The correlation of upper airway abnormalities with obstructive sleep apnea syndrome in young adult

Obstructive Sleep Apnea Syndrome (OSAS) is a form of sleep disorder characterised by blockages in the upper respiratory tract for 10 seconds or more during sleep.1-3 As the most common sleep disorder, 10% of adults in the worldwide are estimated to suffer from OSAS.4,5 The prevalence of OSAS in the general population, around 11.4% for men and 4.7% for women and is expected to increase every year.6 OSAS screening can be done using the Berlin questionnaire and the Epworth Sleepness Scale (ESS) questionnaire.7 But, the gold standard for diagnosis of OSAS can definitely use polysomnography (PSG).8 PSG is a device that can show brain electrical activity, respiration, oxygen saturation during sleep and the severity of OSAS measured by Apnea-Hypopnea Index (apnea-hypopnea index, AHI).9–11 Apart from all clinical and scientific advances regarding OSAS, most (70-90%) people affected by OSAS remain undiagnosed.6 Lack of patient awareness, medical personnel have not received the training needed to help speed up case finding, and the high price of PSG examinations as gold OSAS standards are the cause of many undiagnosed OSAS patients. Therefore, knowledge of risk factors for OSAS is important to direct diagnostic attention to those with the highest risk.4,8 Risk factors for OSAS include obesity, middle age, menopause in women, large neck circumference, craniofacial structural abnormalities, and upper airway structural abnormalities.10 In children, the main cause of OSAS is tonsillar and adenoid hypertrophy, which can increase airway resistance.12 Whereas in adults, OSAS is often associated with obesity. Obesity can change the volume and anatomical shape of the airways thereby reducing upper airway volume.13 Various studies have shown that there is a relationship between upper airway structure abnormalities and OSAS in children and the elderly. One of Factors that play a role in the pathogenesis of OSAS is craniofacial abnormalities ranging from the nose to the hypopharynx which can cause narrowing in the upper airway. This regional abnormality can produce high resistance. This resistance also predisposes to the collapse of the upper airway. Pharyngeal collapse is found in 81% of 64 OSA patients and 75% of them have more than one upper airway constriction.14 ABSTRACT


INTRODUCTION
Obstructive Sleep Apnea Syndrome (OSAS) is a form of sleep disorder characterised by blockages in the upper respiratory tract for 10 seconds or more during sleep. 1-3 As the most common sleep disorder, 10% of adults in the worldwide are estimated to suffer from OSAS. 4, 5 The prevalence of OSAS in the general population, around 11.4% for men and 4.7% for women and is expected to increase every year. 6 OSAS screening can be done using the Berlin questionnaire and the Epworth Sleepness Scale (ESS) questionnaire. 7 But, the gold standard for diagnosis of OSAS can definitely use polysomnography (PSG). 8 PSG is a device that can show brain electrical activity, respiration, oxygen saturation during sleep and the severity of OSAS measured by Apnea-Hypopnea Index (apnea-hypopnea index, AHI). [9][10][11] Apart from all clinical and scientific advances regarding OSAS, most (70-90%) people affected by OSAS remain undiagnosed. 6 Lack of patient awareness, medical personnel have not received the training needed to help speed up case finding, and the high price of PSG examinations as gold OSAS standards are the cause of many undiagnosed OSAS patients. Therefore, knowledge of risk factors for OSAS is important to direct diagnostic attention to those with the highest risk. 4, 8 Risk factors for OSAS include obesity, middle age, menopause in women, large neck circumference, craniofacial structural abnormalities, and upper airway structural abnormalities. 10 In children, the main cause of OSAS is tonsillar and adenoid hypertrophy, which can increase airway resistance. 12 Whereas in adults, OSAS is often associated with obesity. Obesity can change the volume and anatomical shape of the airways thereby reducing upper airway volume. 13 Various studies have shown that there is a relationship between upper airway structure abnormalities and OSAS in children and the elderly. One of Factors that play a role in the pathogenesis of OSAS is craniofacial abnormalities ranging from the nose to the hypopharynx which can cause narrowing in the upper airway. This regional abnormality can produce high resistance. This resistance also predisposes to the collapse of the upper airway. Pharyngeal collapse is found in 81% of 64 OSA patients and 75% of them have more than one upper airway constriction. 14 Based on the facts above, it can be seen the relationship between upper airway structure abnormalities and OSAS. In previous studies, we have not discussed the relationship of upper airway abnormalities to OSAS in young adults. The researcher was interested in seeing the relationship between upper airway abnormalities and OSAS in young adults, especially students of the Faculty of Medicine, Diponegoro University.

