History and exam

Key diagnostic factors

common

obesity

Considered a key risk factor.

male sex

Considered a key risk factor. In the general adult population, OSA prevalence of 13% to 33% has been reported in men (6% to 19% in women).[13]

The estimated prevalence of at least mild OSA (Apnea-Hypopnea Index [AHI] ≥5 episodes/hour) in the Wisconsin Sleep Cohort Study (2007-2010) for men and women (ages 30-70 years) was 34% and 17%, respectively.​[3][4]

maxillomandibular anomalies

Have been associated with increased risk of OSA.[34] Assessment should be made for narrowing of jaws, overbite, overjet, malocclusion.

excessive daytime sleepiness

It is important to ask about adequate sleep duration, environment, and whether there is sleepiness while driving.

The patient's level of daytime fatigue can be assessed using the Epworth Sleepiness Scale. [ Epworth Sleepiness Scale (ESS) Opens in new window ]

episodes of apnea

Episodic cessation of breathing terminated by a loud snore.

episodic gasping

Commonly observed by the patient's bed partner.

restless sleep

Bed partner will often complain about excessive motion of the patient during sleep. Patients who sleep alone will often unravel the bedsheets.

insomnia

More frequently experienced by women.[59][60]

macroglossia

Tongue is relatively large for the oral cavity and pharynx, and obstructs view of oropharynx.[35] May have crenations (lateral indentations from the dentition). Assessment of the oropharynx in these patients commonly requires use of tongue depressors.

chronic snoring

Common symptom. Often audible beyond the bedroom.

Other diagnostic factors

common

cardiovascular disease

Highly prevalent in OSA.

May include systemic and/or pulmonary hypertension, dysrhythmias, heart failure, coronary artery disease, or stroke.[64][79]

Many patients with pharmacologically resistant hypertension, stroke, recurrent atrial fibrillation will have OSA.[12][25]​​​​​​​​

weight gain

Patients often present for evaluation after weight gain accompanied by worsening of snoring and/or sleepiness.

Risk of OSA increases with increasing BMI.[4][29]

large neck circumference

Patients are often overweight or obese and have a large neck circumference (≥40 cm).

A neck circumference of >40 cm has a sensitivity of 61% and specificity of 93% for OSA.[34]​ 

endocrine disorders

Type 2 diabetes, metabolic syndrome, polycystic ovary syndrome, hypothyroidism, and acromegaly are associated with OSA.​[28][43][80][81]

history of difficult intubation for general anesthesia; obstruction during sedation

Potentially related to anatomic features such as mandibular anomalies and macroglossia.

family history of OSA or snoring

A history of other family members who have OSA or who snore is common.

Estimated heritability for OSA, as defined by the the Apnea-Hypopnea Index, is 0.30 to 0.40.[16]

history of mucopolysaccharidoses

Associated with OSA.[46][47]​ 

history of GERD

Commonly associated with OSA and obesity.[82][83]

history of Down syndrome

OSA is highly prevalent in children with Down syndrome.[44]

history of tooth extractions for crowding

Extractions of bicuspids (premolars) for crowding of dentition may lead to a narrowed mandible and/or maxilla and a smaller airway.[65]​ Shape and size of jaws should be assessed.

history of motor vehicle accidents

Can occur as a consequence of sleepiness while driving.[26][27]​​​​

neurocognitive dysfunction

Patients may report problems with attention, learning, and memory.[24]​​

mood disorders

Depression, anxiety, and irritability are commonly reported. Diagnosis of OSA may sometimes be delayed as patients could be treated for mood disorders.

nocturia

People with OSA may report a high incidence of nocturia.[84]

erectile dysfunction

Possibly related to hypoxemia. May respond to continuous positive airway pressure treatment.

morning headaches

Associated with snoring and sleep apnea.

heartburn/dyspepsia

Patients may complain about retrosternal burning or choking episodes at night due to laryngospasm.

dry mouth

Caused by mouth breathing.

