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4 Diagnosis: How Is Diagnosis Performed
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Treatment
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“Whatever It Takes”
ClaudioVicini, AngeloCannavicci, EleonoraCioccioloni,
GiuseppeMeccariello, GiovanniCammaroto,
RiccardoGobbi, AntonioSanna,
DomenicoMaurizioToraldo, GiulioAlessandriBonetti,
FrancescoMariaPassali, AriannaAlagna,
MicheleDe Benedetto, MicheleArigliani, LuanaConte,
FabrizioSalamanca, GiannicolaIannella,
andAhmedYassinBaghat
C. Vicini (*)
Head-Neck and Oral Surgery Unit, Department of Head-Neck Surgery, Otolaryngology,
Morgagni Pierantoni Hospital, Azienda USL della Romagna, Forlì (FC), Italy
e-mail: claudio@claudiovicini.com
A. Cannavicci · E. Cioccioloni · G. Meccariello · G. Cammaroto · R. Gobbi
Azienda ASL Romagna, ENT Unit, Morgagni-Pierantoni Hospital, Forlì (FC), Italy
e-mail: angelo.cannavicci@auslromagna.it; eleonora.cioccoloni@auslromagna.it; giuseppe.
meccariello2@auslromagna.it; giovanni.cammaroto@auslromagna.it; riccardo.gobbi@
auslromagna.it
A. Sanna
Pneumology and Bronchial Endoscopy Unit, Azienda USL Toscana Centro, San Giuseppe
Hospital, Empoli (FI), Italy
D. M. Toraldo
Cardiorespiratory Rehabilitation Unit, Department of Rehabilitation, “V.Fazzi” Hospital,
Lecce, Italy
G. A. Bonetti
DDS Department of Orthodontics, School of Dentistry, University of Bologna, Bologna, Italy
e-mail: giulio.alessandri@unibo.it
F. M. Passali · A. Alagna
Department of Clinical Sciences and Translational Medicine, University of Rome Tor
Vergata, Rome, Italy
e-mail: passali@med.uniroma2.it; alagna@med.uniroma2.it
M. De Benedetto · M. Arigliani
ENT Unit, Vito Fazzi” Hospital, ASL (Local Health Authority), Lecce, Italy
5
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
P. M. Baptista et al. (eds.), Obstructive Sleep Apnea,
https://doi.org/10.1007/978-3-031-35225-6_5
85
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L. Conte
Laboratory of Biomedical Physics and Environment, Department of Mathematics and
Physics, University of Salento, Lecce, Italy
e-mail: luana.conte@unisalento.it
F. Salamanca
OSA-Center, Humanitas University, San Pio X, Milan, Italy
G. Iannella
Department of ‘Organi Di Senso’, University “Sapienza”, Rome, Italy
e-mail: giannicola.iannela@uniroma1.it
A. Y. Baghat
Department of Otorhinolaryngology, Alexandria University, Alexandria, Egypt
C. Vicini et al.
5.1 Introduction: OSA asaChronic andDifficult
toTreat Disease
Obstructive sleep apnea (OSA) treatment is one of the most difcult challenges of
the modern medicine for many and not related reasons.
1. First of all, OSA is by its nature a worsening disease with a natural trend to
became more severe along the time. Basically, to treat OSA is like to swim
against the current. Any possible treatment must face this natural trend of OSA
to become more severe along the time, even if treated.
2. The detailed pathophysiology of OSA seems to be very complex and different in
different subjects and probably not yet really well understood into detail. In the
last decade, a set of most prominent pathophysiological components were
described and introduced into the practice mainly for treatment selection.
3. From the surgeon perspective, the number of possible treatments (conservatives
and surgical ones) is relatively high, and the selection rules for each of them are
not completely clear-cut. There is a real risk that any different specialist overestimates the role of his own option among the many available.
4. From the patients’ perspective, very frequently, the real impact of the disease
into the patient’s health is not completely understood, and this underestimation
may produce a low level of motivation and more difcult treatment acceptation.
5. Moreover, a personal preference or not acceptance may compel the surgeon to
shift to a treatment option different: from the most effective one to the best
accepted by the patient. It implies that even along the time a therapy must be
discontinued because it not anymore accepted by the patient, seeking for a different modality.
6. The different levels of efcacy of many treatments, frequently inferior to 100%,
may require in a signicant number of cases a combination of more than one
single treatment, that’s the complex problem of multimodal therapy.
7. Last but not least, all the conservative treatments (e.g., ventilation, MAD, etc.)
must face the problem of long-term treatment adherence, and on the other hand,
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treatments like surgery may pay the toll of a real efcacy only in a short or
middle time span.
