Central Annals of Otolaryngology and Rhinology

Cite this article: Duarte LP, da Silveia PL, Mathias Duarte AS, Silva VG, Baptista Carvalho EG, et al. (2016) Association between Physical Examination and Comorbidities in OSAS Severity. Ann Otolaryngol Rhinol 3(10): 1136.

*Corresponding author

Laíza Araújo Mohana Pinheiro, Rua Quinze de Novembro, 1054, São Carlos, São Paulo-SP. Brazil, CEP: 13561-206; Fax: 55-1633711005, Email:

Submitted: 06 June 2016

Accepted: 16 September 2016

Published: 19 September 2016

ISSN: 2379-948X

Copyright© 2016 Duarte et al.

OPEN ACCESS

Keywords•Sleep apnea syndromes; Hypertension; Physical

examination; Overweight

Research Article

Association between Physical Examination and Comorbidities in OSAS SeverityLaízaMohana Pinheiro Duarte*, Priscila Leite da Silveia, Alexandre Scalli Mathias Duarte, Vanessa Gonçalves Silva, Eduardo George Baptista Carvalho, Edilson Zancanella, and AgrícioNubiato CrespoDepartment of Otolaryngology, Head and Neck Surgery, University of Campinas, Brazil

Abstract

Introduction: Obstructive Sleep Apnea Syndrome (OSAS) is a chronic, multifactorial disorder which affects 4% men and 2% women in middle aged adults. It is featured by episodes of partial or total obstruction of the upper airway during sleep, which results in oxygen desaturation and micro-awakenings.

Objective: Associate anthroprometric data, otolaryngological exam and comorbidities with OSAS severity assessed by sleep apnea-hypopnea index (AHI).

Methods: We analyzed 350 medical records from patients with sleep disorders from tertiary hospital, (June/2007 to May/2012). Incomplete records excluded. Patients were divided into 4 groups according to AHI: snoring, mild apnea, moderate apnea and severe apnea. Variables analysed: age, sex, the Epworth Sleepiness Daytime Scale (ESS), comorbidities, body mass index(BMI), neck circumference(NC), Brodsky Palatine Tonsil classification, Modified Mallampati(MM) score and the Friedman index. Data was analysed statistically.

Results: 249 patients evaluated, 129 men/120 women, mean age 50.9 years. 28/snoring, 45/mild, 73/moderate and 103/severe apnea. Systemic Arterial Hypertension was more prevalent in severe OSAS (p=0.045). BMI, NC, MM scores and Friedman presented higher values with worsening AHI(p<0.05). ESS, tonsil classification and other comorbidities did not present correlation with OSAS severity.

Conclusion: OSAS severity showed a association with BMI, neck circumference, the Friedman index, the modified Mallampati classification and with the prevalence of arterial hypertension.

INTRODUCTIONObstructive Sleep Apnea Syndrome (OSAS) is a chronic,

multi factorial disorder which affects 4% men and 2% women in middle aged adults [1]. It is featured by episodes of partial or total obstruction of the upper airway during sleep, which results in oxygen desaturation and micro-awakenings. It is closely related to cardiovascular [2,3] and cerebrovascular diseases [4], as well as having a negative impact on the quality of life2. These implications worsen with the severity of the symptoms and the importance of early diagnosis should be taken into account. In Brazil, one epidemiological study estimated a prevalence of apnea of 32,8% among the adult population of São Paulo [5].

Predictors to diagnose OSAS in the population include snoring, age, overweight, daytime sleepiness and witnessed apneia [6]. Obesity, especially central adiposity, is consistently recognised as one of the strongest risk factors for OSA.OSA is present in 41% of patients with a body mass index (BMI) greater than 28 and the prevalence can be as high as 78% in patients referred for bariatric surgery [2].These factors have been useful

in terms of showing high prevalence of this disorder, especially in middle age [3,7].

Anthroprometric data was correlated with OSAS severity in patients [8,9]. The most studied are cervical, abdominal and pelvic circumferences, as well as the Body Mass Index (BMA). Among them, cervical circumference has shown to be the most serious predictor [8].

Studies have shown that not only OSAS present risk factors in common with cardiovascular diseases, but it can also increase the rate of cardiovascular events independently. The most common events are systemic arterial hypertension, coronary artery disease, congestive heart failure and cerebrovascular accidents [2-4]. Metabolic changes triggered by sleep apnea can explain this association [10]. Gastroesophageal reflux has also been associated to episodes of obstructive sleep apnea in a cause and effect correlation, which is still not well explained [11].

