*2.2.5 Examination of the tonsils*

*Updates in Sleep Neurology and Obstructive Sleep Apnea*

mucopolysaccharidosis and amyloidosis (deposition) [12–16].

*2.2.1 Craniofacial factors*

the absence of obesity [17, 18].

tious, or neoplastic in nature [19].

*2.2.2 Nasal factors*

*2.2.3 Neck circumference*

*2.2.4 Pharynx examination*

Mallampati classification is as follows:

Class 4: Soft palate is not visible.

Class 2: Soft palate, fauces, and uvula are visible.

for OSA [18].

micrognathia. Obesity mechanically obstructs pharyngeal soft tissues and results in pharyngeal compression. Also decreased lung volume through CNS-acting signaling proteins (adipokines) may alter airway neuromuscular control [10, 11]. Individuals with OSA have severe obesity due to sleep deprivation, hypersomnia, and altered metabolism. OSA is associated with endocrinopathies like hypothyroidism and acromegaly. Hypothyroidism is a known cause for secondary OSA. Myopathy of oropharyngeal airways, edema, and obesity lead to upper airway obstruction and collapse in these patients. Acromegaly is caused by excessive levels of growth hormones; there is enlargement of craniofacial bones, enlargement of the tongue (macroglossia), and thickening and widening of the laryngeal region. All these factors can contribute to the obstruction of the upper respiratory airways. In addition to acromegaly and hypothyroidism, goiter which is associated with a euthyroid state can as well contribute to OSA. Among factors contributing to the narrowing of upper airways, we can list Down syndrome and storage diseases like

Cephalometric measurements demonstrate that when compared with controls, individuals with OSA have important changes in the size and position of soft palate and uvula, in the volume and position of the tongue, the position of the hyoid bone, and mandibulomaxillary protrusion. Mandibular retrognathia and micrognathia cause the tongue to stay at a higher position; these can be diagnosed during the examination by observing the patient from the side view. Racial differences in cephalometric features possibly play a role in the development of risks for OSA in

Examination of nasal airways should focus on the anatomical abnormalities that might contribute to nasal obstruction. These can be of congenital, traumatic, infec-

Increased neck circumference is an important risk factor for OSA. Patients with a neck circumference of more than 48 cm (19.2 inches) have a 20 fold increased risk

There are two well-defined classifications to identify the relationship of the tongue with the pharynx. The Mallampati classification is a method first used by anesthesiology specialists to foresee difficult tracheal intubations. Friedman classification describes prognostic indicators for a successful surgery for sleep disorders by combining the position of the palate with the size of the tonsils [20, 21]. The

Class 1: Soft palate, fauces, uvula, and posterior and anterior pillars are visible.

Class 3: Soft palate, fauces, and only the base of uvula are visible.

**132**

Enlarged tonsils and adenoids are the primary causes of upper airway obstruction and sleep apnea in children, only a small portion of the adults can have an enlargement of these structures leading to obstruction of the airways. Adenoids cannot be visualized during a routine physical examination or the examination of tonsils, and a tongue depressor might be necessary. The size of the tonsils can be measured on a scale of 1–4 [22].
