Obstructive Sleep Apnea: A Case Report

Obstructive sleep apnea (OSA) is characterized by repeated episodes of upper airway blockage and collapse during sleep accompanied by awakenings with or without oxygen desaturations. During obstructive sleep apnea events, the oropharynx in the back of the throat compresses, causing arousal, oxygen desaturation, or both, leading to fragmented sleep. The hyperplastic uvula is a common clinical finding in patients with obstructive sleep apnea. The various diagnostic and treatment modalities of obstructive sleep apnea are discussed in this article.


Introduction
Repeated episodes of upper airway obstruction and collapse during sleep, followed by awakenings with or without oxygen desaturations, are the hallmarks of obstructive sleep apnea (OSA). During obstructive sleep apnea (OSA) events, the oropharynx in the back of the throat compresses, causing arousal, oxygen desaturation, or both, leading to fragmented sleep [1]. The risk factors for obstructive sleep apnea include increased obesity, body mass index (BMI), increased hip-waist ratio, chronic smokers, obese people with a BMI over 35, people with congestive heart failure, atrial fibrillation, treatment-resistant hypertension, type 2 diabetes, stroke, nocturnal dysrhythmias, pulmonary hypertension, high-risk driving populations (like commercial truck drivers), and people undergoing bariatric surgery are all examples of high-risk patients [1,2].

Case Presentation
A 46-year-old male reported to our department with a chief complaint of the feeling of irritation in the throat for the past six months. On eliciting a history, the patient revealed that he has episodes of disturbed sleep and wakes suddenly from sleep due to choking and difficulty breathing while sleeping at night. A general examination revealed his vitals are stable and afebrile. Extraoral examination revealed no cervical lymphadenopathy. On intraoral examination, his uvula appeared long and increased in size (Figure1). The Mallampati score was an independent predictor of obstructive sleep apnea, which describes the visual evaluation of the space available for intubation procedure during general anesthesia based on the distance between the base of the tongue and the roof of the mouth. It is a deceptive method of determining how challenging intubation is. The Mallampatti score, in our case, was assessed as Class II (in which soft palate, fauces, and a major part of the uvula are visualized) [3].

FIGURE 1: Intraoral clinical photograph revealed a hyperplastic uvula
The tip of the uvula was visualized only when the patient was asked to pronounce the word "ah" during clinical examination with a mouth mirror [VIDEO 1].

FIGURE 2: MRI-Sagittal section revealed long uvula that constricts the airway spaces
Correlating the history of the feeling of irritation in the throat for the past six months and the history of disturbances during sleep due to choking and the presence of hyperplastic uvula, a provisional diagnosis of obstructive sleep apnea due to hyperplastic uvula was made. The differential diagnosis includes epidermoid cysts affecting the uvula and human papillomavirus-induced papillary hyperplasia of the uvula. The epidermoid cysts affecting the uvula are developmental and gradually increase in size during the growth period of the individual. Papillomas affecting the uvula usually have a tiny finger or cauliflower-like projections on the surface of growth with seropositivity for the human papillomavirus. Narcolepsy is a chronic sleep disorder characterized by extreme daytime sleepiness and unexpected sleep bouts. Regardless of the situation, people with narcolepsy frequently struggle to stay awake for extended periods. The patient denied surgical treatment.

Discussion Definition
Obstructive sleep apnea (OSA) is characterized by repeated episodes of upper airway obstruction and collapse during sleep, followed by microarousals with or without oxygen desaturations, which are the hallmarks of obstructive-sleep apnea (OSA) [1]. Snoring and/or increased respiratory effort as a result of increased upper airway resistance and pharyngeal collapsibility are symptoms of obstructed sleepdisordered breathing (SDB), which is not a distinct illness. Instead, it is a syndrome of abnormal upper airway function when you sleep. A sleep disorder called obstructive sleep apnea (OSA) also referred to as obstructive sleep apnea-hypopnea, causes the airflow to halt or drastically decrease even when breathing is being actively worked. Obstructive sleep apnea is characterized by a considerably diminished (hypopnea) or absent (apnea) airflow at the nose and/or mouth during sleep as a result of the upper airway's increased collapsibility. Oxygen hemoglobin desaturation is commonly followed by a transient micro-arousal, which are brief recurrent minor awakening or arousal lasting for 1.5 to 3 seconds [3].

Epidemiology
According to apnoea-hypopnea index (AHI) standards, the prevalence of obstructive sleep apnea (OSA) is 7.5% in urban India and around 3.73% in rural India. The term "apnea" refers to the recurrent episodes of complete cessation of airflow through the nostrils, and "hypopnea" refers to the diminished airflow through the nostrils that occur in patients with obstructive sleep apnea. In obstructive sleep apnea, the "apneahypopnea index" is the number of times apnea and hypopnea happen simultaneously regularly. Men were affected 50% and females 25% in the middle-age group. The prevalence of obstructive sleep apnea (OSA) increases to 36.34 million people when extrapolating these statistics to the 974.3 million rural residents of India [2,3]. The prevalence rate of obstructive sleep apnea was reported in other countries by meta-analytic studies [4] [ Table 1].

Author
Year

Classification of obstructive sleep apnea
During obstructive sleep apnea (OSA) events, the oropharynx in the back of the throat compresses, causing arousal, oxygen desaturation, or both, leading to fragmented sleep [3]. The American Academy of Sleep Medicine classifies the severity of obstructive sleep apnea as described below [2] ( Table 2).

Risk factors
The various structural and non-structural risk factors for obstructive sleep apnea are described in Table 3 [3].

