OBSTRUCTIVE

SLEEP APNEA Arief Fakhrizal

Supervisor : Dr. dr. Sinta Sari Ratunanda, M. Kes., Sp. T.H.T.K.L. (K)

Department of Otorhinolaryngology-Head & Neck Surgery

Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung - 2021
Contents

Introduction Anatomy
01 02

Clinical Science Conclusion

03 04
 01
INTRODUCTION
INTRODUCTION
OSA induces nocturnal hypoxemia, hypercapnia and sleep
fragmentation 

Excessive daytime sleepiness (EDS), mood problems, poor

neurocognitive performance and cardiovascular disorders

↓ patient’s quality of life (QOL)

 Terminology
Obstructive Sleep Upper Airway
Apnea/Hypopnea Resistance Syndrome Primary Snoring
Syndrome (OSAHS) (UARS)

Symptoms
Respiratory
ofevents
OSA and
(OSA)
polysomnographic
occur 5x/hour ofevidence
sleep and
of are
sleep
associated
fragmentation
with
but
symptoms,
who havemost
minimal
commonly
obstructive
snoring,
apneas
excessive
or hypopneas
daytime fatigue,
(Respiratory
and
Disturbance Index < 5) andwitnessed
do not exhibit
apneas
oxyhemoglobin desaturation.

• Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy. Edisi ke 1. Elsevier Health Sciences; 2009.
• Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
Goal of This Presentation
To learn and apply to the patient about the disease,
 Anamnesis, physical examination, radiological and special
inspection and management.

Anamnesis, physical examination, dan clinical feature 

Predict OSAS in about 50% of patients

Snoring and witnessed apneas  increase the sensitivity and

specificity to 78% and 67% respectively.

Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy. Edisi ke 1. Elsevier Health Sciences; 2009.
 ANATOMY
02
ANATOMY
• The human upper airway is a complex structure extending from the
external nares to the epiglottis.
• The main site of collapse in patients with OSA ranges from the
back of the nasal septum or choannae to the epiglottis, with most
such collapse occurring behind either the uvula/soft palate or
behind the tongue.
• Collapse at the level of the epiglottis may also occur
 UPPER AIRWAY REGION

(A) Midsagittal MRI in a normal subject, highlighting the four upper airway regions: the nasopharynx, which is defined from the nasal
turbinates to the hard palate; the retropalatal (RP) oropharynx, extending from the hard palate to the caudal margin of the soft
palate; the retroglossal (RG) region from the caudal margin of the soft palate to the base of the epiglottis; and the hypopharynx,
which is defined from the base of the tongue to the larynx. (B) The diagram demonstrates important midsagital upper airway, soft
tissue, and bone structures.
 NASOPHARYNX

- The nasopharynx is found between

the base of the skull and the soft
palate.
- It is continuous with the nasal
cavity, and performs a respiratory
function by conditioning inspired air
and propagating it into the larynx.
- The posterosuperior nasopharynx
contains the adenoid tonsils

Bailey’s head and neck surgery-otolaryngology, Jonas T Johnson, Clark A Rosen, 5th Edition 2014
 OROPHARYNX
• The oropharynx is the middle part of the
pharynx, located between the soft palate and
the superior border of the epiglottis.

• It contains the following structures:

1. Posterior 1/3 of the tongue.
2. Lingual tonsils
3. Palatine tonsils
4. Superior constrictor muscle

Bailey’s head and neck surgery-otolaryngology, Jonas T Johnson, Clark A Rosen, 5th Edition 2014
 LARYNGOPHARYNX
• Located between the superior border
of the epiglottis and inferior border of
the cricoid cartilage (C6).
• Found posterior to the larynx and
communicates with it via the laryngeal
inlet  the piriform fossae.
• Contains the middle and
inferior pharyngeal constrictors.

Bailey’s head and neck surgery-otolaryngology, Jonas T Johnson, Clark A Rosen, 5th Edition 2014
 NORMAL ROLE AND CONTROL OF
PHARYNGEAL MUSCULATURE
As the oropharynx is the primary site for airway collapse in patients with OSA, control of the
muscles that make up the airway walls is important in sleep apnea pathogenesis.

