina-tion findings

p

Septal deviation –0.040 0.442Turbinate hypertrophy –0.019 0.708Tonsil size 0.109 0.032

Fujita classification 0.220


3/6

Karakoc /Akcam /Gerek /Genc /OzgenORL 2012;74:136–140138

Tonsils were determined as (+1) in 206 (80.2%) pa-tients, (+2) in 22 (8.6%), (+3) in 11 (4.3%) and (+4) in 2(0.8%). Sixteen (6.2%) of patients had had a tonsillectomy.There were not an adequate number of patients in eachgroup according to tonsil size to make a comparison be-tween groups.

There was a significant difference between patientgroups according to the Mallampati classification ( 2 =

42.699; p ! 0.001). Collapse at the velopharyngeal andhypopharyngeal levels showed a significant differencebetween the groups ( 2 = 42.699; p ! 0.001 and 2 =35.650; p ! 0.001, respectively).

Of the habitual snorers, 79.8% were Fujita type I and60.9% of severe OSA patients were Fujita type II. Therewas a significant difference between patient groups ac-cording to the Fujita classification ( 2 = 25.475; p ! 0.001).

The relationship between the results of the physicalexamination and AHI is shown in table 2. When we madeROC analysis as accepting AHI 6 5 to diagnose OSA,27.40 was the right cut-off point for BMI and 40.5 cm forthe neck circumference for men, and 29.14 and 38.5 cmfor women, respectively. Figures 1 and 2 show diagramsof this analysis.

Discussion

Obesity is a basic risk factor for snoring and OSA. Insome studies, it is has been noted that 70% of OSA pa-tients are overweight [4, 5]. While OSA is diagnosed in4–9% of middle-aged men and 1–2% of women, the per-centage can increase 10–12 times more in obese patients[6].

0

0

0.3

0.5

S e n s i t i v i t y

0.8

1.0

0.3 0.5

Specificity

BMI (men)

0.8 1.0

0

0

0.3

0.5


0.8

1.0

0.3 0.5

Specificity

BMI (women)

0.8 1.0

0

0

0.3

0.5


0.8

1.0

0.3 0.5

Specificity

Neck circumference (men)

0.8 1.0

0

0

0.3

0.5


0.8

1.0

0.3 0.5

Specificity

Neck circumference (women)

0.8 1.0

Fig. 1. ROC analysis for BMI.

Fig. 2. ROC analysis for neck circumfer-ence.

C o l o r v e r s i o n

a v a i l a b l e

o n l i n e

C o l o r v e r s i o n a

v a i l a b l e

o n l i n e


4/6

Upper Airway Evaluation of Habitual

Snorers and OSA Patients

ORL 2012;74:136–140 139

Anthropometric measures like BMI, neck circumfer-ence, waist circumference and skin thickness can be usedas predictor factors for OSA and the severity of OSA [7,8]. Katz et al. [9] found neck circumference greater in ap-neics than in nonapneics and demonstrated neck circum-ference, BMI and pharynx circumference as predictor

factors for OSA in 123 snoring patients. In this study,however, there was a significant relationship betweenBMI, neck circumference and AHI in men but not inwomen. This can result from the localization of differentfat tissues between men and women. When women gainweight, fat tissue first localizes around the lower regionsof the body so gaining weight may not affect the upperairway as much as it may affect men.

When we investigated the predictive value of BMI andneck circumference in the OSA diagnosis, we got statisti-cally significant ROC curves for men. However, in wom-en, we got significant curves only for BMI. We considered

these to not be good predictive parameters because AUC(area under the curve) values were not high enough. Lowaverage BMI values in both groups, i.e. men and women,could be the reason for this.

The nose plays an important role in snoring and allother respiratory system pathologies. Due to the inspira-tory negative pressure that occurs as a result of nasal ob-struction, air turbulence increases and the severity of thesnoring [10, 11]. In addition, breathing by mouth duringsleep increases the collapsibility of the upper airway andcontributes to SDB [12]. Miyazaki et al. [13], in their epi-pharyngeal pressure increase follow-up study, stated thatnasal obstruction disturbs sleep but it is not the one of thebasic factors. They also stated that it could accompanyOSA. In this study, 16.3% of all patients complained of apermanent nasal obstruction. There was no differencebetween habitual snorers and OSA patients regarding na-sal obstruction and the distribution of nasal pathologies.In addition, there was no correlation between AHI andnasal pathologies.

In different studies, a relationship is shown betweenAHI and tonsils [14, 15]. It has been presented that tonsil-lectomy can be an effective treatment in selected OSA

patients [14]. Hence, the success rate of uvulopalatopha-ryngoplasty (UPPP) in patients without tonsillectomy is52%, and in patients with previous tonsillectomy it is 7%[15]. We found that tonsil hypertrophy was not so com-mon in adult OSA patients. Those with large tonsils (3+and 4+)comprised 5.1% of all patients. In other studies,this ratio was 13–14.4% [1, 16]. Although tonsil hypertro-phy is not often seen in adult OSA patients, tonsillectomyand UPPP are the most-performed surgeries.

