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Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
OSA Part 1 - What ? How? Who ? Am I the One ? What is OSA and how does OSA happen? Breathing problems can occur during sleep giving rise to disorder called 'Sleep -disordered breathing (SDB)' "Apnea" =  Derived from the Greek word for "lack of breath," means a condition whereby a person stops breathing for at least 10 seconds, or even longer. Therefore, "Sleep apnea" = apnea occurring during a person's sleep There are 3 types of sleep apnea: (as in the Venn diagram) 1. Obstructive-OSA is the commonest type of sleep apnea 2. Central 3. Mixed Central sleep apnea (CSA) occurs when breathing effort stops resulting in reduction and cessation of airflow during sleep. It is usually caused by various neurologic disorders and failure of the breathing centre in the brain. Normally   during   sleep,   the   muscles   that   control   the   tongue   and   soft   palate hold   the   airway   open.   Snoring   occurs   as   a   result   of   sound   produced   by vibrations   of   the   soft   tissue   structures   which   can   be      due   to   turbulent   flow through a narrowed airway. In   OSA ,   these   upper   airway   muscles   relax,   resulting   in   snoring   and   breathing difficulties.   The   degree   of   narrowing   depends   on   the   severity   of   these   soft tissue   collapse,   therefore   the   name   "Obstructive" .      However,   in   OSA,   one continues   with   his   breathing   effort,   though   with   much   difficulty   (as   compared to   CSA   where   the   persons   stops   his   breathing   effort-involuntarily). Therefore, in   OSA,   one   stops   breathing   repeatedly   and   intermittently   for   at   least   10 seconds,   may   last   for   30   seconds   or   even   longer. The   more   severe   the   OSA, the   more   frequent   the   cessation   of   breathing.   The   patient   also   tends   to breathe through the mouth in order to overcome the obstruction. With no/reduced air flowing into the lungs, oxygen levels drop and carbon dioxide levels rise in the blood. The level of carbon dioxide  would rise so much as to remind the brain to resume breathing, hence causing the arousal. Eventually, the patient awakens abruptly and resumes breathing. He quickly falls back to sleep again -and resumes the loud snoring. During   the   brief   arousal   from   deep   sleep,   the   blood   pressure   spikes   up, sometimes   by   as   much   as   30   mm   Hg   systolic   (the   top   number   in   your hypertension   reading).   As   the   person   goes   back   to   sleep,   typically   unaware of   having   awakened,   the   throat   muscles   relax   once   again,   the   airway   closes, and   the   sleep   apnea   pattern   is   repeated   again   and   many   times   throughout the entire night. These subsequent and frequent arousals, although necessary for breathing to restart, prevent the patient from getting enough restorative, deep sleep - hence waking up feeling unrefreshed and excessively sleepy the next day, affecting the quality of your life, work and relationships in the long run. ...... Is this you ? What is the difference between snoring and OSA ? While everyone with SDB tends to snore, but not everyone who snores has SDB. Snoring in the absence of SDB is termed primary or simple snoring i.e. snoring without obstructive apnea, frequent arousals or gas exchange abnormalities that brings about health complications. Snoring is very common in OSA, but its absence does not exclude OSA. Therefore a proper consultation with clinical examination is necessary. (Are you confused yet ? Hopefully things are clearer as you read on) What is the current problem with OSA ? Lack of awareness (thank you for reading this, at least there is one less person less aware of OSA now) In a US study, it is estimated that up to 93% of females and 82% of males with moderate to severe OSA remain undiagnosed. There is also much room of improvement in terms of awareness of this condition among the doctors (i.e general practitioners, physicians, surgeons alike. So, why should I worry if I have OSA ? OSA can cause serious health problems. In addition to affecting the quality of your life due to disrupted sleep patterns, untreated OSA (through chronic complex body physiological and biochemical changes) can lead to: 1. Stroke (Almost 70% of people who had suffered from a stroke have sleep apnea) 2. Hypertension (>35% of people with sleep apnea suffer from hypertension) o People with mild to moderate sleep apnea were twice as likely to become hypertensive. o People with moderate to severe sleep apnea were almost 3 times as likely to become hypertensive. o Usually, normal adults who do not have OSA will typically experience nighttime blood pressure drops of about 10%. o In OSA, during sleep, the heart tries to counter the build-up of carbon dioxide by pumping harder. Increases in arterial pressures of 30 mm Hg or more do occur. 