0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Original Article |

Correlation Between Otorhinolaryngologic Evaluation and Severity of Obstructive Sleep Apnea Syndrome in Snorers FREE

Alfred Dreher, MD; Richard de la Chaux, MD; Christine Klemens, MD; Robert Werner, MD; Fiona Baker, PhD; Gabriele Barthlen, MD; Gerd Rasp, MD
[+] Author Affiliations

Financial Disclosure: None.


Arch Otolaryngol Head Neck Surg. 2005;131(2):95-98. doi:10.1001/archotol.131.2.95.
Text Size: A A A
Published online

Objectives  To examine whether medical history and nasopharyngeal examination are useful for predicting obstructive sleep apnea syndrome (OSAS) and to compare these findings with those of the gold standard, polysomnography.

Design  Patients underwent polysomnography recordings for 2 nights and an otorhinolaryngologic examination, including flexible endoscopy and the Müller maneuver. Nasal and pharyngeal findings were scored in a semiquantitative way. The medical history of each patient was taken using a standardized questionnaire. Anatomic and functional findings and patient history were correlated with the mean apnea-hypopnea index (AHI).

Setting  An otorhinolaryngologic clinic.

Patients  A total of 101 patients presenting with a primary complaint of snoring.

Main Outcome Measures  Differences between patients with OSAS and primary snorers were assessed using the Mann-Whitney test (anatomic findings), t test (Müller maneuver), and χ2 test after Pearson correlation (questionnaire). P values less than .05 were considered statistically significant.

Results  The mean ± SD AHI of the patients was 19.7 ± 21.5); 52 patients had an AHI higher than 10, which confirmed the diagnosis of OSAS. These patients tended to report the occurrence of apneas more frequently than patients with an AHI of 10 or lower. The average ranks (Mann-Whitney findings) of patients with AHIs higher than 10 vs those with AHIs of 10 or lower were 52 vs 50 for septal deviation; 50 vs 52 for tonsil size; 53 vs 49 for low velum level; and 56 vs 46 for hyperplasia of the tongue base. None of these differences reached statistical significance. Mean ± SD narrowing of the airway during the Müller maneuver was significantly (P<.05) more pronounced in patients with an AHI higher than 10 than in patients with an AHI of 10 or lower at the levels of the velum (80% ± 20% vs 68% ± 30%) and the tongue base (57% ± 24% vs 44% ± 27%).

Conclusions  None of the reported medical history and/or anatomic parameters alone or in combination could be used to distinguish patients with OSAS from snoring patients. Snoring patients, therefore, should be examined at least by a nocturnal screening test for OSAS before any therapeutic decision is made.

Figures in this Article

Snoring is one of the main symptoms of obstructive sleep apnea syndrome (OSAS). Often, patients first seek an otorhinolaryngologic (ENT) evaluation rather than presenting to a sleep center. Snoring has a prevalence of 30% to 50% in the general population, while the prevalence of OSAS is only 2% to 4%. The ENT specialist, therefore, must differentiate between these 2 entities to provide appropriate treatment.1,2 Toward this end, oxygen saturation and airflow are commonly measured with screening instruments, but polysomnography is considered the gold standard for diagnosis of OSAS. However, both techniques are cumbersome. Thus, it would be useful to have a simple tool for predicting OSAS based on history and physical examination.

In populations with suspected sleep apnea, physical features may be predictive of OSAS severity,35 but it is not known whether physical examination can be used to distinguish patients with OSAS in a group of patients who present to an ENT clinic with a chief complaint of snoring. Our aim was therefore to assess the predictive power of history and routine physical examination as performed by an ENT specialist to identify OSAS in patients seeking treatment for snoring.

We evaluated 101 patients who presented to an ENT clinic with a chief complaint of snoring (88 men, 13 women; mean ± SD age, 54.7 ± 11.6 years; body mass index, calculated as weight in kilograms divided by the square of height in meters, 28.6 ± 4.6). Informed consent was obtained from all patients according to the Declaration of Helsinki. The patients completed a 20-question questionnaire routinely used in our clinic to obtain information about their symptoms and medical history. Three questions from the questionnaire, 1 each concerning excessive daytime sleepiness (EDS), snoring, and self-reported apneic events, which had to be answered yes or no, were evaluated for this study. We did not use more extensive measures of EDS, such as the Epworth Sleepiness Scale, because we wanted our study to reflect the realistic time constraints of routine examination.