Episodic swelling of the uvula may also occur.

nocturnal sweating

May be noted by partner of adult patient. Common symptom in pediatric patients.[85]

Risk factors

strong

obesity

Large epidemiologic studies report an association between obesity and risk of obstructive sleep apnea (OSA).[4][13][28]​ Risk increases with increasing BMI.[4][29]​ The association of OSA with obesity appears to diminish with age.[4][30]​​​

male sex

Increases the probability of OSA. In the general adult population, OSA prevalence of 13% to 33% has been reported in men (6% to 19% in women).[13] The estimated prevalence of at least mild OSA (Apnea-Hypopnea Index [AHI] ≥5 episodes/hour) in the Wisconsin Sleep Cohort Study (2007-2010) for men and women (ages 30-70 years) was 34% and 17%, respectively.​[3][4]

postmenopause (women)

Risk of OSA is increased in postmenopausal women.[31][32] Surgical menopause may be associated with greater risk than natural menopause.[33]

large neck circumference

A neck circumference of >40 cm has a sensitivity of 61% and specificity of 93% for OSA.[34] Neck is measured at the level of the cricothyroid space. Patients are asked if neck collar size has increased over the last 6-12 months in association with increased symptoms.

maxillomandibular anomalies (e.g., narrowing, retrognathia, and high, arched palate)

Have been associated with increased risk of OSA.[34]

Excessive protrusion of the upper over the lower incisors (overjet) is common.

The hard palate may be narrow, arched, and crossbite may be present.

Mandibular exostoses may elevate and displace the tongue and increase pharyngeal obstruction.

increased volume of soft tissues (includes tonsils, adenoids, and tongue)

Anatomic studies using MRI to compare soft tissue volumes of patients with OSA versus control patients found greater volume of soft palate, tongue, and lateral pharyngeal walls in patients with OSA.[18]

Patients with OSA have been found to have a large tongue, whether they had small or large craniofacial dimensions, compared with non-OSA patients who have matching craniofacial dimensions.[35]

Adenotonsillar hypertrophy in association with normal tongue size/position may be predictive of increased surgical success rates.[36]

Lateral narrowing of the pharyngeal area (or medialization of the pharyngeal walls) should be assessed on exam.

family history of OSA

Estimated heritability for OSA, as defined by the the Apnea-Hypopnea Index, is 0.30 to 0.40.[16]

High rates of prevalence in children of patients with OSA have also been identified.[37]

chronic snoring

Has been found to have a positive predictive value of 0.63 and negative predictive value of 0.56 for OSA (Apnea-Hypopnea Index [AHI] ≥15 episodes/hour) in a population of patients referred to a sleep clinic for suspicion of OSA.[38]

Important for the diagnosis of OSA in the setting of a mildly elevated AHI.[39] Nonreporting by patient does not rule out OSA.

polycystic ovary syndrome (PCOS)

One systematic review and meta-analysis reported OSA prevalence of 35% among women with PCOS.[40]

High levels of androgenic hormones may contribute to increased risk.[41][42]

hypothyroidism

Treatment of hypothyroidism may improve OSA, but outcome must be verified by using polysomnography.[43]

Down syndrome

Prevalence of OSA (defined as AHI >5 episodes/hour) among children with Down syndrome who underwent polysomnography has been reported to be 50%.[44] Prevalence appears to be higher in male than in female patients.[45]

mucopolysaccharidoses

Has been associated with increased risk of OSA.[46][47]​​​

Significant increase in prevalence in this population may be high due to skeletal and soft tissue factors.

increasing age

Prevalence of OSA increases with age.[13]

In the Wisconsin Sleep Cohort Study, at least mild OSA (AHI ≥5 episodes/hour) was reported in 27% of men and 9% of women ages 30-49 years, increasing to 43% and 28%, respectively, in individuals ages 50-70 years.[4]

black, Hispanic, or Asian ethnicity

African-Americans have been reported to be at higher risk for OSA than white people.[5][6][7]​​ Data indicate an elevated prevalence of OSA among US Hispanic people compared with US white people.[8]

tobacco smoking

Smokers with a 20-year pack history are at greater risk of OSA compared with never smokers.[48]

weak

nasal obstruction

Congestion due to allergy (self-reported) has been found to have an odds ratio of 1.8 for an Apnea-Hypopnea Index (AHI) >15 episodes/hour.[49] Another study reported an adjusted odds ratio (adjusted for sex, age, body habitus, and smoking) for habitual snoring with severe nasal congestion was 3.0 in patients with AHI of <5 episodes/hour.[50]

levels of sex hormones

Testosterone administration in men is associated with higher risk or severity of OSA.[51][52]​ The effect is likely small.

alcohol use

In one meta-analysis of crossover randomized trials, alcohol use (2-3 standard alcoholic drinks) resulted in significantly increased OSA severity compared with placebo.[53]​​

environmental tobacco smoke exposure

Secondhand smoke exposure has been reported to be significantly associated with OSA.[54]

opioid use

Chronic opioid therapy can alter sleep architecture and cause respiratory depression, increasing the risk for sleep-disordered breathing.[55][56]

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