Obstructive Sleep Apnea — MCQs

10 questions

All of the following criteria are required for diagnosis of obesity hypoventilation syndrome except -

Modafinil is approved by FDA for treatment of all except:

During polysomnography, which stage of sleep is represented by the marked areas when observing the following wave patterns? EOG (Electrooculography) EEG (Electroencephalography) EMG (Electromyography)

Which of the following statements about obstructive sleep apnea is false?

Obesity is associated with the MOST SIGNIFICANT increased risk of:

The sleep apnea syndrome is defined as -

All are absolute indications of tonsillectomy except which of the following?

All of the following are correct about the image shown except:

Mainstay of treatment of glue ear -

Q10

A neonate with micrognathia has episodes of cyanosis while feeding. Best management is:

Obstructive Sleep Apnea Indian Medical PG Practice Questions and MCQs

Question 1: All of the following criteria are required for diagnosis of obesity hypoventilation syndrome except -

A. PaCO2 > 45 mmHg
B. BMI 30 kg/m2
C. Hypertension (Correct Answer)
D. Sleep disorder breathing

Explanation: ***Hypertension*** - While **hypertension** is a common comorbidity in patients with **obesity hypoventilation syndrome (OHS)**, it is _not_ a diagnostic criterion. - OHS is defined by specific respiratory and obesity-related parameters, not the presence of associated cardiovascular conditions. *BMI $\geq$ 30 kg/m$^2$* - A **body mass index (BMI)** of **30 kg/m$^2$** or greater is a fundamental criterion for diagnosing OHS, as the syndrome is directly linked to obesity. - Severe obesity leads to mechanical compression of the lungs and chest wall, contributing to hypoventilation. *PaCO$_{2}$ > 45 mmHg* - A **daytime arterial partial pressure of carbon dioxide (PaCO$_{2}$)** greater than **45 mmHg** is a key diagnostic criterion, indicating chronic alveolar hypoventilation. - This persistent hypercapnia is present even when other causes like obstructive lung disease have been excluded. *Sleep-disordered breathing* - **Sleep-disordered breathing**, most commonly **obstructive sleep apnea (OSA)**, is almost universally present in OHS patients and is a required diagnostic criterion [1]. - The combination of severe obesity and OSA often leads to the development of chronic hypoventilation [1].

Question 2: Modafinil is approved by FDA for treatment of all except:

A. Narcolepsy
B. Shift work sleep disorder (SWSD)
C. Obstructive sleep apnea syndrome (OSAS)
D. Lethargy in depression (Correct Answer)

Explanation: ***Lethargy in depression*** - Modafinil is **not FDA-approved** for treating lethargy or fatigue specifically in the context of depression. Its primary indications are for disorders of excessive daytime sleepiness. - While it may be used off-label in some cases for depression-related fatigue, it lacks formal FDA approval and specific efficacy data for this indication. *Narcolepsy* - Modafinil is **FDA-approved** as a wakefulness-promoting agent for the treatment of excessive daytime sleepiness associated with **narcolepsy**. - It helps reduce the frequency and severity of sleep attacks by promoting wakefulness through effects on **dopamine**, **norepinephrine**, and **histamine** systems in the brain. *Shift work sleep disorder (SWSD)* - Modafinil is **FDA-approved** to improve wakefulness in patients with excessive sleepiness associated with **shift work sleep disorder**. - It helps individuals working non-traditional hours (night shifts, rotating shifts) maintain alertness during their work periods. *Obstructive sleep apnea syndrome (OSAS)* - Modafinil is **FDA-approved** as an **adjunctive treatment** for residual excessive daytime sleepiness in patients with **obstructive sleep apnea/hypopnea syndrome (OSAHS)** who are receiving adequate treatment with CPAP. - It addresses persistent sleepiness that remains even after appropriate primary airway management.

Question 3: During polysomnography, which stage of sleep is represented by the marked areas when observing the following wave patterns? EOG (Electrooculography) EEG (Electroencephalography) EMG (Electromyography)

A. REM sleep
B. NREM I sleep (Correct Answer)
C. NREM II sleep
D. NREM III sleep

Explanation: ***NREM I sleep*** - This stage is characterized by a transition from wakefulness to sleep, identifiable by the appearance of **slow eye movements** in the EOG and a reduction in EEG frequency with the presence of **theta waves**. - The EMG shows a decrease in muscle tone but without the complete atonia seen in REM sleep. *REM sleep* - **Rapid eye movements** are characteristic in the EOG, and the EEG shows **low-amplitude, mixed-frequency waves** similar to wakefulness. - The EMG would display profound muscle atonia, which is not evident in the provided tracing. *NREM II sleep* - This stage is marked by the presence of **sleep spindles** and **K-complexes** in the EEG, which are absent in the marked area. - Eye movements are generally absent, and muscle activity continues to be low. *NREM III sleep* - This is the deepest stage of sleep, characterized by **high-amplitude, slow-delta waves** (20-50% of the epoch) in the EEG. - Eye movements are typically absent, and muscle tone is very low but not completely absent.