For all the above-mentioned reasons, OSA treatment for the single patients may
be difcult to properly select, requires a high level of cooperation by the patient and
an open and honest discussion among different specialists, and must be checked for
persistent efcacy along the time. Many of these concepts are summarized in the
so-called P4 medicine. “The four Ps offer a means to: Predict who will develop
disease and co-morbidities and prevent rather than react to disease (see below);
Personalize diagnosis and treatment; have patients Participate in their own care. P4
medicine is very applicable to obstructive sleep apnoea (OSA) because each OSA
patient has a different pathway to disease and its consequences.”
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5.2 Treatment Goals
The common goals of all the proposed treatment for OSA may be summarized as:
(a) Relief of diurnal and nocturnal symptoms
(b) Prevention of possible complications
(c) Improvement of Quality of Life (QOL)
5.3 Primary, Secondary andTertiary Prevention inOSA
• Obesity and increasing median age of patients play signicant roles in the sig-
nicant prevalence of OSA.The rise in body mass index (BMI) and medical
comorbidities are shown to be directly associated with both the prevalence and
the severity of OSA.A healthier lifestyle with regular exercise associated with
weight loss has been shown to improve OSA in selected patients. Since the
1980s, it is known that alcohol ingestion increases the incidence of arterial oxy-
gen desaturation and disordered breathing during sleep, and its consumption
should be avoided. Other lifestyle interventions like sleep hygiene and tobacco
cessation are recommended in OSA’s prevention, although their real effective-
ness has not been proved yet. As sleep quality is related to daily functioning and
mood, which have an impact on overall quality of life, lifestyle interventions
may entail not only reductions of cognitive impairments and depressive symp-
toms but also an increase of the patients’ overall well-being.
• Secondary prevention emphasizes early disease detection, and its target is
healthy-appearing individuals with subclinical forms of the disease. The sub-
clinical disease consists of pathologic changes, but no overt symptoms that are
detectable by physician’s evaluation. Secondary prevention often occurs in the
form of screenings, which aim to offer an early treatment or intervention and
thereby reduce the incidence and mortality of the health problem within the pop-
ulation. Thus, it is crucial to identify as accurately as possible specic
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C. Vicini et al.
demographic- clinical patterns in order to select high-risk populations who should
undergo screening for OSA.It needs to be noted that a screening program would
focus in particular on asymptomatic patients, because this group has a particularly
high risk in developing neurological, pulmonary and cardiovascular complica-
tions, given the low motivation of this type of patients. However, evidence is still
not sufcient to determine whether treatment of screen-detected asymptomatic
OSA improves outcomes, in particular mortality or cardiovascular events.
Several different morbidity biomarkers have been proposed for OSA.Data in
literature show impaired levels of inammatory markers related to oxidative
stress in the exhaled breath of OSA patients in the form of an increase in proin-
ammatory cytokines and a decrease in anti-inammatory cytokines. A perturba-
tion of lipid metabolism, with an elevation of both fasting and postprandial lipid
levels in blood or urines, is also described.
• Tertiary prevention is enforced in symptomatic patients and aims to reduce the
severity of the disease as well as of any associated sequelae. While secondary
prevention seeks to prevent the onset of illness, tertiary prevention focuses on
reducing the effects of the disease once established in an individual. It is estab-
lished that severe OSA is associated independently with higher incidence of
stroke and with the presence of hypertension (OR=1.60), diabetes (OR=2.00),
metabolic syndrome (OR=2.80) and depression (OR=1.92). From this per-
spective, the patient, in addition to the specic OSA treatment, should always be
referred to cardiological, neurological, endocrinological evaluations and
follow-up.
Endotypes and Phenotypes-Guided Treatment is the modern way to describe,
classify and select in a unitary way the different interventions for addressing
OSA.In Table1, treatments are listed according to the target endotype.
1. Anatomic: Upper Airways (UARWs) increased collapsibility
• CPAP
• Surgery
• Mandibular advancement devices
• Weight loss
2. Functional: Reduced muscle responsiveness
• Myofunctional therapy
• Hypoglossus nerve stimulation
3. Functional: Increased loop gain
• O
2
• CO
2
• Drugs (e.g., Acetazolamide)
4. Functional: Low respiratory arousal threshold
• Drugs (e.g., Trazodone, etc.)
In all OSA patients, some degree of collapse is observed and treated with one or
more than one so-called anatomical interventions (CPAP, surgery, MAD and weight
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loss). In about one-third of all the OSA patients, an additional functional endotype
may be demonstrated, possibly requiring an additional modality of treatment.