METHOD
The design of this study is a case control. The sample amounted to 44 people aged 18-23 years who were asked to be used as samples with written approval. The sample consisted of 22 cases based on the results of the PSG examination was proven to be OSAS and control with the results of PSG examination showed not to have OSAS. The subjects were taken by consecutive sampling method. The tools and materials used were PSG for the OSAS gold standard headlamp, nose speculum for physical examination of the nose, tongue spatel for physical examination of the oral cavity, microtoise for measuring height bodies, digital scales to measure body weight, informed consent sheet and ISAAC questionnaire, ESS questionnaire. This study used descriptive analysis to study the demographic characteristics of each variable, then continued the bivariate Chi-square analysis to determine the relationship between the independent variables and the variables studied, and multivariate analysis to determine the most preferred independent variables with OSAS. Ethical clearance was obtained from the Ethical Committee of the Faculty of Medicine, Universitas Diponegoro with reference number: No.217/EC/FK_RSDK/IV/2018.

Characteristics of Sample
The table above shows that from the polysomnographic examination OSAS respondents and NonOSAS respondents were the same numbers. Based on a physical examination of the nose performed on 44 respondents, the majority of respondents did not have a septal deviation or normal (61.4%) and had turbinate hypertrophy (63.6%). Based on examination of the oral cavity, the majority of respondents did not have tonsillar hypertrophy or normal (54.5%) and had a mild mallampati score (56.8%). Based on BMI examination, the majority of respondents were obese (54.5%) and had a majority of the neck circumference not large (52.3%). The majority of respondents also had obese abdominal circumference (52.3%). The majority of respondents were male (52.3) and did not suffer from allergic rhinitis (79.5%) ( Table 1).

Bivariate Analysis
From the table above it can be obtained the nasal septal deviation (p = 0.005 OR = 6.5), tonsillar hypertrophy (p = 0.015; OR= 4,667) and mallampati score (p<0.001; OR=16,889) associated with the occurrence of OSAS. The confounding variables included BMI (p<0.001; OR=133), neck circumference (p<0.001; OR=28.5), abdominal circumference (p<0.001; OR=63.3), and gender (p= 0.035; OR=3.75) significantly associated with the incidence of OSAS. Nasal turbinate and allergic rhinitis are not significantly associated with OSAS. It was proven by the value of p = 0.21 for nasal turbinate and p = 0.457 for allergic rhinitis ( Table 2).

Homogeneity Test of Nasal Turbinate Hypertrophy
Homogeneity test it can be seen the value of p = 0.034. Because the significance is more than 0.05, it can be concluded that the relationship of turbinate hypertrophy based on the incidence of OSAS has a different variance. Levene Statistic shows that the smaller the value, the greater the homogeneity (

