eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Palatal & Maxillofacial Surgery

Snoring and Obstructive Sleep Apnea, CPAP: Differential Diagnoses & Workup

Author: Vittorio Rinaldi, MD, Resident in Otolaryngology, Department of the Campus Bio-Medico, University of Rome
Coauthor(s): Fabrizio Salvinelli, MD, Professor of Otolaryngology, Campus Bio-Medico, University of Rome; Manuele Casale, MD, Specialist in Otolaryngology, Campus Bio-Medico, University of Rome School of Medicine; Francesco Faiella, MD, Resident in Otolaryngology, Campus Bio-Medico University of Rome School of Medicine; Marco Pappacena, MD, Resident, Department of Otolaryngology, Campus Bio-Medico University, Rome; Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
Contributor Information and Disclosures

Updated: Oct 6, 2008

Differential Diagnoses

Other Problems to Be Considered

The differential diagnosis includes simple snoring, central sleep apnea, and other disorders that cause day-time sleepiness (eg, insufficient sleep, a circadian-rhythm abnormality, narcolepsy, periodic limb movement disorder). 

Workup

Laboratory Studies

The relation between snoring, obstructive sleep apnea and hypothyroidism has been confirmed by many authors. Thyroid-stimulating hormone (TSH) levels should be determined in patients who are newly diagnosed with sleep-disordered breathing (SDB) because sleep-disordered breathing (SDB) is relatively common among patients with hypothyroidism.

Imaging Studies

Radiologic and diagnostic studies have been used to identify the obstruction site, direct surgical intervention and predict outcomes of sleep apnea surgery. These studies include lateral cephalometric radiographs, CT, MRI, asleep fluoroscopy, asleep and awake endoscopy with Mueller maneuver, upper airway manometry, and acoustic reflection techniques. Most of those techniques have limitations (dynamic and tridimensional evaluation) in the mechanism of occlusion investigation. Ultrafast MRI provides a reliable and noninvasive method for static and dynamic evaluation of the soft tissue structures surrounding the upper airway during the respiratory cycle in wakefulness and sleep.

Other Tests

  • The Epworth Sleepiness Scale (Epworth Sleepiness Scale) is a questionnaire filled out by the patient that estimates the likelihood of falling asleep in different situations. This permits a standardized semiquantitative subjective assessment of daytime sleepiness.
  • The polysomnography (PSG) is the criterion standard diagnostic test for obstructive sleep apnea syndrome (OSAS).
    • A respiratory event suggestive of obstructive sleep apnea syndrome (OSAS) is defined as a decrease in nasal and oral airflow, alone or with thoraco-abdominal movements, more than 90% (apnea) or more than 50% and less than 90% (hypopnea) that lasted for at least 10 seconds. A decrease in SaO2 of 4% or more is considered significant oxygen desaturation.
    • Information from the PSG is reported as the Respiratory Disturbance Index (RDI). The RDI is the number of apneas or hypopneas 10 seconds or longer occurring per hour of sleep. A normal RDI is less than 5. A RDI less than or equal to 5 is considered suggestive of simple snoring with no OSAS. Greater than 5 and less than or equal to 15 is suggestive of mild OSAS. More than 15 and less than or equal to 30 is suggestive of moderate OSAS. Finally, more than 30 is suggestive of severe OSAS. The loudness and persistence of snoring (constant versus intermittent) are usually reported. Body position is also recorded so one can determine what position (usually supine) and in what sleep phase (usually rapid eye movement [REM] sleep, when muscle tone is most relaxed) the patient is in when respiratory events occur.
  • The PSG has several limits including the necessity to perform the test in a sleep laboratory, high costs, considerable technical expertise, and long analyzing time by the operator. In addition, the examination often needs to be repeated because of the interference of monitoring electrodes with the physiological sleep of the patient (“first night effect”). Therefore, timely access to PSG is often a problem.
  • An extensive interest in alternative diagnostic approaches, such as clinical prediction rules and portable monitors, has been expressed. A limited number of questionnaires are available to detect some sleep disorders, but those instruments do not achieve the reliability of PSG, which remains the recommended method of assessing patients with suspected sleep disorders. The role of those questionnaires is mainly of a screening tool for identifying patients at risk for obstructive sleep apnea syndrome (OSAS).
  • Various types of ambulatory (to be used at home) monitors can measure parameters such as airflow, chest, and abdomen movements (as indicators of respiratory effort); oxygen desaturations; snoring; pulse; and body position. Although the data from such studies are not as detailed or accurate as an overnight PSG, these studies can often be used to differentiate primary snoring from snoring with apneas and can usually provide an indication of the frequency with which apneas are occurring. In contrast, techniques that measure only one parameter (eg, home oximetry alone) seem to be less accurate than those that track several measurements.
  • Acoustic analysis of snoring sounds may help differentiate between primary snoring and obstructive sleep apnea (OSA). Other researchers have investigated the combination of clinical variables such as neck and chest circumference, body mass index, and resting room air oxygen saturation; however, none of these have been shown to differentiate consistently between primary snorers and patients with significant apneas and desaturations during sleep.
  • Home sleep testing pursues the goal of simplify the diagnosis of sleep apnea while retaining the essential recording features of PSG.
    • Recent studies suggested that home sleep studies have benefits in terms of time and cost, but for diagnostic reliability, an in-laboratory sleep study may be required in more than half of the cases.
    • EdenTrace portable monitor measures nasal and oral air flow using thermistors, chest wall impedance, oxygen saturation with finger pulse oximetry, heart rate, and movement detected by electrical comparison of the signals from the ECG and the pulse oximetry.
    • The MESAM IV system evaluates sleep-disordered breathing based on an analysis of snoring, heart rate, and saturation change. Even if in many studies there is a good agreement between the AHI measured in the laboratory and with the home sleep testing, there is a risk that ambulatory diagnostic procedures may alter the relationship of patients to their disease and/or the medical staff so that subsequent compliance with treatment may be decreased.
    • The Nightwatch system has the ability to calculate the AHI. It records eye movement (1 channel, piezo electrode), leg movement (1 channel, piezo electrode), arterial oxygen saturation (finger pulse oximeter), nasal oral air flow (thermistor), chest and abdominal movements (piezo electrodes), body position and movement (mercury gauge placed on the chest), and heart rate. The Nightwatch system has also got the ability to send to the laboratory data for analysis by modem 2-minute portions of the complete recording so that signal quality can be assessed and transducer function corrected if needed. However, further studies are necessary before this technology can be put into widespread use.

