**2.2 Physical examination findings in OSA**

There is not any specific physical examination finding diagnostic for OSA. By approaching from a wider perspective, evaluation should be made for several disciplines (**Figure 1**). OSA is related to multiple anatomic risk factors. The most important one is central-type obesity with increased body mass index and increased neck circumference. On the other hand, many patients with OSA are not obese, yet they can demonstrate decreased oropharyngeal air space, retrognathia or

#### **Figure 1.**

*The physician speaks with husband and wife. And he learns by the medical history of the patient, a list of previously used medications, family history, and detailed information about school, work, family, and social life. And he makes a physical exam of bodily systems.*

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