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5.4 Continuous Positive Airway Pressure Therapy
The application of a continuous positive pressure in the airways (CPAP), through a
nasal or oronasal mask, or nasal pillow, is the rst therapeutic option that is found
to prevent narrowing of the pharynx, the cause of snoring and apneas and hypopneas. The CPAP normalizes the respiratory activity during sleep and restores a correct sleep architecture. The CPAP titration consists in nding the therapeutic value
of the PAP, i.e., the minimal positive pressure that prevents the occurrence of apneas
and hypopneas. There are two main ways of titrating CPAP, manually in sleep laboratory and with autoadjusting PAP (APAP) at home. The second one, less time consuming and expensive, is currently the most widely used in daily clinical practice.
A meta-analysis showed that in adults with OSA, positive airway pressure (PAP)
compared to no treatment results in a clinically signicant reduction in disease
severity, sleepiness, blood pressure and motor vehicle accidents, and improvement
in sleep-related quality of life. In addition, the initiation of PAP in the home demonstrated equivalent effects on patient outcomes when compared to an in-laboratory
titration approach. It has been also demonstrated that the use of APAP or the noninvasive ventilation with a double level of pressure support (bilevel PAP) did not
result in clinically signicant differences in patient outcomes compared with standard continuous PAP.The APAP has a role in nding the therapeutic value of the
PAP rather than in OSA therapy. When apnea and hypopnea events are associated
with other and/or predominant respiratory disorders like hypoventilation or Cheyne–
Stokes breathing, the treatment of choice is bilevel-PAP.It has shown a clinically
signicant improvement in PAP adherence with the use of educational, behavioral,
troubleshooting and telemonitoring interventions. Systematic reviews for specic
PAP delivery method showed that nasal mask compared to oronasal mask has
improved adherence and slightly greater reductions in OSA severity; heated humidication compared to no humidication reduces some continuous PAP-related side
effects; and pressure prole PAP did not result in clinically signicant differences
in patient outcomes compared with standard continuous PAP.CPAP is safe, effective and well-tolerated treatment in adults and even in children with severe OSA,
especially in those with craniofacial abnormalities, neurological disorders or obese.
Adherence to the treatment is considered valid if carried out for at least 4h per night
for at least 70% of the nights. It has no absolute contraindications. Relative contraindications are the presence of bubbles in the lung and infectious pathology of the
upper airways and ear. The most common adverse effects of CPAP are the onset of
rhinitis symptoms, dryness of the nasal and oropharyngeal mucous membranes,
conjunctivitis, injuries and ulcers of the nasal bridge, feeling of suffocation and
claustrophobia. Any functional (nasal valve collapse or oppy epiglottis) or anatomic (nasal septum deviation, tonsillar-adenoid hypertrophy, sinonasal polyposis)
cause of signicant upper airway occlusion can result in CPAP fails. All patients
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that fail CPAP therapy would benet from upper airway evaluation by the otolaryngologist to consider site-specic surgical therapies. In pandemic era, CPAP treatment should not be interrupted. Indeed, adopting mandatory government guidelines
and local healthcare facilities to minimize the spread of viral infection ensured
workplace safety and safety measures for patients and for health workers.
Among the various therapeutic options available today, the CPAP is the one for
which there is evidence of a positive effect on cardiovascular and cerebrovascular
morbidity, decrease in motor vehicle accidents and reduced mortality. Although it
was proposed 40 years ago, the CPAP still represents the only effective therapy
regardless of OSAS severity, as well as the treatment with the greatest evidence in
terms of long-term benets.
C. Vicini et al.
5.5 Oral Appliances (MAD)
A valuable conservative therapy for OSA, alternative to CPAP, is represented by the
mandible protrusion by means of an oral appliance (OA). This device covers both
the upper and lower dental arches and is congured so that the lower jaw is held
forward in a more protruded position, thus allowing to widen the size of the pharynx, stretch tongue muscles counteracting tongue’s collapse during sleep, stabilize
the hyoid bone and the soft palate, and prevent the posterior rotation of the jaw. OA
is indicated for patients with mild to moderate OSA or primary snoring and is also
an accepted therapy for patients with severe OSA who are unresponsive or unable/
unwilling to tolerate CPAP.An adequate number of healthy teeth (at least 6–10 teeth
in each dental arch) should be present to anchor the OAs, and patients should be
able to protrude the mandible forward and open the jaw without signicant limitations in order to be suitable for OA treatment. The American Academy of Sleep
Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM)
guidelines suggest the use of custom-made OAs (i.e., fabricated with patientspecic design features obtained from impressions) and titratable (i.e., a mechanism
allows the mandible to be moved gradually in a forward position). Currently, there
is no well-dened protocol that indicates the mandibular protrusion in which to
build the device since there is no dose-dependent effect of mandibular advancement
on treatment success. It is advisable to provide an individualized therapy for each
single patient, start with a slight mandibular advancement and gradually increase
the mandibular protrusion through the use of titratable OAs until the highest reduction in AHI is achieved. It is necessary to identify the minimum amount of mandibular advancement required for an individual patient while getting the highest
reduction in AHI in order to optimize treatment efciency while reducing the risk of
side effects and, also, improving treatment adherence. Early recognition and adequate control of possible unwanted effects are crucial for the success of therapy with
OA, as the effectiveness of therapy depends not only on the efciency of the device
in reducing AHI, but also on patient compliance. Uncontrolled side effects could in
fact lead to a reduction in compliance up to the interruption of therapy with serious
effects on the patient’s health. Equally crucial for adherence to therapy is therefore
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to inform the patient with specic informed consent about the possible onset of
undesirable effects before undertaking therapy with OA, also underlining how such
undesirable effects should not be considered as a factor limiting therapy in the light
of the more serious risk to health of not treating a patient affected by OSA.