OBJECTIVEThe aim of this research is to associate anthropometric data,

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otolaryngological exam and comorbidities with OSAS severity assessed by the sleep apnea-hypopnea index (AHI).

MATERIALS AND METHODSData was analysed between June, 2007 and May, 2012 from

medical records of 350 outpatients from the sleep disorder outpatient care service on the Department of Otolaryngology, Head and Neck Surgery at a tertiary university hospital. 101 patients were excluded due to incomplete data.

The patients were divided into 4 groups according to the apnea-hypopnea index (AHI): snoring (group 1 – AHI <5 events/hour); mild apnea (group 2 – 5≥AHI<15 events/hour); moderate apnea (group 3 - 15≥AHI<30 events/hour) and severe apnea (group 4 – AHI ≥30 events/hour).

The following variables were analysed: age; sex; the Epworth Sleepiness Daytime Scale (ESS) [12]; comorbidities; anthropometric data and physical examination. The evaluation of comorbidities was performed by responses to our questionnaire, which included: Systemic Arterial Hypertension (SAH), diabetes Mellitus, hypothyroidism, dislipidemia (DLP), gastro esophageal symptoms (GS), neuropathies, depression and rhinitis. The anthropometric data and the physical examination were: the Body Mass Index (BMI) [13] neck circumference (NC); the Brodsky Palatine Tonsil classification [14]. Modified Mallampati (MM) [13] scores and the Friedman index [13]. The NC was measured along a horizontal line across the midline of the thyroid cartilage [8].

The data was analysed statistically by the SAS System 9.2. Tukey tests was used to compare the averages between groups and Cochran- Mantel-Haenszel Statistics to detect associations. P <0.05 was considered significant.

This research was previously accepted by the Ethics committee at Clinical Hospital, nº 83946/2012.

RESULTSA total number of 249 patients were evaluated: 129 men and

120 women, average age of 50.9 years old (11-85 years old). Twenty eight patients suffered from snoring, 45 from mild apnea, 73 from moderate apnea and 103 from severe apnea.

The Sleepiness Daytime Scale was higher in patients with severe apnea (group 4) and lower in the snoring group (group 1). This fact did not present statistical relevance (p=0.069) (Table 1).

Concerning the comorbidities, Systemic Arterial Hypertension was more prevalent when the level of apnea-hypopnea was higher and thus this fact was statistically significant (p=0.045) (Table 2). Rhinitis was more prevalent in patients who snored, with statistical significance (p=0.03) (Table 3). Hypothyroidism, dislipidemia and Diabetes Mellitus were more prevalent in groups 3 and 4 than in groups 1 and 2, not presenting a statistical significance, as in the other Comorbidities (Table 4).

The anthropometric data, the BMI and the neck circumference showed progressively higher values with the worsening of AHI, statistically significant (p<0.01) (Table 5).

The tonsil classification did not present a correlation

Table 1: EDS index per group.

Group N AverageEDS P=0.0695

1 28 8.6

2 45 10.9

3 73 11.1

4 103 12EDS: Excessive Daytime Sleepiness. P <0.05 References:0-5: Lower Normal. 6-10: Higher Normal 11-12: Mild Excessive13-15: Moderate Excessive 16-24: Severe Excessive

Table 2: Prevalence of SAH.

Group Present Absent TOTAL P = 0.0457

1 9 (32.1%) 19 (67.9%) 28 (11.24%)

2 17 (37.8%) 28 (62.2%) 45 (18.07%)

3 36 (49.3%) 37 (50.7%) 73 (29.32%)

4 52 (50.5%) 51 (49.5%) 103 (41.37%)

TOTAL 114 (54.22%) 135 (45.78%) 249 (100%)

SAH: Systemic Arterial Hypertension. P<0.05

Table 3: Prevalence of Rhinitis (P<0.05).

Grupo Absent Present Total P= 0.0324

1 19 (67.9%) 9 (32.1%) 28 (11.24%)

2 40 (88.9%) 5 (11.1%) 45 (18.07%)

3 61 (83.6%) 12 (16.4%) 73 (29.32%)

4 92 (89.3%) 11 (10.7%) 103 (41.37%)

Total 212 (85.14%) 37 (14.86%) 249 (100%)

with OSAS severity. On the other hand, both the Mallampati classification and the Friedman index showed higher values with the worsening of AHI. (Table 6).