Symptoms
Obstructive sleep apnea symptoms include loud snoring that occurs frequently, observable apneas, restless sleep, nocturia, and mouth breathing. The observed apneas during sleep are the distinguishing feature of obstructive sleep apnea [3]. Some daytime signs could be: Sleep that does not restore energy (such as "rising just as exhausted as when they went to bed"), headache, dry or sore throat in the morning, excessive drowsiness during the day (EDS), which typically starts during quiet activities, daytime drowsiness or tiredness, memory and intellectual disability; cognitive deficiencies, and sexual problems, including lowered libido and impotence. Unwanted snoring is annoying and can accurately predict 71% of sleep-disordered breathing (SDB). The specificity of disruptive snoring and documented apneas for sleep-disordered breathing (SDB) is 94% [3].

Diagnostic modalities for obstructive sleep apnea
The various diagnostic modalities for obstructive sleep apnea are discussed in Table 4. 2023

TABLE 4: Types of sleep studies and diagnostic modalities for obstructive sleep apnea
Screening questionnaires for obstructive sleep apnea Table 5 shows the various questionnaires used for assessing the severity of obstructive sleep apnea [3].

Screening questionnaires for obstructive sleep apnea
Epworth sleepiness scale (ESS): Epworth sleepiness scale (ESS) helps to assess obstructive sleep apnea subjectively. To assess a patient's subjective level of sleepiness, the Epworth Sleepiness Scale is frequently employed in sleep medicine. The test asks you to score your propensity to nod off in eight situations on a scale from 0 (no likelihood of nodding off) to 3 (high chance of nodding off). Then, a scale from 0 to 24 calculates your final score. The ranking determines whether you feel overly sleepy and may need medical intervention.

Medical management of obstructive sleep apnea
Dronabinol: A nonselective agonist of the cannabinoid type I and type II receptor, it has been shown to lower central apneas and the apnea-hypopnea (AHI) index. The recommended dosage for the treatment of obstructive sleep apnea is 2.5-10 mg/day [2].
Modafinil: Modafinil has been approved by the US Food and Drug Administration (FDA) for use in patients who still feel sleepy during the day despite using continuous positive airway pressure (CPAP) to the fullest extent possible. Patients who used modafinil at 200-400 mg/d daily doses reported the greatest improvements. Unknown is the modafinil's wakefulness-inducing mode of action. Its wake-promoting effects are comparable to those of sympathomimetic drugs [2].
Armodafinil: The R-enantiomer of modafinil, armodafinil, 250 mg per day, has just received US Food and Drug Administration (FDA) approval for its use in patients with obstructive sleep apnea [2].

Neurostimulation
Hypoglossal nerve stimulation. Beneficial in patients with BMI less than 50.

TABLE 6: Non-surgical and surgical treatment modalities for obstructive sleep apnea
Thiol-disulphide is an essential redox parameter and is assessed as a screening tool in obstructive sleep apnea to monitor affected patients, and such parameters are increased when compared to healthy unaffected individuals [14]. Obstructive sleep apnea was successfully controlled using DIORS OAm (an oral appliance with mandibular advancement), a novel technology that used the Camper plane as a reference for disocclusion [15]. Transoral epiglottopexy, also known as glossoepiglottopexy, is the least invasive surgical procedure available for treating patients with obstructive sleep apnea caused by epiglottis closure. It also has the lowest risk of complications and postoperative morbidity [16,17]. Bleeding (2.6%), candidiasis (0.3%), dryness (7.2%), dysgeusia (0.3%), dysosmia (0.2%), globus sensation (8.2%), surgical site infection (1.3%), velopharyngeal (VP) insufficiency (3.9%), and VeloPharyngeal stenosis (1.6%) are the percentages and associated complications of laser-assisted uvulopalatoplasty (LAUP) [18]. Local anesthesia may be used during laser-assisted uvulopalatoplasty (LAUP) and radiofrequency-assisted uvulopalatoplasty (RAUP) procedures. The CO2 laser is most frequently used in LAUP, while some authors also advocated the use of NdYAG and KTP lasers in the treatment of obstructive sleep apnea (Shiffman HS, Khorsandi J, Cauwels NM 2021). To shield the posterior pharyngeal wall from the laser beam, a backstop should be introduced. On either side of the uvula, triangular incisions are made to remove extra mucosa. The procedure is repeated several times to get the desired result. RAUP is carried out using a radiofrequency generator. Similar to this, triangular incisions are made into the soft palate on either side of the uvula. When necessary, the redundant posterior arch, soft palate, and uvula mucosa are removed; this process is repeated until the desired result is obtained [19]. NightLase® LAUP is a minimally invasive outpatient laser-assisted uvulopalatoplasty surgery that is a safe and effective treatment option for obstructive sleep apnea [20].

Novelty
The case describes a unique cause of hyperplastic uvula that caused obstructive sleep apnea. The case report enlightens us about the importance of early diagnosis and screening of patients with obstructive sleep 2023  apnea, its diagnostic, and non-surgical and surgical treatment modalities.

Limitations
Post-treatment photographs and follow-up are not done, as the patient refused treatment.

Conclusions
Obstructive sleep apnea is still a commonly neglected, ubiquitous medical health problem. Obstructive sleep apnea though common, typically goes undiagnosed. Loud snoring, nocturnal awakenings, and daytime tiredness are symptoms of obstructive sleep apnea. An increase in the awareness of the consequences of obstructive sleep apnea among the public is essential. The barriers to diagnosis and treatment have significantly decreased in recent years thanks to strategic treatment planning with a multidisciplinary approach by the clinicians, which made it easier for primary care doctors to manage obstructive sleep apnea (OSA) early. More research studies are needed in this field of sleep medicine to manage obstructive sleep apnea in the near future.

Additional Information Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.