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Key Features

Essentials of Diagnosis

  • Daytime somnolence or fatigue

  • A history of loud snoring with witnessed apneic events

  • Overnight polysomnography demonstrates apneic episodes with hypoxemia

General Considerations

  • Upper airway obstruction results from a loss of pharyngeal muscle tone during sleep

  • Patients with narrowed upper airways are predisposed to the condition

  • Ingestion of alcohol or sedatives before sleep and nasal obstruction from any cause may precipitate or worsen the condition

  • Cigarette smoking and hypothyroidism are risk factors

Demographics

  • Most patients are obese, middle-aged men

Clinical Findings

Symptoms and Signs

  • Patients complain of daytime somnolence or fatigue, morning sluggishness, or cognitive impairment

  • Recent weight gain, headaches, and erectile dysfunction may be present

  • Bed partners usually report loud cyclical snoring and witnessed apneas with restlessness and thrashing movements during sleep

  • Arterial hypertension is usually present

  • Physical examination may show evidence of pulmonary hypertension with cor pulmonale

  • Oropharyngeal narrowing due to excessive soft tissue may be seen

  • A short, thick neck is common

  • Bradydysrhythmias may occur during sleep

  • Tachydysrhythmias may be seen once airflow is reestablished following an apneic episode

Differential Diagnosis

  • Central sleep apnea

  • Mixed sleep apnea

  • Obesity-hypoventilation syndrome (Pickwickian syndrome)

  • Narcolepsy

  • Alcohol or sedative abuse

  • Depression

  • Hypothyroidism

  • Seizure disorder

Diagnosis

Laboratory Tests

  • Erythrocytosis is common

  • Serum thyroid-stimulating hormone (TSH) should be checked

Diagnostic Procedures

  • Overnight polysomnography is essential to make the diagnosis

    • Includes electroencephalography, electro-oculography, electromyography, electrocardiography, pulse oximetry, and measurement of respiratory effort and airflow

    • Reveals apneic episodes lasting as long as 60 seconds

  • Oxygen saturation falls, often to very low levels

  • Bradydysrhythmias such as sinus bradycardia, sinus arrest, or atrioventricular block may occur

  • Tachydysrhythmias, including paroxysmal supraventricular tachycardia, atrial fibrillation, and ventricular tachycardia, may be seen once airflow is reestablished

  • Screening with home nocturnal pulse oximetry has a high negative predictive value in ruling out significant sleep apnea

Treatment

Medications

  • Pharmacologic therapy is not successful

Surgery

  • Uvulopalatopharyngoplasty, the resection of pharyngeal tissue and removal of a portion of the soft palate and uvula, is helpful in approximately half of selected patients

  • Nasal septoplasty is performed if gross nasal septal deformity is present

  • Tracheostomy is the definitive therapy, but is reserved for life-threatening, refractory cases

Therapeutic Procedures

  • Weight loss and avoidance of alcohol and hypnotic medications are initial steps

  • 10–20% weight loss may be curative

  • Nasal continuous positive airway pressure (CPAP) is curative in many patients

  • Polysomnography is often necessary to determine the level of CPAP (usually 5–15 mm Hg) required

  • Prosthetic devices inserted into the mouth to prevent pharyngeal occlusion can be modestly effective, ...

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