Question 4: Which of the following statements about obstructive sleep apnea is false?

A. Apnea is associated with high respiratory effort
B. Apnea is associated with fall in SpO2
C. Apnea is associated with sudden awakening
D. Contraction of pharyngeal muscles can worsen obstruction (Correct Answer)

Explanation: ***Contraction of pharyngeal muscles can worsen obstruction*** - In **obstructive sleep apnea (OSA)**, the pharyngeal muscles are normally responsible for maintaining airway patency [1]. - A *contraction* of these muscles would *open* the airway, whereas *relaxation* or *loss of tone* leads to collapse and obstruction. *Apnea is associated with high respiratory effort* - During an **apneic episode** in OSA, the airway is *obstructed*, leading to continued but **unsuccessful inspiratory efforts** against a closed airway. - This results in a significant increase in **respiratory effort** as the diaphragm and accessory muscles try to overcome the obstruction. *Apnea is associated with fall in SpO2* - The cessation of airflow during **apnea** prevents **gas exchange**, leading to a progressive decrease in **oxygen saturation (SpO2)**. - This **hypoxia** is a hallmark physiological consequence of apneic events and often triggers arousal from sleep [2]. *Apnea is associated with sudden awakening* - The combination of **hypoxia** and **hypercapnia** (increased CO2), along with the increased respiratory effort, stimulates the central nervous system [2]. - This stimulation causes a **brief arousal or awakening** from sleep, often accompanied by gasping or snorting, to re-establish airway patency.

Question 5: Obesity is associated with the MOST SIGNIFICANT increased risk of:

A. Hyperuricemia
B. Osteoporosis
C. Heart disease (Correct Answer)
D. Hypertension

Explanation: ***Heart disease*** - **Obesity** is a major independent risk factor for **cardiovascular diseases**, including coronary artery disease, heart failure, and stroke, due to its impact on metabolic and inflammatory pathways. - It contributes to **atherosclerosis** [1], hypertension, dyslipidemia, and insulin resistance, all of which significantly increase the risk of heart disease. *Hypertension* - While **obesity** is a significant risk factor for **hypertension**, hypertension itself is a component of the broader risk of heart disease, not the most significant singular outcome of obesity. - Elevated blood pressure in obese individuals often results from increased sympathetic activity, insulin resistance, and activation of the **renin-angiotensin-aldosterone system**. *Hyperuricemia* - **Obesity** is associated with **hyperuricemia** due to increased purine production and decreased uric acid excretion, which can lead to **gout**. - However, the overall health burden and mortality risk associated with hyperuricemia are generally less significant compared to heart disease linked to obesity. *Osteoporosis* - **Obesity** is generally considered to be protective against **osteoporosis** because increased body weight places mechanical stress on bones, which can increase bone mineral density. - While obesity can lead to other musculoskeletal issues like osteoarthritis, it does not typically increase the risk of osteoporosis.

Question 6: The sleep apnea syndrome is defined as -

A. Apnea-Hypopnea Index (AHI) ≥ 5/hour (Correct Answer)
B. Apnea-Hypopnea Index (AHI) ≥ 10/hour
C. Apnea-Hypopnea Index (AHI) ≥ 30/hour
D. Apnea-Hypopnea Index (AHI) ≥ 15/hour

Explanation: ***Apnea-Hypopnea Index (AHI) ≥ 5/hour*** - The definition of **sleep apnea syndrome** generally requires an **AHI of 5 or more events per hour**, often accompanied by symptoms like excessive daytime sleepiness or cardiovascular complications [1]. - This threshold identifies individuals with clinically significant sleep-disordered breathing that warrants further evaluation and potential treatment [1]. *Apnea-Hypopnea Index (AHI) ≥ 10/hour* - While an AHI of 10/hour indicates sleep apnea, it is a higher severity criterion and does not represent the **minimum threshold** for defining the syndrome [1]. - Patients with an AHI between 5 and 10 also have sleep apnea and can experience significant symptoms. *Apnea-Hypopnea Index (AHI) ≥ 30/hour* - An AHI of 30/hour or more signifies **severe sleep apnea**, which requires aggressive management. - This is far above the **general diagnostic threshold** for sleep apnea syndrome. *Apnea-Hypopnea Index (AHI) ≥ 15/hour* - An AHI of 15/hour is typically classified as **moderate sleep apnea**. - This value is higher than the **lowest AHI threshold** used to define the presence of sleep apnea syndrome.