There are four major groups of muscles

that are involved
These include:
1. Muscles controlling tongue position and shape.
2. Muscles controlling palatal shape and position.
3. Muscles influencing hyoid bone position.
4. Pharyngeal constrictor muscles.
 03
CLINICAL
SCIENCE
 DEFINITION
 Obstructive sleep apnea (OSA) is a common
disorder characterized by repetitive collapse
of the pharyngeal airway during sleep

 Afflicted individuals generally breathe quite

normally during wakefulness, but cannot
maintain airway patency during sleep.

The site of collapse is most often behind the uvula, soft palate, or
tongue or some combination of these structures.
White, D. P., and M. K. Younes. "Obstructive Sleep Apnea." Compr Physiol 2, no. 4 (Oct 2012): 2541-94.
Epidemiology
OSA (AHI>15)
Occurs in approximately 2% to 14% of
the adult population, depending on
gender and ethnicity

20% of adults have mild OSA (AHI

5-15) and 6% to 7% have moderate
to severe OSA (AHI > 15)

The occurrence of sleep apnea has been associated with a number

of traits with body mass index (BMI) or, more specifically central
obesity
• Cessation of • ↓ airflow 30-50% in
breathing ≥10 sec ≥10 seconds, with ↓
(>2 breath cycle) 4% O2 saturation

Apnea Hypopnea

●
cessation of airflow ≥
10 seconds, there’s
effort of breathing
Obstructive apnea

●
cessation of airflow ≥ • cessation of airflow ≥10 seconds,
there is no effort of breathing but
10 seconds, no effort towards the end there is effort to
of breathing breath without airflow

Central apnea Mixed apnea

 CLASSIFICATION OF APNEA
SEVERITY
The number of apneas plus hypopneas per hour of sleep is called the
apneahypopnea index (AHI):

•RDI / AHI ≥ 5x/hour  sleep apnea (adult)

•RDI / AHI ≥ 1x/hour  sleep apnea (pediatric)

Adult • Mild (5-15)

• Moderate (15-30)
• Severe (>30)
AHI > 5 :
ABNORMAL • Mild (1-5)
• Moderate (6-10)
Pediatric • Severe (>10)
 CLINICAL MANIFESTATION

 Individuals with sleep apnea often present with complaints of loud

snoring, witnessed gasping, choking, or apnea, and daytime
sleepiness.
 They may also have morning headaches, sexual dysfunction, and
depression

White, D. P., and M. K. Younes. "Obstructive Sleep Apnea." Compr Physiol 2, no. 4 (Oct 2012): 2541-94.
 RISK FACTORS
Risk factors for the diagnosis of OSA include :
• Male gender
• Obesity
• Age over 40
• History of hypertension
• Smoking
• Alcohol use
• Anatomic characteristics that narrow the upper airway
• A family history of sleep apnea

White, D. P., and M. K. Younes. "Obstructive Sleep Apnea." Compr Physiol 2, no. 4 (Oct 2012): 2541-94.
PATHOGENES
IS

http://www.dr-jhsimmons.com/HTML/Sleep-Apnea.htm
 PATHOGENESIS

Eckert DJ, Malhotra A. Pathophysiology of Adult Obstructive Sleep Apnea. Proceedings of the American Thoracic Society. 2008;5(2):144-53.
PATHOPHYSIOLOGY
SLEEP is fundamental
process that needed by SLEEP
human.
PHYSIOLO
Consist of 2 stages :
(6-8 hours/day) • NREM (80%
time)
GY from whole sleep

• REM (20% from whole sleep

time)
 NREM

Stage 1 Stage 2 Stage 3 and 4

• Sleep serves a transitional • Approximately last 10- • Referred to as slow-wave

sleep,
role in sleep-stage cycling. 25 minutes in the initial • Stage 3 last only a few
• This stage usually lasts 1-7 cycle and lengthens with minutes and constitutes
minutes in the initial cycle each successive cycle about 3 to 8 percent of sleep.

Colten H. R., Altevogt B.M., 2006. Sleep Disorders and Sleep Deprivation : An Unmet Public Health Problem . Washington : National Academies Press. http://www.nap.edu/catalog/11617.html
 REM
• REM sleep is defined by the presence of desynchronized (low-
voltage, mixed-frequency) brain wave activity, muscle atonia,
and bursts of rapid eye movements.

