CURRICULUM VITAE

Nama : Prof. Sri Herawati Juniati, dr, Sp.THT-KL(K)

Tempat/ tanggal lahir : Solo, 1 Juni 1949
Posisi : Ketua Divisi Endoskopi Bronko-Esofagologi,
Dep. THT-KL FKUA
Ketua KODI Endoskopi Bronko-Esofagologi,
PERHATI-KL
RIWAYAT PENDIDIKAN :
• Lulus Dokter : di FKUA, Surabaya (1974)
• Lulus Spesialis THT : di FKUA, Surabaya (1979)
• Konsultan THT-KL bidang Endoskopi (2004)
• Pelatihan /Kursus :
– Additional training in Endoscopy , di Academisch Ziekenhuis Groningen,
Nederland (1985)
– Kursus, Diseksi Kadaver dan Demo Operasi BSEF, di Makassar (2000)
– Laryngology and Phonosurgery Course, di HUKM, Kuala Lumpur, Malaysia
(2004)
– LPR Course, di Annual Meeting of the AAO-HNS, New York, USA (2004)
– Voice Diagnostic Course, ATMOS, Chennai, India (2005)
– Workshop Transnasal Esophagoscopy, Singapore (2008)
DIAGNOSIS OF
OBSTRUCTIVE SLEEP APNEA
SYNDROME
Sri Herawati

Bronchoesophagology Division
Dept. of Otorhinolaryngology-Head and Neck Surgery
School of Medicine Airlangga University
Surabaya
2015
OBSTRUCTIVE SLEEP APNEA SYNDROME
(OSAS)

• Is a sleep disorder in which repeated

events of cessation / reduction of airflow
• Caused by partial or complete narrowing
of the upper airway during sleep
~ sleep fragmentation
~ excessive daytime sleepiness
~ cognitive impairment

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 DIAGNOSIS

▪ Anamnesis / Symptoms
▪ Physical Examination
▪ Polysomnography (PSG)
▪ Imaging Studies

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 Symptoms of sleep apnea
Day- time Night- time
 Excessive sleepiness  Snoring
 Morning headache  Observed choking
 Intellectual deterioration  Arousal from sleep
 Personality change  Repeated waking
 Depression  Impotence
 Xerostomia
 Fatique

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 Epworth daytime sleepiness scale
0 = would never doze 2 = moderate chance of dozing
1 = slight chance of dozing 3 = high chance of dozing

Score > 16 = moderate to severe sleep apnea

Situation Chance of dozing
Sitting and reading
Watching TV
Sitting inactive in a public place (theatre or meeting)
As a passanger in a car for an hour without a break
Lying down for a rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car while stopped for five minutes in traffic
Total Scoring

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 History from sleep partner

• Body position
• Snoring
• Apnea / choking
• Arousal from sleep
• Alcohol consumption
• Sedative use

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 Physical Examination
• BMI
• Tongue size
• Tonsil size
• Uvula & Palatum molle
• Deformity of the lower face
(micro/retrognathia)
• Site of airway obstruction

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OBESE

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TONGUE SIZE

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TONSIL SIZE

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UVULA & PALATUM MOLLE

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 Polysomnography
• Gold-standard
• Parameters :
 EEG  sleep stadium
 EOG  REM and non-REM
 ECG  cardiac monitor
 Oxygen saturation
 Nasal-oral airflow
 Chest and abdominal movement detector
 Sleeping position detector
 Tracheal microphone

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 OSAS …..

 Snoring  breathing noise due to partial upper

airway obstruction
 Apnea  cessation of breathing for ≥10 seconds
 Hipopnea  decreased airflow (>50%) with oxygen
desaturation (min 3%) for ≥10 seconds
 AHI (Apnea Hipopnea Index)
 Apnea + Hipopnea / 1-hour period of sleep
 Sleep apnea  ≥30 episodes of apnea / 7-hour period
of sleep
≥ 5 episode apnea / 1-hour period of
sleep

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BREAS SC20

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 DIAGNOSIS OSA
--------------------------------------------------------------------------------------------------
AHI Arousals / h Daytime Snoring
Alertness
------------------------------------------------------------------------------------------------------------
Snoring <5 < 10 + Normal

OSA
- Mild 5 – 15 5 – 20 + Mild
impairment
- Moderate 15 – 30 10 – 30 + Moderate
impairment
- Severe > 30 > 30 ++ Severe
impairment

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 STADIUM OSA
CRITERIA FUJITA & AHI
Stadium Tongue position Tonsil BMI AHI ESS

Stadium 1 1 3, 4 < 30 5 – 15 10-15

2 3, 4 < 30

Stadium 2 1, 2 0, 1, 2 < 30 15 – 30 >15-30

3, 4 3, 4 < 30

Stadium 3 3 0, 1, 2 any > 30 > 30

4 0, 1, 2 any
any any > 30

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 Site of airway obstruction
• Obstruction :
▫ nasal cavity & nasopharynx
▫ oral cavity & oropharynx
▫ hypopharynx & larynx

• Müller's maneuver

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Site of obstruction .....

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 Nasal Obstruction

Concha hypertrophy Septum deviation

Polyp
Tumor

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Hipertrophy adenoid

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 Hypopharynx & Larynx

Lingual Tonsil Hypertrophy Epiglottis cyst

Laryngeal papilloma
Omega shaped epiglottis

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 Müller's maneuver
• Introduced flexible endoscope via nasal
 identifies weakened sections of airway
at levels of soft palate & tongue base,
during this maneuver

• After a forced expiration

 attempt inspiration with closed mouth & nose

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Müller's maneuver …..

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Retropalatal airway during Müller's maneuver (A) and during passive inspiration (B).
Retroglossal airway during Müller's maneuver (C) and during passive inspiration (D).
.

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 Imaging studies
• Controversial
 not routinely obtained :
- cost
- do not add to the airway assessment
• Cephalometry
• CT Scan
• MRI

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 Imaging .....

Cephalometry
- evaluate postnasal space
- evaluate tongue position & size
in correlation with mandibula
 used for: - surgical planning
- predicting outcome

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Cephalometry …..

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 Imaging .....

CT Scan :
– excellent resolution for soft tissue,
airway & bone
– evaluate the efficacy of dental
appliances & mandibular advancement

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 Imaging .....

MRI :
- superior soft tissue resolution
- multiplane imaging
- 3-dimensional reconstruction
- lack of radiation exposure
- useful in evaluate the efficacy of soft tissue
surgery but not predicting surgical outcome

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 General Investigations
• Complete blood count: anemia,
polycythemia
• Arterial blood gas analysis
• Chest x-ray: cardiomegaly,
pulmonary disorder
• Lung function: spirometry
• ECG: arrhytmia
• Thyroid function tests: hypothyroidism

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Thank You

GULMARG, KASHMIR, DEC. 2014

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