Nasal and pharyngeal configurations were assessed in a semiquantitative manner (Table). Each patient underwent the Müller maneuver while in a 45° recumbent position to estimate the degree of obstruction at the base of the tongue and at the velum. The findings of the ENT examinations were scored in agreement by 2 examiners (A.D. and R. de la C.). Following the routine examination, all patients underwent standard polysomnography recordings, including electroencephalogram, electrooculogram, submental and tibial superficial electromyogram, and measurements of nasal-oral airflow, thoracic and abdominal respiratory effort, snoring, oxygen saturation, and body position using a digital electroencephalograph (Schwarzer, Munich, Germany).

Table Graphic Jump LocationTable. Nasal and Pharyngeal Configuration Assessed in a Semiquantitative Manner

Patients were monitored for 2 nights, but only the second night was analyzed to allow for the first-night effect. Sleep stages were scored based on the criteria set out by Rechtschaffen and Kales.6 Total sleep time as well as percentages of sleep stages were calculated. A respiratory event had to be of at least 10 seconds’ duration and was classified as an apnea if there was a 90% reduction in airflow and as a hypopnea if there was a 50% reduction in airflow combined with at least a 4% oxygen desaturation. Apneas and hypopneas were combined to calculate the apnea-hypopnea index (AHI). An AHI higher than 10 indicated OSAS.

Anatomic and functional findings and patient history were correlated with the AHI. Differences between patients with OSAS and primary snorers were assessed using the Mann-Whitney test (anatomic findings), t test (Müller maneuver), and χ2 test after Pearson correlation (questionnaire). P values less than .05 were considered statistically significant.

The mean ± SD total sleep time for the 101 patients was 404 ± 63 minutes. Patients spent a mean ± SD of 14.5% ± 13.5% of time in stage 1 sleep, 56.5% ± 10.9% in stage 2 sleep, 9.5% ± 9% in stage 3 sleep, 3.9% ± 6.6% in stage 4 sleep, and 18.3% ± 6.3% in rapid-eye-movement sleep. The mean ± SD AHI of the 101 patients was 19.7 ± 21.5; 52 patients had an AHI higher than 10 (classified as patients with OSAS); 49 patients had an AHI of 10 or lower (classified as primary snorers).

Based on the questionnaire, all patients complained of snoring; 72% reported nocturnal breathing pauses; and 61% complained of EDS. There were no significant differences between the number of patients with an AHI higher than 10 (OSAS) and those with an AHI of 10 or lower (snorers) who reported either nocturnal breathing pauses (Figure 1) or EDS (Figure 2). The results of the physical examination for the patients with OSAS and primary snorers are compared in Figure 3, Figure 4, Figure 5, and Figure 6. The mean ranks (Mann-Whitney test) of patients with OSAS vs snorers were as follows: septal deviation, 52 vs 50; tonsil size, 50 vs 52; velum level, 53 vs 49; and size of tongue base, 56 vs 46. There were no significant differences between the patients with OSAS and the snorers based on physical examination. Patients with OSAS had a significantly greater reduction in mean ± SD airway diameter than snorers (t test, P<.05) during the Müller maneuver at the velar level (80% ± 20% vs 68% ± 30%) and at the tongue base level (57% ± 24% vs 44% ± 27%).

Place holder to copy figure label and caption
Figure 1.