• During the initial cycle, the REM period may last only 1 to 5
minutes; however, it becomes progressively prolonged as the
sleep episode progresses

Colten H. R., Altevogt B.M., 2006. Sleep Disorders and Sleep Deprivation : An Unmet Public Health Problem . Washington : National Academies Press.
Colten H. R., Altevogt B.M., 2006. Sleep Disorders and Sleep Deprivation : An Unmet Public Health Problem . Washington : National Academies Press.
http://www.nap.edu/catalog/11617.html
 DIAGNOSIS
• History of habitual snoring, excessive daytime sleepiness,
or witnessed apneas.
• Neck size > 17 inches in males or > 15 inches in females
and/or body mass index (BMI) > 27 kg/m2.
• Definitive evidence of OSA by polysomnography.

• History of snoring, witnessed apneas, restless sleep, or

enuresis.
• Evidence of obstructive tonsils and/or adenoids on
physical exam.
• Evidence of OSA from overnight PSG.
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
ANAMNESIS
Adult Children
Heavy persistent snoring Snoring
Excessive daytime sleepiness Restless sleep
Apneas as observed by bed partner Sleepiness
Choking sensations while waking up Hyperactivity
Gastroesophageal refl ux Aggression and behavioral disturbance
Reduced ability to concentrate Frequent colds or coughing
Memory loss Odd sleeping positions
Personality changes
Mood swings
Night sweating
Nocturia
Dry mouth in the morning
Restless sleep
Morning headache
Impotence
Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy.Edisi ke 1. Elsevier Health Sciences; 2009.
 PEMERIKSAAN FISIK Systemic Evaluation

• Obesity
• Hipertention
• Hormonal disturbances
• Heigh, weight, neck circumferences and BMI
• Mental states & conciousness

Nose and nasofaring

• External nose
• Air passage with anterior rhinoscopy or
Bailey BJ, Johnson JT, Newlands SD. Head & Neck Surgery - Otolaryngology.Edisi ke 4. Lippincott
with nasal endoscope
Williams & Wilkins; 2006.
• Posterior rhinoscopy /nasopharyngoscopy
 IKEMATSU CLASSIFICATION
 Soft palate length (±50 mm)
 Uvula lenght (±11 mm)
 Wide uvula (±10 mm)
 Pillar arch morphology (4 types : parallel, webbed, embedded, emerging)
 Oropharyngeal narrowing (anterior arch ±20 mm, posterior arch ±15 mm,
shallow oropharynx ±5 mm)
 Enlarged tongue dorsum (oropharynx not seen with phonation)

Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
 FUJITA CLASSIFICATION
• Tipe I : upper oropharynx obstruction (abnormality of palate, uvula,
tonsils, and upper pharynx)
• Tipe II : oropharyngeal dan hypopharyngeal obstruction
• Tipe III : only hypopharyngeal obstruction (base of tongue, lingual tonsils,
supraglottic and hypopharynx)

Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
 Grade I: Grade II: tonsils
tonsils are in the are visible
tonsillar fossa, beyond the
barely seen anterior pillars
Tonsil
Grade III: tonsils Grade IV:
extend three "kissing" tonsils
quarters of the
way to the midline

Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy.Edisi ke 1. Elsevier Health Sciences; 2009.
 Friedman Tongue Position (FTP)

Grade II: soft palate, Grade IV: hard

uvula and fauces are palate is visible
visible

Grade I: soft
palate, uvula and Grade III:
pillars are visible soft palate and base
of tongue is visible

Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy.Edisi ke 1. Elsevier Health Sciences; 2009.
 Mueller manouver

Site of obstruction oropharynx hypopharynx

Type I Normal palatal position
N(+,-) oropharyngeal 3+, 4+ 0, 1+
Low palatal position
Type II
a. predominantly oropharynx 3+, 4+ 1+, 2+
N(+,-)
b. oro-hypopharynx involved 3+, 4+ 3+, 4+
Normal orophayrnx
Type III hypopharyngeal obstruction
0, 1+ 3+, 4+
(retrognathia, micrognatia)
Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
 (A) Retropalatal airway with Müller's
maneuver.
(B) Retropalatal airway with passive
inspiration.
(C) Retroglossal airway with Müller's
maneuver.
(D) Retroglossal airway with passive
inspiration.