Difficult intubation is often seen in OSA patients. TheMallampati classification is usually used to predict thedifficult intubation [17]. The Friedman-modified Mal-lampati classification takes the tongue to be in a neutralposition in the mouth, which is more similar to the posi-tion in sleep [1].

In this study, we saw a significant relationship betweenAHI and the Mallampati classification, and found in-creased Mallampati scores when the OSA severity in-creased. This supports the results of other studies [1, 16].Zonato et al. [16] showed 21.2% of patients were Mallam-pati classification I–II and 78.8% were III–IV. We found78.8% of all patients were Mallampati classification I–IIand 21.2% were III–IV. We think this difference could bea result of the distribution of patients into groups; in ourstudy, 50.4% of patients were habitual snorers as opposedto 18.4 % in theirs.

The relationship between AHI and Mallampati classi-

fication can be due to various causes. It has been postu-lated that high Mallampati scores in OSA are due to a longuvula and a soft palate. Mallampati is known to be a clas-sification describing the tongue size [18]; if this score ishigh in an OSA patient, we can assume that the size of thetongue could be contributing to upper airway obstruction.

To understand the pathophysiology of upper airwayobstruction in patients with SDB, it is important to exam-ine the upper airway under negative intraluminal pres-sure. The Müller maneuver may mimic apnea in creatingan artificial collapse. Hence, fiber-optic nasopharyngos-copy with modified Müller’s maneuver is used to deter-mine the obstruction area and/or the area that tends tocollapse and can be performed regardless of examinerdifference and experience [19].

When Bogaard et al. [20] compared habitual snorersand OSA patients according to airway collapsibility re-sults with modified Müller’s maneuver, they found thatboth the soft palate and the base of the tongue often col-lapse, but that the significant difference is only on thetongue base. Sleep endoscopy demonstrates the same re-sults [21]. We found a significant relationship betweencollapsibility and AHI on both the retropalatal and

tongue base with modified Müller’s maneuver. From re-gression analysis, we also decided the collapsibility of thetongue base has more predictivity value on AHI.

Due to the difference in collapsibility ratios of normalindividuals and OSA patients, the success rate of nasopha-ryngeal fiber-optic endoscopy with modified Müller’smaneuver has been investigated to predict the outcome ofthe UPPP procedure. Although Sher et al. [22] affirmedthis maneuver to be successful in predicting the outcome


5/6

Karakoc /Akcam /Gerek /Genc /OzgenORL 2012;74:136–140140

of UPPP with a success rate of 87%, Katsantonis et a l. [23]reported a 33% success rate, but that they were better atpredicting the unsuccessful patients with a ratio of 77.7%.These studies are conflicting, but in our opinion, thismethod is not deemed unnecessary in the evaluation ofOSA patients; we found that when OSA severity increases

modified Müller’s maneuver scores increase in both theretropharyngeal and tongue-base regions. Therefore, theimportance of the results found in this examination maynot be underestimated. On the other hand, it would notbe appropriate to decide on surgery with only collapsibil-ity ratios emerging from this examination. Although thecollapsibility of the upper airway is one of the major fac-tors contributing to OSA, there are many other factors inthe etiology of OSA. Endoscopic examinations should beinterpreted along with other findings.

Conclusion

There are different treatment modalities in OSA. Sur-gery is one of the choices. The most important factor inthe decision to perform surgery is to determine the ob-struction sites; if this is not correct, the surgical proce-

dure could fail. OSA patients often have a narrow upperairway, but there is no standard examination method todetermine the obstruction site. In this study, we showedthat the hypopharyngeal area often contributes to ob-struction and that some examination methods correlatebetter with AHI. This can aid sleep physicians in the eval-uation of OSA patients.

References

1 Friedman M, Tanyeri H, La Rosa M, Lands-berg R, Vaidyanathan K, Pieri S, CaldarelliD: Clinical predictors of obstructive sleepapnea. Laryngoscope 1999; 109: 1901–1907.

2 Fujita S: Surgical treatment of obstructivesleep apnea. UPPP and lingualplasty (lasermidline glossectomy); in Guilleminault C,Partinen M (eds): Obstructive Sleep ApneaSyndrome: Clinical Research and Treat-ment. New York, Raven Press, 1990, pp 129–151.

3 Iber C, Ancoli-Israel S, Chesson A, Quan SF:

The AASM Manual for the Scoring of Sleepand Associated Events: Rules, Terminologyand Technical Specifications, ed 1. West-chester, American Academy of Sleep Medi-cine, 2007.

4 Bearpark H, Elliott L, Grunstein R, Cullen S,Schneider H, Althaus W, Sullivan C: Snoringand sleep apnea. A population study in Aus-tralian men. Am J Respir Crit Care Med1995; 151: 1459–1465.