3. Increased risk for heart attack  (myocardial infarction) (in >35% of sleep apnea patients) o Among 6 major disease groups reviewed, cardiovascular diseases which occupied third place as a cause of death in 1950 emerged as the number one killer during the 1970s and has remained so since o Mortality due to coronary heart disease has increased by more than three fold over the last 40 years and is still rising -Cardiovascular/heart disease is in fact the number 1 killer in Malaysia ! 4. Increased risk of motor vehicle accidents (7 times more likely to occur in OSA patients) -even without OSA, some of us are already sleepy when driving especially after a stressful tiring day. What more with OSA. 5. Increased risk of work-related accidents  6. Reflux disorder i.e repeated overflow of stomach/gastric contents into the esophagus (Gastroesophageal Reflux Disease, GERD ) or throat (Laryngopharyngeal Reflux, LPR) 7. Diabetes -increasing evidence linking OSA and exacerbation of diabetes 8. Appetite increase - OSA causes increased appetite stimulant hormone (ghreline) and decresed appetite suppresant hormone (leptin). Increased appetite leads to worsening of the vicious cycle of OSA and obesity. 9. Depression - People with sleep apnea often complain of fatigue, lack of energy and poor sleep, all of which are hallmarks of depression. 10. Memory loss 11. Increased incidence of marital disharmony - even 'spousal arousal syndrome' has been coined as a result the bed partner’s snoring 12. Decreased quality of life There are thousands of clinical research papers backing these data. Still, the list is being expanded at a worrisome rate (no joke really!) as new research data pours in. How do know if I probably have OSA? The dominant symptoms of OSA are excessive sleepiness, impaired concentration and snoring. OSA symptoms include: Restless sleep, moving around or unusual sleep position Choking episodes-waking up at night to 'catch a breath' Nocturia/enuresis  - awaken as a result of SDB, and then they notice the urge to urinate Morning headache Excessive daytime sleepiness (EDS) -a very common symptom, may cause o Personality changes -eg. irritability o impaired cognitive skills o Job performance to be affected weight gain sexual dysfunction- decreased libido sedative use-in an attempt to improve sleep at night, some may develop dependance Bed partner's input are good indicators: -look for choking episodes, witnessed episodes of breathing cessation (apnea), tossing and turning in bed. For screening purposes, Epworth Sleepiness Score can be used as as a validated guide as a method of assessing the likelihood of falling asleep or EDS in 8 different situations. Download link here.   Who is at risk of OSA? Having all these physical attributes put you at a higher risk for OSA: increased neck circumference [ > 17 inches (43cm) in men, > 16 inches (38cm) in women]. short neck body mass index (BMI) > 30 kg/m2 o The excess adipose tissue of obese individuals acts to narrow the airway and alter airway shape, increasing the susceptibility of the upper airway to collapse. a high Modified Mallampati score (a uniform clinical method af assessing the palate space in the mouth)  the presence of retrognathia (lower jaw displaced backwards) lateral peritonsillar narrowing, large tongue (macroglossia), tonsillar hypertrophy, elongated/enlarged uvula, high arched/narrow hard palate, nasal abnormalities (polyps, septal deviation, valve abnormalities, turbinate hypertrophy) and/or overjet (protrusion of upper jaw over the lower jaw) (Clinical examination and flexible endoscopy of the upper airway can identify the above findings) Smoking and alcohol consumption also contribute to snoring and OSA, not to mention it is already a known high risk factor for heart/cardiovascular disease OSA is common among those with heart/cardiovascular disease. -It affects as many as 30% of coronary artery disease patients, 50% of congestive heart failure patients, 60% of stroke patients and 80% of drug resistant hypertensive patients High-risk factors: obesity congestive heart failure atrial fibrillation treatment refractory hypertension type 2 diabetes stroke, nocturnal dysrhythmias pulmonary hypertension high-risk driving populations (such as bus drivers, pilots, commercial truck drivers), patients being evaluated for bariatric surgery (surgery to correct morbid obesity). OSA General info Prevalence rate is about- 2% in women, 