Distribution of nocturnal breathing pauses. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Distribution of daytime sleepiness. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Distribution of the severity of septal deviation. For explanation of septal deviation grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Distribution of the severity of the size of tonsils. For explanation of tonsil size severity grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Distribution of the severity of velum position. For explanation of velum position severity grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Distribution of the size of the tongue base. For explanation of tongue base size grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location

The significance of patient history for detection of OSAS is controversial. In a study of 354 patients with possible OSAS, Pouliot et al7 predicted that patients with an Epworth Sleepiness Scale score of less than 12 and a body mass index lower than 28 would not have OSAS. Only 2 of 33 patients fulfilling those above criteria had OSAS, meaning that Pouilot’s et al prediction was correct in 31 patients. However, neither Crocker et al8 nor Viner et al3 could confirm any positive predictive value of reported daytime sleepiness. The present study also shows no significant predictive value of subjectively reported daytime sleepiness in patients with OSAS compared with snorers.

Flemons et al9 found a significant difference between patients with OSAS and asymptomatic controls in their history of breathing pauses and snoring. Crocker et al8 also found a higher incidence of reported nocturnal breathing pauses in patients with OSAS than in controls. However, in the present study, we did not find a significant correlation between reported breathing pauses and the presence or absence of OSAS. These differences may be a consequence of different study populations. Only 64% and 79% of patients complained of snoring in the studies by Flemons et al9 and Crocker et al,8 respectively, while the primary complaint of all our patients was snoring. Therefore, it seems that questions concerning daytime sleepiness, fatigue, or reported apneas are not able to distinguish between snorers and snorers with OSAS.

The influence of nasal obstruction in OSAS is controversial: While Lavie et al10 and McNicholas et al11 found a positive correlation between nasal obstruction and AHI, such a correlation was refuted by Miljeteig et al12 and Atkins et al.13 The results of the present study support the latter findings. Enlarged tonsils can cause OSAS, and surgical removal usually results in a cure.14,15 Friedman et al4 found a positive correlation between tonsillary enlargement and presence of OSAS. Our study, however, was unable to confirm such a correlation in that the mean age of our study population was 55 years, and tonsillary hypertrophy was rare.

A low-set soft palate was found more frequently in patients with OSAS than in snorers in our study, although the difference was not significant. These characteristics of the palate in patients with OSAS were described earlier in cephalometric studies.16 Friedman et al4 and Zonato et al5 found a significant positive correlation between a low-set soft palate and OSAS, but Woodson and Haganuma,17 reporting results similar to ours, did not find a significant association. These results show that although a low-set soft palate may be commonly found in patients with OSAS, it is not a sufficient predictor of OSAS.

Base of tongue hypertrophy has also been found to be predictive of OSAS, as confirmed in studies using cephalometrics.16 However, the present study and Woodson and Haganuma17 did not find a significant positive correlation between tongue base hypertrophy, assessed by physical examination, and AHI.

The Müller maneuver has been validated by Sher et al18 as a functional examination to select patients for uvulopalatopharyngoplasty.18 As the only statistically significant finding, we confirmed a positive correlation between the degree of obstruction and presence of OSAS. However, the Müller maneuver is performed on an awake patient and heavily depends on the patient’s cooperation, which may explain why neither Woodson and Haganuma17 nor Friedman et al4 found a positive correlation between performance on the Müller maneuver and the presence of OSAS.

In contrast to our findings, Viner et al,3 Friedman et al,4 and Zonato et al5 concluded that it is possible to identify patients with OSAS based on history and/or anatomic findings. What are the reasons for these different results and conclusions? In general, all of the measurements described herein concerning the size of the tonsils or the shape of the palate have a subjective component, which makes it difficult to compare the results of different investigators. Digital picture analysis might provide more consistent results in the future. In addition, our patient population was different from that used in previous studies in several aspects: while other study populations were composed of about 90% snorers, all of our patients were snorers who primarily sought therapy for snoring. Also, the other study populations were preselected regarding suspected OSAS. In the study by Friedman et al,4 for example, 400 patients had to complete a questionnaire concerning daytime sleepiness and other symptoms of OSAS; 260 of these patients were suspected of having OSAS, and only 172 finally underwent polysomnography. Also, the anatomic findings were different between studies. In contrast to the findings of Friedman et al,4 tonsillary hyperplasia was rare in our population, possibly because the patients in our study were slightly older.

