by Carrissa Hankins, MSN, APRN, FNP-C, Hello Sleep Health & The Sleep NP LLC
I recently found myself dining alone...
I was at Cracker Barrell - on my way home from speaking at a conference about sleep apnea.
One of the things that came up is how you can literally see the risk factors of sleep apnea before they say anything about how much they snore (or don't) and how bad they sleep (or don't).
It was on the heels of this conversation that I looked up from my plate to see this picture supervising my supper.
My question for you is...
Do you see what I see?
If you're not skilled at looking for signs of sleep apnea, you'd miss it.
You'd think this was just a picture of a random guy who has long since expired. But there's a lesson I want you to take away from this.
Some signs of sleep apnea are easy to observe.
When I first started in Sleep Medicine, The STOP Questionnaire was all the rage.
- Snoring
- Tired
- Observed apneas
- High blood Pressure
Two of 4 "yes" answers and you had yourself an increased risk for obstructive sleep apnea.
But then we added BANG.
- BMI elevation
- Age over 50 (although my radar starts around age 40)
- Neck size: over 16 inches for women & over 17 inches for men
- Gender: men more than women (but ladies catch up after menopause)
Together a STOP BANG of 3 or 4 of 8 is supposed to be a moderately increased risk for sleep apnea. Over 5 is a high risk.
But we can take BANG a step further...and that's where the Doorway Exam (and the lesson from this picture comes in).
The Doorway Exam
While I'd like to say that I coined the phrase "doorway exam," someone else thought of it first inside the emergency medicine space.
- It's the thing you do when you arrive at the scene of an emergency.
- It's the assessment you do oh-so-briefly when you walk into a room or look an EKG or chest x-ray.
- It's the thing that (as a healthcare provider) tells you how worried you need to be when it comes to whatever it is you're about to step into.
I just happened to transition the concept to sleep medicine. If I am in a clinic situation with my patients, I'll do it in 2 parts. If I'm just people watching, Part 1 is good enough to get a conversation going.
Part 1 - "The Face BANG"
We talked about BANG already. These are traits that are easy enough to identify from the "doorway." Here are the ones I usually check off in my head in short order.
- How old do they appear to be? (Age)
- How much "extra insulation" do they appear to have? (BMI)
- Do they appear to have a large neck? (Neck)
- What gender do they appear to be? (Gender)
- Are they someone who appears to be peri or postmenopausal?
- Do they appear to belong to a cultural group known to have a higher risk for OSA? (African, Asian, American Indian, etc)
These are all things that can be inferred visually and confirmed later (as appropriate).
But there are a few features that BANG misses out on entirely. Including...
- Ptosis or Floppy Eye Lid Syndrome
- Rhinophyma
- Small and/or recessed jaw
Floppy Eye Lid Syndrome
Ptosis (pronounced "toe-sis") is a sagging of the eyelids. Sometimes it's severe enough to obscure vision, but not everyone's is that pronounced.
My dinner guest has what I would call modest ptosis.
From the research that we have available, we know that 90% of people with this type of eyelid finding have sleep apnea.
While it isn't a diagnostic criteria for sleep apnea, it is a red flag that's easy to appreciate from the doorway.
Rhinophyma
Rhinophyma (pronounced "rhino-fi-muh") is a bullous feature of the nose with a couple of interesting connections to OSA. It can be seen in the setting of excessive alcohol consumption. It can also be a feature of rosacea (pronounced "ro-zay-shah").
Rhinophyma alone can be a sign of OSA. And both excessive alcohol consumption and rosacea have ties to OSA as well.
Small/Recessed Jaw
Micrognathia (meaning small jaw) and retrognathia (meaning jaw that sits towards the back) are the last features we want to assess from the doorway, when we can. These signs are important because they give us information on whether or not (from the outside at least) the box the tongue lives inside might be too small. When the box is too small, the base of the tongue is more likely spill into and block off the airway at the level of the throat.
Part 2 - "Say Ah!"
Part 2 is much more "up close & personal," but just as simple.
We ask permission to check out the person's mouth.
Here's what we're looking for...
- How crowded is the oral airway?
- What condition are the teeth in?
- Are there ridges on the sides of the tongue?
Mallampati Scoring
When I have a patient "open wide," I'm assessing how far back I can see.
- If I can see the whole way back, it's a Mallampati of 1.
- If I can see almost everything back there, it's a 2.
- If I can only see part of the uvula, it's a 3.
- If all I can see is tongue, it's a 4.
The 3's and 4's are where the risk lives.
Lateral Tongue Crenations
Crenations is just the fancy medical term for "wrinkles."
Yup. We're actually looking for tongue wrinkles as an additional indicator that the box the tongue lives in is too small.
A Matter Of Teeth
While teeth aren't super important when it comes to risk for sleep apnea (although the risk is supposed to be less with dentures in rather than out), dentition matters when we start looking at treatment options for sleep apnea.
Without teeth - the kind that don't come out at night - an oral appliance for treating sleep apnea is going to be a non-starter.
Without teeth - which support at least a modest lower teeth ridge - getting a full face mask to seal - and not end up in the person's mouth - might be impossible.
Knowing if dentures are in play or pending is helpful to be aware of. It helps you set realistic expectations surrounding sleep apnea treatments. It helps your patient understand why certain treatment options aren't on the table.
And there you have it...
The answer to the question that got this whole thing started is the fact that my silent dinner guest has ptosis or floppy eyelids.
And I see sleep apnea everywhere.
Ready For More?
If you're a healthcare provider and you want to add Sleep Medicine Management services to your clinical toolbox, email me at carrissa@hellosleephealth.com.
Tell me (1) who you are, (2) what you're looking for help with, (3) your preferred timeline, and (4) the best way (and time) to get in touch with you.
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