DISCUSSIONOSAS is considered a public health issue having a high rate in

both men and women [15,16]. Diagnosing it is essential due to severe consequences of patients´ health and quality of life [2,8]. Excessive daytime sleepiness is a common complaint in OSAS. It is triggered by sleep fragmentation due to recurrent obstructive events which take place owing to pharangyeal structure collapse [17]. Our study found a high rate of this complaint related to OSAS severity, however, no statistically significant difference was found between groups, despite de P value (0,065) was nearly significant. In the literature, the highest prevalence of day time sleepiness in apneics compared to simple snoring was shown [9].

A series of studies relate Systemic Arterial Hypertension with OSAS. Intermittent hypoxemia caused by sleep apnea has been pointed out as a key factor contributing to co-existent hypertension [18]. A dose-response relationship between OSA severity and the likelihood of prevalent hypertension has been identified [19], as well as an independent association between them [3]. Our study corroborates these observations.

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Table 4: Prevalence of comorbidities.

Group DM Hypothyroidism DLP Neuropathy Depression GS

1 2 (7.1%) 2 (7.1%) 4 (14.3%) 3 (10.7%) 4 (14.3%) 6 (21.4%)

2 4 (8.9%) 4 (8.9%) 8 (17.8%) 7 (15.6%) 7 (15.6%) 2 (4.4%)

3 11 (15.1%) 8 (11%) 16 (22%) 9 (12.3%) 10 (13.7%) 2 (2.7%)

4 17 (16.5%) 11 (10.7%) 22 (21.4%) 7 (6.8%) 8 (7.8%) 10 (9.7%)

Total 34 (13.6%) 25 (10%) 50 (20%) 26 (10.4%) 29 (11.6%) 20 (8%)

ValorP 0.115 0.56 0.387 0.208 0.162 0.343

DM: Diabetes Mellitus DLP: Dyslipidemia GS: Gastroesophageal Symptoms P< 0.05

Table 5: Values of neck circumference and BMI.

Groups 1 2 3 4 ValueP

BMI 27.2 28.5 29.7 30.7 0.0017

NC 38.4 38.5 39.6 40.4 0.009

BMI = Body Mass Index NC = Neck circumference (cm) P<0.05

Table 6: Average of Friedman and Mallampati values according to AHI.

Groups 1 2 3 4 Valor P

Friedman 2.53 2.77 2.72 2.83 0.0265

Mallampati 2.67 3.02 2.83 3.14 0.0079

Tonsils 1.42 1.17 1.31 1.26 0.611

P<0.05

The prevalence of OSA is closely related to overweight and obesity [20]. Obesity contributes to the pathogenesis of OSAS by altering upper airway anatomy and collapsibility, ventilatory control and increasing respiratory work load [21]. Regarding neck circumference, Pinto et al., concluded that anthropometric measure is the best anthropometric data indicative of OSAS severity. Bedialauneta et al., also found similar results concerning the cervical circumference and BMI [9]. In our results, neck circumference and BMI showed association with OSAS severity.

Allergic rhinitis directly affects sleep related breathing disorders as nasal congestion is associated to micro-awakenings and consequent excessive daytime sleepiness and suitable treatment of allergic symptoms improves sleep quality [22,23]. In this study, we found rhinitis to be more prevalent in patients who snored. A probable explanation for this finding would be that nasal obstruction alone is a common cause of snoring, however it is not directly responsible for OSAS severity [24] .

We observed a correlation between the modified Mallampati, the Friedman index and OSAS severity. This data is compatible with previous findings from Friedman [25,26] and Rodrigues [15]. Hulkins, on the other hand, found an association between these factors in a retrospective study, however pointed out that the modified Mallampati classification played a limited role as a predictor factor of the disease27.

Even being often associated to OSAS, our sample did not show evidence of an association of other comorbidities [10,11,28,29]. The limitations of this study included the modest sample of patients (n = 249) and the comorbidity diagnosis, which relied

solely on the response to our questionnaire. Additional studies are needed to clarify associations between pathologies.

CONCLUSIONSOSAS severity showed aassociation with BMI, neck

circumference, the Friedman index, the modified Mallampati classification and with the prevalence of arterial hypertension.

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Duarte LP, da Silveia PL, Mathias Duarte AS, Silva VG, Baptista Carvalho EG, et al. (2016) Association between Physical Examination and Comorbidities in OSAS Severity. Ann Otolaryngol Rhinol 3(10): 1136.

Cite this article

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