Different statistical methods might also have contributed to different findings between studies. Most authors used the Pearson product moment correlation coefficient for comparing anatomic findings and the AHI. This analysis presupposes that the intervals between the grades for tonsil size, for example, are equal, which, in our opinion, is not the case. Therefore, we used the Mann-Whitney test to compare the average ranks of simply snorers and snorers with OSAS. These factors may explain why we did not find any predictive value for OSAS with the methods applied (except weakly for the Müller maneuver).

We also doubt that the physical examination correlations found by Viner et al3 (specificity of 28% and sensitivity of 94%) and Friedman et al4 (positive predictive value of 90%, negative predictive value of 67%) are adequate to predict OSAS. In our opinion, all patients seeking treatment for snoring should be screened overnight using a device measuring at least oxygen saturation and airflow. If the results are suggestive of OSAS, or if patients complain of EDS, standard polysomnography should be applied. In conclusion, we believe that medical history, anatomic findings, and functional factors are insufficient to adequately predict the presence or absence of OSAS.

Correspondence: Alfred Dreher, MD, Department of Otorhinolaryngology, Klinikum Großhadern, Marchioninistr 15, 81377 Munich, Germany (dreher@ithnet.com).

Submitted for Publication: August 18, 2004; accepted November 1, 2004.

Gislason  TAlmqvist  MEriksson  GTaube  ABoman  G Prevalence of sleep apnea among Swedish men: an epidemiological study. J Clin Epidemiol 1988;41571- 576
PubMed
Young  TPalta  MDempsey  JSkatrud  JWeber  SBadr  S The occurence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;3281230- 1235
PubMed
Viner  SSzalai  JPHoffstein  V Are history and physical examination a good screening test for sleep apnea? Ann Intern Med 1991;115356- 359
PubMed
Friedman  MTanyeri  HLa Rosa  M  et al.  Clinical predictors of obstructive sleep apnea. Laryngoscope 1999;1091901- 1907
PubMed
Zonato  AIBittencourt  LRMartinho  FLSantos  JFGregorio  LCTufik  S Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome. Laryngoscope 2003;113973- 980
PubMed
Rechtschaffen  AKales  A A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects.  Los Angeles: University of California;1973
Pouliot  ZPeters  MNeufeld  HKryger  MH Using self-reported questionnaire data to prioritize OSA patients for polysomnography. Sleep 1997;20232- 236
PubMed
Crocker  BDOlson  LGSaunders  NA  et al.  Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis 1990;14214- 18
PubMed
Flemons  WWWhitelaw  WABrant  RRemmers  JE Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med 1994;1501279- 1285
PubMed
Lavie  PGertner  RZomer  JPodoshin  L Breathing disorders in sleep associated with “microarousals” in patients with allergic rhinitis. Acta Otolaryngol 1981;92529- 539
PubMed
McNicholas  WTTarlo  SCole  P  et al.  Obstructive apneas during sleep in patients with seasonal allergic rhinitis. Am Rev Respir Dis 1987;1351316- 1319
PubMed
Miljeteig  HSavard  PMateika  SCole  PHaight  JSHoffstein  V Snoring and nasal resistance during sleep. Laryngoscope 1993;103918- 923
PubMed
Atkins  MTaskar  VClayton  NStone  PWoodcok  A Nasal resistance in obstructive sleep apnea. Chest 1994;1051133- 1135
PubMed
Mangat  DOrr  WCSmith  RO Sleep apnea, hypersomnolence and upper airway obstruction secondary to adenotonsillar enlargement. Arch Otolaryngol 1977;103383- 386
PubMed
Orr  WCMartin  RJ Obstructive sleep apnea associated with tonsillar hypertrophy in adults. Arch Intern Med 1981;141990- 992
PubMed
Pracharktam  NNelson  SHans  MG  et al.  Cephalometric assessment in obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1996;109410- 419
PubMed
Woodson  BTHaganuma  H Comparison of methods of airway evaluation in obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 1999;120460- 463
PubMed
Sher  AEThorpy  MJShprintzen  RJSpielmann  AJBurack  BMcGregor  PA Predictive value of Müller maneuver in selection of patients for uvulopalatopharyngoplasty. Laryngoscope 1985;951483- 1487
PubMed

Figures

Place holder to copy figure label and caption
Figure 1.