DISCUSSION
OSAS prevalence increased with increasing tonsil size. The results of the bivariate analysis in this study, there was a significant relationship between tonsillar hypertrophy and the incidence of OSAS in young adults with a p-value of 0.015. This is consistent with the study of Li et al. Concerning the relationship of tonsillar hypertrophy with the degree of OSAS severity in children. From a study of 35 children with an average age of 6.2 years, a p value <0.0001 was identified which indicates that tonsillar hypertrophy is associated with the degree of OSAS severity in children. 15 From a study conducted by Dayyat et al. regarding the relationship between adenotonsillitis size and index number of apnea-hypopnea in non-obese OSAS patients, a p value <0.0001 indicates that adenotonsillar size is associated with the incidence of OSAS in non-obese patients. 16 The results of the bivariate analysis in this study found a significant relationship between the mallampati score and OSAS in young adults (p = 0,0001). Guerreiro et al. reported in his study that there was a significant relationship between the mallampati score and OSAS (p=0.003). The mallampati score was also found to be significantly correlated with the apnea-hypoapnea index in OSAS, as reported by Yuksel (p=0.001) and korakoc et all (p<0.001) in their study. 17, 18 The results of multivariate analysis in this study identified mallampati scores as factors associated    19 Tonsillar hypertrophy and severe mallapati scores are a craniofacial disorder that can reduce the size of the oropharynx and can cause narrowing of the upper airway. This regional abnormality can produce high resistance. Reduction of the size of the oropharynx causes the ability to stretch the upper airway decreases so that it tends to collapse if there is negative pressure and can increase the occurrence of OSAS. Pharyngeal collapse is found in 81% of 64 OSAS patients and 75% of them have more than one upper airway constriction. 14 Based on the results of the analysis of this study, there is a significant relationship between nasal septal deviation between the incidence of OSAS with a value of p = 0.005. This is in accordance with Kara et al. study which states that the variable anatomy of the nose (hypertension of rice concha, septal deviation of rice, internal valve and nasal externa) is associated with sleep disorders including OSAS. 20 In normal individuals, the nose is a component of the airway with the greatest resistance. The presence of resistance in the upper airway plays a role in the occurrence of OSAS. The nose is not a common site of collapse in OSAS, although the resistance is large. This is because nasal patency is maintained by the structure of collagen around the nose and only minimally affected by muscle activity. 21, 22 The lateral wall of the pharynx is mainly composed of muscle tissue. Muscles around the pharynx can significantly affect their shape and size. Increased resistance to the nose increases negative pressure on the pharynx. So that the resistance of airflow to the channel above the pharynx causes pharyngeal collapse. 21, 22 Based on the results of the analysis of this study, there was no significant relationship between Turbinate hypertrophy and the incidence of OSAS in young adults with a p-value of 0.210. Turbinate hypertrophy not related to OSAS in this study could be due to the distribution of non-homogeneous research samples (p=0.034). Vidigal et al. reported in his study that there was a significant relationship between inferior turbinate hypertrophy and OSAS incidence (p=0.01). Whereas Leitzen et al. Stated that there was a significant relationship between Turbinate hypertrophy with nasal obstruction, but Turbinate hypertrophy was not associated with OSAS. 23, 24 The difference in the results of the research obtained can be because the risk factors for OSAS in patients cannot stand alone. OSAS is classified as a multifactorial disease which can be caused by various factors that can be influenced by sex, neck circumference and large abdominal circumference, obesity and upper airway disorders. According to the literature, the majority of OSAS sufferers who have obesity are also associated with Turbinate hypertrophy and high septal deviation. Abnormalities in the upper airway that collapse if the pharyngeal pressure is negative as long as inspiration exceeds the strength of the dilator muscle and abductor of the upper airway. Turbinate hypertrophy is one of the trigger factors for resistance in the airways so that the airways collapse and there is a disruption of breath flow. However, in the nasal cavity there are many other anatomical buildings that can affect the breathing process. [25][26][27] This study analysed confounding variables namely obesity, gender, and a history of allergic rhinitis. Obesity variables assessed including criteria for body mass index, abdominal circumference and neck circumference gave a significant correlation with the incidence of OSAS, with each p-value being p<0.001 on body mass index, p<0.001 on neck circumference, p<0.001 on the abdominal circumference. The sex indicator has a significant relationship with the incidence of OSAS in young adults with p=0.035. The incidence of allergic rhinitis did not have a significant relationship (p=0.457) with the incidence of OSAS. The results of the bivariate analysis of the criteria for BMI, abdominal circumference, neck circumference and gender were then entered into a multivariate analysis and the results showed that gender, abdominal circumference and neck circumference were not independent risk factors for OSAS. However, the results of the bivariate body mass index analysis included in the multivariate analysis revealed that body mass index was an independent risk factor for the occurrence of OSAS. This can be because the research sample in this study was mostly obese.

CONCLUSION
The conclusion of this study is that tonsillar hypertrophy is a risk factor for OSAS in young adults. 4.6 times greater than young adults who are not tonsillar hypertrophy. Rice septal deviation is a risk factor for OSAS in young adults. 6.5 times greater than young adults who do not have septal deviation. Hypertrophy of rice concha is not a risk factor for OSAS in young adults. The mallampati score is a risk factor for OSAS in young adults, 16.8 times greater than young adults with low pigeon night scores.
Suggestions for this study are, this study should be used as a basis for further research on complications that can be caused by OSAS. Future studies should use the gold standard for the diagnosis of allergic rhinitis, Skin Prick Test and further research on the relationship of channel abnormalities. upper breath with OSAS but in the sample not obese.

FUNDING
Current study doesn't receive any specific grant from government or any private sectors.