Fairbanks DNF, Mickelson SA, Woodson BT. Snoring and obstructive sleep apnea.Edisi ke 3. New York: Raven Press; 2003.
 RADIOLOGICAL EXAMINATION

X-Ray Cephalometry

Fluoroscopy and
Somnofluoroscopy

Computed
Tomography

Magnetic Resonance
Imaging

Bailey’s head and neck surgery-otolaryngology, Jonas T Johnson, Clark A Rosen, 5th Edition 2014
RADIOLOGICAL EXAMINATION
The most common : shortening of maxillary and
mandibular lengths CEPHALOMETRY
(ANS-PNS and Go-Gn, respectively)

retrodisplacement of the tongue and

other oral soft tissues,

↓ diameter of the oropharyngeal

lumen

Ryan CM, Bradley TD. Pathogenesis of obstructive sleep apnea. Journal of Applied Physiology. 2005;99(6):2440-50.
 RADIOLOGICAL EXAMINATION
CT scan and MRI
MRI in OSA patients. Retropalatal
levels in a normal patient (left) and
an apneic patient (right)
(1) increased lateral pharyngeal
wall dimensions,
(2) decreased retropalatal airway
area, and
(3) increased lateral pharyngeal fat
pads
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
SPESIFIC EXAMINATION
• How easily patients can fall asleep at the present time.
Stanford Sleepiness Scale
• Measure the current state of drowsiness
(SSS) • Benefits : can be done several times during the day
• Disadvantages : can not distinguish between acute sleep
deprivation and sleep disorders based on underlying
diseases

Epworth Sleepiness Scale • Measures the overall tendency to fall asleep during normal
(ESS) activities
• ESS has weak correlation with OSAS
• There’re misperception of the questions in the
questionnaire

Polysomnography (PSG) Nami MT. Evaluation of the sleepy patient. Australian Family Physician. 2012;41:787-90.
 Epworth Sleepiness Scale (ESS)
Epworth Sleepiness Scale
Situation : 0 1 2 3
1. Sitting and reading
2. Watching TV
3. Sitting inactive in a public place
4. Being a passenger in a motor vehicle for an hour or more
5. Lying down in the afternoon
6. Sitting and talking to someone
7. Sitting quietly after lunch (no alcohol)
8. Stopped for a few minutes in traffic while driving
Score
Total score

0 = would never doze or sleep.

1 = slight chance of dozing or sleeping
2 = moderate chance of dozing or sleeping
Bailey’s head and neck surgery-otolaryngology, Jonas T
3 = high chance of dozing or sleeping Johnson, Clark A Rosen, 5th Edition 2014
Polysomnography
Standard PSG: Complete PSG;
● Recording respiratory airflow, Type 1
minimum
● Breathing movements Portable sleep
consists of 7
Examination
● Electroencephalography (EEG) apnea testing is
Type 2 channels in the
conducted
● Electromyography (EMG) betterrecord
Only known as
observed in
residence ofthe
the
● Electrooculogrophy (EOG) cardio-
nasal airflow and
laboratory
patient, notwith
● Electrocardiography (ECG), Type 3 respiratory
oxygen levels
specialized
directly
● O2 saturation and body recording
personnel
observed
position throughout the
Type 4
night.
 EXAMINATION
• Assessed from the number of
micro-arousals that cuts the sleep,
↓ O2 saturation, heart rate and
rhythm, as well as the duration of
each episode stopping breathing`

• Sleep architecture and the degree

of severity of OSA patients were
assessed by the apnea-hypopnea
index (AHI)

Eckert DJ, Malhotra A. Pathophysiology of Adult Obstructive Sleep Apnea. Proceedings of the American Thoracic Society. 2008;5(2):144-53.
 QUESTIONNAIRES :

● Child Health Questionarie Parent Form (CHQ-PF),

● Pediatric Sleep Questionaire (PSQ),
● Obstructive Sleep Disorder–6 (OSD-6), dan
● Obstructive Sleep Apnea-18 (OSA-18)

OSA-18  sensitivity 95% and specificity of 90%,

so it is accurate to use as a single questionnaire to
measure sleep-disordered breathing.