Histologic Findings

Histology of the soft palate and uvula in snorers and patients with obstructive sleep apnea (OSA) syndrome has been a subject of investigation of many authors. Some authors observed muscular atrophy, dilatation and congestion of the blood vessels, lymphocytic infiltrations, and hypertrophy of superficial salivary glands localized between the muscle bundles and epithelium. Those histopathologic changes were related to the influence of the vibration on the soft palate and uvula and were considered responsible for the excessive flaccidity of these structures. Other authors observed similar contents of glands, muscle, fat, blood vessels, and the epithelium in the uvula and the soft palate of either OSAS and control subjects.

More on Snoring and Obstructive Sleep Apnea, CPAP

Overview: Snoring and Obstructive Sleep Apnea, CPAP
Differential Diagnoses & Workup: Snoring and Obstructive Sleep Apnea, CPAP
Treatment & Medication: Snoring and Obstructive Sleep Apnea, CPAP
Follow-up: Snoring and Obstructive Sleep Apnea, CPAP
References
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Further Reading

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Keywords

CPAP, apnea, sleep apnea, snoring, obstructive sleep apnea, sleep apnea snoring, obstructive sleep apnea syndrome, OSAS, upper airway obstruction occurring during sleep, sleep-disordered breathing, SDB, upper airway resistance syndrome, UARS, laryngopharyngeal reflux, insomnia, daytime somnolence, narcolepsy, nasal continuous positive airway pressure, n-CPAP, CPAP machine, CPAP machines, CPAP masks, CPAP mask, CPAP apnea, CPAP sleep, sleep apnea treatment, sleep, snore, sleep apnea machine, apnea treatment, sleep disorder

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Contributor Information and Disclosures

Author

Vittorio Rinaldi, MD, Resident in Otolaryngology, Department of the Campus Bio-Medico, University of Rome
Disclosure: Nothing to disclose.

Coauthor(s)

Fabrizio Salvinelli, MD, Professor of Otolaryngology, Campus Bio-Medico, University of Rome
Disclosure: Nothing to disclose.

Manuele Casale, MD, Specialist in Otolaryngology, Campus Bio-Medico, University of Rome School of Medicine
Disclosure: Nothing to disclose.

Francesco Faiella, MD, Resident in Otolaryngology, Campus Bio-Medico University of Rome School of Medicine
Disclosure: Nothing to disclose.

Marco Pappacena, MD, Resident, Department of Otolaryngology, Campus Bio-Medico University, Rome
Disclosure: Nothing to disclose.

Karen Hall Calhoun, MD, William E Davis Professor and Chair, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Jack A Coleman, MD, Consulting Staff, Franklin Surgical Associates
Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US
Disclosure: Influent  None Review panel membership; accarent, inc Honoraria Speaking and teaching

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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