5 Bloom JW, Kaltenborn WT, Ouan SF: Riskfactors in a general population for snoring.Importance of cigarette smoking and obesi-ty. Chest 1988; 93: 678–683.

6 Kyzer S, Charuzi I: Obstructive sleep apneain the obese. World J Surg 1998; 22: 998–1001.

7 Dixon JB, Schacter LM, O’Brien PE: Predict-ing sleep apnea and excessive day sleepinessin the severely obese: indicators for polysom-nography. Chest 2003; 123: 1134–1141.

8 Schafer H, Pauleit D, Sudhop T, Gouni-Berthold I, Ewig S, Berthold HK: Body fatdistribution, serum leptin, and cardiovascu-lar risk factors in men with obstructive sleepapnea. Chest 2002; 122: 829–839.

9 Katz I, Stradling J, Slutsky AS, Zamel N,Hoffstein V: Do patients with obstructivesleep apnea have thick necks? Am Rev RespirDis 1990; 141: 1228–1231.

10 Fairbanks D: Snoring: An Overview withHistorical Perspectives. Snoring and Ob-structive Sleep Apnea, ed 2; by FairbanksDNF, Fujita S (eds): Raven Press Ltd., 1994,chapt 1, pp 1–16.

11 Hudgel D, Harasick T: Fluctuation in timingof upper airway and chest wall inspiratorymuscle activity in obstructive sleep apnea. J

Appl Physiol 1990; 69: 443– 450.12 Meurice JC, Marc I, Carrier G, Series F: Ef-

fects of mouth opening on upper airway col-lapsibility in normal sleeping subjects. Am JRespir Crit Care Med 1996; 153: 255–259.

13 Miyazaki S, Itasaka Y, Ishikawa K, Togawa K:Influence of nasal obstruction on obstruc-tive sleep apnea. Acta Otolaryngol Suppl1998; 537: 43–46.

14 Verse T, Kroker BA, Pirsig W, Brosch S: Ton-sillectomy as a treatment of obstructive sleepapnea in adults with tonsillar hypertrophy.Laryngoscope 2000 ; 110: 1556–1559.

15 Guirth WF Jr, Johnson JT, Sanders MH: Pre- vious tonsillectomy as prognostic indicatorfor success of uvulopalatopharyngoplasty.

Laryngoscope 1995; 105: 1253–1255.16 Zonato AI, Bittencourt LR, Martinho FL, Ju-

nior JF, Gregorio LC, Tufik S: Association ofsystematic head and neck physical examina-tion with severity of obstructive sleep apnea-hypopnea syndrome. Laryngoscope 2003;113: 973–980.

17 Mallampati SR, Gatt SP, Gugino LD, DesaiSP, Waraksa B, Freiberger D, Liu PL: A clini-cal sign to predict difficult tracheal intuba-tion: a prospective study. Can Anaesth Soc J1985; 32: 429–434.

18 Woodson T: Evaluation by physical exami-nation and special studies; in Fairbanks D,Mickelson S, Woodson T (eds): Snoring andObstructive Sleep Apnea, ed 3. LippincottWilliams & Wilkins, Philadelphia, 2003,chapt 2, pp 19–25.

19 Terris DJ, Hanasono MM, Liu YC: Reliabilit y

of the Müller maneuver and its associationwith sleep-disordered breathing. Laryngo-scope 2000; 110: 1819–1823.

20 Bogaard JM, van der Meche FG, PoublonRM, Ginai AZ, Schmitz PI, Bubberman A,Slappendel AM, Boot H: Indices from flow- volume curves in relation to cephalometric,ENT- and sleep-O2 saturation variables insnorers with and without obstructive sleep-apnoea. Eur Respir J 1995; 8: 801–806.

21 Steinhart H, Kuhn-Lohmann J, Gewalt K,Constantinidis J, Mertzlufft F, Iro H: Upperairway collapsibility in habitual snorers andsleep apneics: evaluation with drug-inducedsleep endoscopy. Acta Otolaryngol 2000;120: 990–994.

22 Sher AE, Thorpy MJ, Shprintzen RJ, Speil-man AJ, Burack B, Gregor PA: Predict ive val-ue of Müller maneuver in selection of pa-tients for uvulopalatopharyngoplasty. La-ryngoscope 1985; 95: 1483–1487.

23 Katsantonis GP, Maas CS, Walsh JK: Thepredictive eff icacy of the Müller maneuver inuvulopalatopharyngoplasty. Laryngoscope1989; 99: 677–680.


6/6

Reproducedwithpermissionof thecopyrightowner. Further reproductionprohibitedwithoutpermission.

The Upper Airway Evaluation of Habitual Snorers and Obstructive Sleep Apnea Patients

Documents

Transcript of The Upper Airway Evaluation of Habitual Snorers and Obstructive Sleep Apnea Patients