Bower MC, Ray MR. Pediatric sleep disorder. Dalam clinician’s guide to pediatric sleep disorder. Editor: Richardson MA, Friedman NR, 2006:1-18.
 COMPLICATION

Lattimore J-DL, Celermajer DS, Wilcox I. Obstructive Sleep Apnea and Cardiovascular Disease. Journal of the American College of Cardiology. 2003;41(9):1429-37
48
Kim S-K, Oh J-H. Snoring & Obstructive Sleep Apnea Syndrome. Journal [serial on the Internet]. 2008
 MANAGEMENT
GOAL:
To resolve signs and symptoms of OSA, improve sleep quality, and
normalize the apnea-hypopnea index (AHI) and oxyhemoglobin
saturation levels.

Management:
1. Education & behaviour
2. Positive airway pressure therapy
3. Alternative

Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
 Disease severity:
MANAGEMENT Mild (AHI  5-15)
- No symptoms : Behavioral modification
Management of OSA based on : - Symptoms : Behavioral modification
the severity of the disease ● Consider oral appliance
● Consider PAP
● Consider surgical intervention
Moderate (AHI  15-30)
- No symptoms : Behavioral modification
● Consider PAP
● Consider oral appliance
● Consider surgical intervention
- Symptoms : Behavioral modification, PAP,
Surgical intervention for PAP failures
● Consider oral appliance
Severe (AHI > 30)
Symptoms or no symptoms : Behavioral
modification (rarely sufficient alone), PAP,
Surgical intervention for PAP failures

Friedman M. Sleep Apnea and Snoring : Surgical and Non-Surgical Therapy. Edisi ke 1. Elsevier Health Sciences; 2009.
 Education
Educate the patient about:
1. Risk factor
2. Natural history
3. Consequences of OSA

All patients should be warned about the increased risk of motor

vehicle accidents associated with untreated OSA and the potential
consequences of driving or operating other dangerous equipment
while sleepy

Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
 Behavior Modification
● Type of modification depend upon the characteristics of the
patient
● Kind of behavior modification:
1. Weight loss and exercise
2. Sleep position
3. Alcohol avoidance
4. Concomitant medications

Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
 Positive Airway Pressure Therapy
● The mechanism of CPAP 
maintenance of a positive
pharyngeal transmural pressure so
that the intraluminal pressure
exceeds the surrounding pressure.
● CPAP  stabilizes the upper
airway through increased end-
expiratory lung volume 
respiratory events due to upper
airway collapse are prevented.
 Alternative Therapies
● Oral appliances
 Decrease the frequency of
respiratory events, arousals, and
episodes of oxyhemoglobin
desaturation, compared to no
treatment or a sham intervention. 
 Mandibular repositioning
 Tongue retainer

Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
 SURGERY
• Septoplasty • Uvulopalatopharyngoplasty
• Nasal polypectomy (UPPP)
• Tonsillectomy / adenoidectomy • Pillar procedures
(most common in children) • Hyoid suspension
• Turbinoplasty • Mandibular advancement,
• Tracheostomy genioglossus advancement/
 Making the airway through maxillary advancement
the anterior of the neck into
the trachea.
 This action is a last resort for
sleep apnea patients.
Lalwani A. CURRENT Diagnosis & Treatment Otolaryngology - Head and Neck Surgery.Edisi ke 2. McGraw-Hill Companies,Incorporated; 2008.
MEDICAL THERAPY FOR OBSTRUCTIVE SLEEP APNEA

Bailey’s head and neck surgery-otolaryngology, Jonas T Johnson, Clark A Rosen, 5th Edition 2014
 CONCLUSION
04
CONCLUSION

● OSA is a sleep disorder that is mainly characterized

by snoring and excessive sleepiness.
● People's knowledge on sleep is still very low, during
his visit to the doctor, they can not reveal the exact
complaint, thus frequently OSA is undiagnosed.
● The diagnosis of OSA should be based on
anamnesis, clinical examination, spesific
examination and polysomnography (PSG)
 CONCLUSION

● Polysomnography (PSG) is gold standard for

diagnosis
● OSA acutely causes cardiac ischemia and arritmia,
as well as causing chronic left ventricular
hypertrophy and eventually became heart failure.
● Treatments are noninvasive behavioral
modifications to nightly use of positive airway
pressure (PAP) devices to surgical treatments that
alter airway anatomy.
Thank
You