Question 7: All are absolute indications of tonsillectomy except which of the following?

A. Peritonsillar abscess
B. Tonsils causing obstructive sleep apnea
C. Chronic tonsillitis (Correct Answer)
D. Suspicious malignancy

Explanation: ***Chronic tonsillitis*** - **Chronic tonsillitis** is a **relative indication** for tonsillectomy, not an **absolute indication**. - It becomes an indication based on frequency criteria (e.g., Paradise criteria: ≥7 episodes in 1 year, ≥5 episodes per year for 2 years, or ≥3 episodes per year for 3 years). - Absolute indications involve conditions requiring urgent surgical intervention. *Suspicious malignancy* - Suspected **malignancy** is an **absolute indication** for tonsillectomy to obtain tissue for histopathological diagnosis. - Early diagnosis and treatment of tonsillar malignancy is critical for patient outcomes. *Peritonsillar abscess* - **Peritonsillar abscess** (quinsy) is typically managed with needle aspiration or incision & drainage plus antibiotics, NOT immediate tonsillectomy. - Acute tonsillectomy during active infection ("hot tonsillectomy") is generally **contraindicated** due to increased bleeding risk and surgical complications. - **Recurrent peritonsillar abscess** may warrant **interval tonsillectomy** (4-6 weeks after resolution) as a **relative indication**, not an absolute one. *Tonsils causing obstructive sleep apnea* - **Obstructive sleep apnea (OSA)** caused by tonsillar hypertrophy is an **absolute indication** for tonsillectomy, particularly in children. - Untreated OSA can lead to serious complications including failure to thrive, cor pulmonale, developmental delays, and neurocognitive problems.

Question 8: All of the following are correct about the image shown except:

A. Omega shaped epiglottis
B. High pitched expiratory stridor (Correct Answer)
C. Cry is normal
D. 10% cases need surgery due to development of OSA or Cor Pulmonale

Explanation: ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.

Question 9: Mainstay of treatment of glue ear -

A. Temporal bone resection
B. Tonsillectomy & adenoidectomy
C. Radical Mastoidectomy
D. Myringotomy + aeration to middle ear (Correct Answer)

Explanation: ***Myringotomy + aeration to middle ear*** - **Myringotomy** involves creating a small incision in the eardrum to drain fluid, and inserting a **grommet (ventilation tube)** to aerate the middle ear, which is the primary treatment for persistent glue ear (otitis media with effusion). - This procedure aims to restore ventilation to the middle ear, allowing trapped fluid to drain and preventing recurrent fluid accumulation, which improves hearing. *Temporal bone resection* - This is a major surgical procedure involving the removal of part of the temporal bone, typically reserved for extensive **malignant tumors** or severe infections, and is not indicated for glue ear. - It carries significant risks and is disproportionate to the treatment of a benign condition like glue ear. *Tonsillectomy & adenoidectomy* - While **adenoidectomy** can sometimes be performed in conjunction with grommet insertion if enlarged adenoids contribute to eustachian tube dysfunction, it is not the **primary treatment** for glue ear itself. - **Tonsillectomy** is generally performed for recurrent tonsillitis and has no direct role in treating glue ear. *Radical Mastoidectomy* - This is a highly invasive surgical procedure involving the removal of the mastoid air cells and part of the external auditory canal, typically performed for severe **cholesteatoma** or chronic mastoiditis. - It is an extensive and risky operation that is not appropriate for the management of glue ear, which is a much milder condition.

Question 10: A neonate with micrognathia has episodes of cyanosis while feeding. Best management is:

A. Tongue-lip adhesion
B. Prone positioning (Correct Answer)
C. CPAP
D. Tracheostomy

Explanation: ***Prone positioning*** - This helps by allowing the **tongue to fall forward** due to gravity, preventing it from obstructing the airway. - It's a non-invasive, initial management strategy for neonates with **micrognathia** causing airway obstruction, especially during feeding. *Tongue-lip adhesion* - This is a surgical procedure considered for more severe cases where **prone positioning** and other conservative measures fail. - It involves suturing the **tongue to the lower lip** to keep the airway open. *CPAP* - **Continuous positive airway pressure** can help maintain airway patency by providing constant pressure. - While it can be useful in some cases of airway obstruction, it might not be the initial best approach for feeding-related cyanosis in micrognathia, and **prone positioning** is simpler and often effective first. *Tracheostomy* - This is an **invasive surgical procedure** to create an artificial airway, reserved for severe, life-threatening airway obstruction that cannot be managed by other means. - It is not the initial or best management for recurrent cyanosis during feeding due to **micrognathia**, unless other measures have proven insufficient.

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