4% in men 85% of OSA patients are of the male gender 2/3 of OSA patients are obese here for the new pandemic -THE OBESITY PANDEMIC incidence increases  with aging -its prevalence increases 2-3 times in older persons (>65 y) compared with individuals aged 30-64 years. About 1% to 10% of children have sleep apnea; In young children, sleep apnea is usually caused by enlarged tonsils and adenoids Prevalence of OSA in women appears to increase after menopause More interesting facts here about sleep and snoring. I'm not even fat or obese, can I still have OSA? Yes, you can still have OSA even if your thin. The "Box vs Contents concept" holds true -theory of relativity.. That is, you have a risk of airway narrowing if have a small bony frame ‘box’  eg small jaw bones, although the soft tissue contents are of normal size ...or you have larger-than-normal ‘contents’ eg. large tonsils, large tongue, thick walls in the throat, although you have jaw bones of normal size What about OSA in children ? All snoring and apnea is abnormal in children About 2% of children are affected, with a peak incidence at age 2-5 years old Unlike adults (who tend to be obese), apneic children tend to be underweight & short True daytime sleepiness as in adults is unusual in children- hyperactivity and irritability on waking more common. Many are mouth breathers Usually due to adenotonsillar hypertrophy unless craniofacial abnormalities in certain congenital syndromes (eg. small lower jaw bone structures).
Snoring   Obstructive Sleep Apnea (OSA) EDUCATION
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The blue boxes represent the bony frame i.e the ‘box’ and the space inside the box, the soft tissue structures i.e ‘contents’.
OSA    is    a    stress    on the    heart,    and    if    left untreated,     leads     to many      complications that    YOUR    body    will later    have    to    take    a beatIng for !
(PDF files will open in a new window)
In a normal subject, air flows into the nose and throat before entering the windpipe into the lungs.
In    an    OSA    patient,    upper    airway    obstruction    reduces/prevents    airflow through   the   nose   and/or   throat,   subsequently   into   the   lungs.   This   can   be caused   by   narrowing   or   backward   collapse   of   the   soft   palate   (yellow   line), tongue (green line), and/or epiglottis (black line) in the animation. (source of unlabelled diagram: Netter Atlas of Anatomy)
© Vincent Tan ENT
20 interesting facts about sleep and snoring. (source : The British Snoring & Sleep Association)’s no longer a laughing matter
Continue to OSA Part 2 -Diagnosis & Treatment
LEVEL OF OBSTRUCTION Physical attributes and findings determine the level of obstruction in OSA. Understanding the level of obstruction is crucial in treating OSA. Other than a thorough clinical examination, flexible   endoscopy   of   the   upper airway   (FNPLS)    in   the   comfort of   the   ENT   clinic   can   yield   much information.
Epworth Sleepiness Scale questionaire
A cross section top view of the upper airway. Oval blue line represents the tonsils, the black line represents the epiglottis (part of your voice box structure). Tongue The same view in a real patient where the left tonsil (red line) is enlarged while the right tonsil is not (blue line). The black line represents the epiglottis. Now... imagine if the right tonsil is enlarged (green line) as well - how narrow can the airway be !? © Vincent Tan ENT © Vincent Tan ENT Right  Left POSTERIOR PHARYNGEAL WALL LARGE LEFT TONSIL BASE OF TONGUE
© Vincent Tan ENT
Adenoids & tonsils- still the 2 commonest culprits for OSA in children © Vincent Tan ENT
This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.
Keen to know more about OSA       Disorder       Services provided here ?
No longer a sign of prosperity... but diseases waiting to happen! © Vincent Tan ENT
OSA        leaves        you unrefreshed      in      the next    morning,    feeling like a ’zombie’ !
NEW evidence linking obstructive sleep apnea (OSA) to cardiovascular/heart disease (eg. hypertension, stroke, heart attack)- the No.1 killer in Malaysia .. Are you at risk ?
The obesity pandemic (as appeared in Malaysian daily The Star on 23/9/11
Why is “SLEEPING SOUNDLY” not as beautiful and healthy as it sounds anymore ?   
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© Vincent Tan ENT Snoring and breathing through mouth ???
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Recommended BMI classification for Asians
Last update:  12/12/15 
Talks about SNORING & O.S.A on 12/1/16 (for educational purposes)
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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