Most side effects of treatment with OAs are temporary and gradually disappear
during the rst few months of treatment. These minor side effects include mucosal
dryness, tooth discomfort and hypersalivation. In the long term, the main side
effects are represented by dento-skeletal changes and temporomandibular disorders
(TMD), often of muscular origin. The dental effects are related to the muscle reaction to OA insertion. The protrusion of the mandible induced by OAs generates
reciprocal forces on the soft tissues and the muscles that attempt to move the mandible backward to restore its normal position. These forces are transmitted to the
teeth and to the bone to which the OA is anchored and thus can produce dentoskeletal changes. A signicant correlation between the duration of the therapy and
the change of these parameters is well documented in the literature. In conclusion,
it is important to spread the idea that a transdisciplinary approach to OSA is essential for the diagnosis, the decision-making process and the monitoring of treatment
response. As dentists, we must be aware that not all the problems related to OSA can
be solved only by means of mandibular protrusion. Clinicians should be kept wellinformed on the most up-to-date scientic evidence in order to provide an evidencebased clinical decision-making process for the treatment of OSA, from which a
greater amount of patients would reliably benet.
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5.6 Drugs
However, the one-size-ts-all approach is not the best one in such complex and
multifactorial pathology. For this reason, four phenotypes have been recognized,
combined with an ideal target medical therapy as described below.
Impaired upper airway anatomy: Obesity is the major cause of narrow pharyngeal airway. Weight loss drugs in OSA have been tested with good results. The
incretin mimic, liraglutide—a glucagon-like peptide-1 receptor agonist—reduced
body weight by approximately 6%, BMI by approximately 10% and apnea/hypopnea index (AHI). Even uid redistribution can accumulate to the neck. Diuretics or
sodium-restricted diets which reduce uid retention have been investigated as a
potential treatment option to prevent nocturnal rostral uid shift in OSA.
Low respiratory arousal threshold: Hypnotics are the target therapy for this phenotype, with the aim of inducing sleep. In the past, hypnotic use was not recommended due to perceived risk of reduced pharyngeal muscle activity combined with
delayed arousal responses, which may cause prolonged respiratory events and
worse hypoxemia. Nevertheless, new trials detected a different outcome with benzodiazepine receptor agonist zopiclone and the tetracyclic antidepressant trazodone.
In any case, new studies are required to better understand the safety prole.
High loop gain: Drugs with carbonic anhydrase inhibitor properties such as
zonisamide and acetazolamide have been shown to reduce OSA severity, potentially
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C. Vicini et al.
via reductions in loop gain. Furthermore, these molecules have weak diuretic properties. Oxygen therapy has been used to reduce loop gain and, in an earlier study, to
reduce the AHI by approximately 50% in people with a high loop gain phenotype.
Upper airway muscle responsiveness: Cannabinoids have been proposed to
improve respiratory stability through attenuation of vagal feedback to the medulla
to help stabilize breathing and activate pharyngeal muscles via serotonergic
processes.
5.7 Nasal Surgery
Nasal surgery for sleep breathing disorders includes all corrective operations on the
nose, united by an identical respiratory purpose, performed anatomically in the axis
between the external valve and the choana (Fig.5.1). The common purpose of all
the nasal procedures on the stenotic nose is to reduce the resistance values to the
passage of air and therefore to increase the nasal respiratory ow. In reality, not all
the mechanisms that link nasal pathology and Disturbed Respiration during Sleep
(DRS) are claried with absolute certainty, and these uncertainties also reverberate
on the therapeutic side. The nasal procedures reviewed and used can be summarized
as follows:
1. Valvuloplasty
2. Septoplasty
3. Rhinoseptoplasty
4. Lower and middle turbinoplasty
5. Polypectomies and ethmoidectomies
6. Ablation of obstructing masses
7. Combinations
ab
Fig. 5.1 (a) Intraoperative view of nasal surgery, (b) nostrils’ view with nasal splints at the end of
the surgery
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