Distribution of nocturnal breathing pauses. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Distribution of daytime sleepiness. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Distribution of the severity of septal deviation. For explanation of septal deviation grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Distribution of the severity of the size of tonsils. For explanation of tonsil size severity grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 5.

Distribution of the severity of velum position. For explanation of velum position severity grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 6.

Distribution of the size of the tongue base. For explanation of tongue base size grades, see Table. AHI indicates apnea-hypopnea index.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable. Nasal and Pharyngeal Configuration Assessed in a Semiquantitative Manner

References

Gislason  TAlmqvist  MEriksson  GTaube  ABoman  G Prevalence of sleep apnea among Swedish men: an epidemiological study. J Clin Epidemiol 1988;41571- 576
PubMed
Young  TPalta  MDempsey  JSkatrud  JWeber  SBadr  S The occurence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;3281230- 1235
PubMed
Viner  SSzalai  JPHoffstein  V Are history and physical examination a good screening test for sleep apnea? Ann Intern Med 1991;115356- 359
PubMed
Friedman  MTanyeri  HLa Rosa  M  et al.  Clinical predictors of obstructive sleep apnea. Laryngoscope 1999;1091901- 1907
PubMed
Zonato  AIBittencourt  LRMartinho  FLSantos  JFGregorio  LCTufik  S Association of systematic head and neck physical examination with severity of obstructive sleep apnea-hypopnea syndrome. Laryngoscope 2003;113973- 980
PubMed
Rechtschaffen  AKales  A A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects.  Los Angeles: University of California;1973
Pouliot  ZPeters  MNeufeld  HKryger  MH Using self-reported questionnaire data to prioritize OSA patients for polysomnography. Sleep 1997;20232- 236
PubMed
Crocker  BDOlson  LGSaunders  NA  et al.  Estimation of the probability of disturbed breathing during sleep before a sleep study. Am Rev Respir Dis 1990;14214- 18
PubMed
Flemons  WWWhitelaw  WABrant  RRemmers  JE Likelihood ratios for a sleep apnea clinical prediction rule. Am J Respir Crit Care Med 1994;1501279- 1285
PubMed
Lavie  PGertner  RZomer  JPodoshin  L Breathing disorders in sleep associated with “microarousals” in patients with allergic rhinitis. Acta Otolaryngol 1981;92529- 539
PubMed
McNicholas  WTTarlo  SCole  P  et al.  Obstructive apneas during sleep in patients with seasonal allergic rhinitis. Am Rev Respir Dis 1987;1351316- 1319
PubMed
Miljeteig  HSavard  PMateika  SCole  PHaight  JSHoffstein  V Snoring and nasal resistance during sleep. Laryngoscope 1993;103918- 923
PubMed
Atkins  MTaskar  VClayton  NStone  PWoodcok  A Nasal resistance in obstructive sleep apnea. Chest 1994;1051133- 1135
PubMed
Mangat  DOrr  WCSmith  RO Sleep apnea, hypersomnolence and upper airway obstruction secondary to adenotonsillar enlargement. Arch Otolaryngol 1977;103383- 386
PubMed
Orr  WCMartin  RJ Obstructive sleep apnea associated with tonsillar hypertrophy in adults. Arch Intern Med 1981;141990- 992
PubMed
Pracharktam  NNelson  SHans  MG  et al.  Cephalometric assessment in obstructive sleep apnea. Am J Orthod Dentofacial Orthop 1996;109410- 419
PubMed
Woodson  BTHaganuma  H Comparison of methods of airway evaluation in obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 1999;120460- 463
PubMed
Sher  AEThorpy  MJShprintzen  RJSpielmann  AJBurack  BMcGregor  PA Predictive value of Müller maneuver in selection of patients for uvulopalatopharyngoplasty. Laryngoscope 1985;951483- 1487
PubMed

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 23

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Topics
PubMed Articles