Surgical Management of Sleep Apnea — MCQs
A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?
Which of the following is not typically performed during septoplasty?
Which one of the following is not a component of THORACOSCORE?
After mandibulectomy, which muscle prevents the tongue from falling back?
Laser uvulopalatoplasty is indicated for which of the following conditions?
Emergency tracheostomy is not indicated in
Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?
All are absolute indications of tonsillectomy except which of the following?
In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
A patient has carcinoid tumour of appendix of size more than 2.5 cm. The management of choice is:
Surgical Management of Sleep Apnea Indian Medical PG Practice Questions and MCQs
Question 1: A 40-year-old man presents with daytime sleepiness and impaired concentration and memory. On examination his BMI is 41 kg/m2, BP is 160/100 mm Hg. His awake ABG analysis is given: PaO2=66 mm Hg, PaCO2=50 mm Hg, HCO3=28 mEq/L. What is the most likely diagnosis?
- A. Obstructive sleep apnea (Correct Answer)
- B. Narcolepsy
- C. Obesity hypoventilation syndrome
- D. Central sleep apnea
Explanation: ***Obstructive Sleep Apnea (Correct Answer)*** - Classic triad: **morbid obesity (BMI 41 kg/m²)**, **excessive daytime somnolence**, and **systemic hypertension (160/100 mmHg)** — hallmarks of OSA - **ABG findings** (PaO2=66 mmHg, PaCO2=50 mmHg, HCO3=28 mEq/L) indicate **chronic nocturnal hypoxemia and hypercapnia** with compensatory **metabolic alkalosis** from repeated apneic episodes - **Cognitive impairment** (impaired concentration and memory) results from **sleep fragmentation** and intermittent nocturnal hypoxia - Obesity promotes **pharyngeal fat deposition** → upper airway narrowing and collapse during sleep → recurrent obstructive events *Narcolepsy* - Causes excessive daytime sleepiness but is **not associated with obesity, hypertension, or ABG abnormalities** - Hallmarks include **cataplexy**, sleep paralysis, and hypnagogic/hypnopompic hallucinations — none present here - Caused by **orexin (hypocretin) deficiency**; associated with **HLA-DQB1*06:02**; ABG is normal *Obesity Hypoventilation Syndrome (OHS / Pickwickian Syndrome)* - Defined as **awake PaCO2 >45 mmHg + BMI >30 kg/m²** with exclusion of other causes of hypoventilation - OHS frequently coexists as an **overlap with and consequence of severe OSA** rather than being the primary diagnosis - In this setting, **OSA is the most prevalent and primary diagnosis**; OHS is specifically considered when awake hypoventilation persists despite adequate OSA treatment *Central Sleep Apnea* - Results from **failure of central respiratory drive** (brainstem), not upper airway obstruction - Associated with **congestive heart failure, opioid use, high-altitude exposure, or neurological disease** — none present here - Not characteristically associated with morbid obesity; clinical and ABG picture here favors an **obstructive** rather than central pattern
Question 2: Which of the following is not typically performed during septoplasty?
- A. Surgical removal of nasal polyps (Correct Answer)
- B. Throat pack
- C. Nasal packing at the end of surgery
- D. Submucosal resection of deviated cartilage
Explanation: ***Surgical removal of nasal polyps*** - Septoplasty is a surgical procedure specifically designed to correct a **deviated nasal septum** by repositioning or removing obstructing cartilage and bone. - **Nasal polyps** arise from the mucosa of the nasal cavity or sinuses and require a separate procedure, typically **functional endoscopic sinus surgery (FESS)** or polypectomy. - While septoplasty and polypectomy may sometimes be performed together, polyp removal is **not part of standard septoplasty**. *Submucosal resection of deviated cartilage* - This is the **core component of septoplasty** - removing or repositioning deviated septal cartilage while preserving the mucosal lining. - The submucosal approach maintains structural support while correcting the deviation. *Throat pack* - A **throat pack** is routinely placed during septoplasty to **prevent aspiration of blood and secretions** into the pharynx and esophagus. - It protects the airway and is removed at the end of the procedure. *Nasal packing at the end of surgery* - **Nasal packing** (splints or packs) is commonly placed after septoplasty to **control bleeding, support the septum, and prevent hematoma formation**. - Modern techniques may use absorbable or non-absorbable packing materials.
Question 3: Which one of the following is not a component of THORACOSCORE?
- A. Performance status
- B. Complication of surgery (Correct Answer)
- C. Priority of surgery
- D. ASA grading
Explanation: ***Complication of surgery*** - THORACOSCORE is a **risk prediction model** for thoracic surgery used to estimate the *probability of mortality and significant morbidity*, but it does not account for the complications of surgery itself as a component. - The score uses **pre-operative patient characteristics** and co-morbidities to predict outcomes, not post-operative events. *Performance status* - **Performance status**, such as the **ECOG scale**, is a crucial component of THORACOSCORE, reflecting the patient's general health and functional capacity prior to surgery. - A lower performance status (indicating poorer functional ability) increases the predicted risk in THORACOSCORE. *Priority of surgery* - The **priority of surgery** (e.g., elective, urgent, emergency) is an important factor in THORACOSCORE, as emergency procedures generally carry a higher risk. - This variable helps to capture the urgency and associated physiological stress on the patient at the time of presentation for surgery. *ASA grading* - The **American Society of Anesthesiologists (ASA) physical status classification system** is a component of THORACOSCORE, assessing the patient's overall health status and anesthetic risk. - A higher ASA grade (indicating more severe systemic disease) contributes to a higher predicted risk in the THORACOSCORE model.
Question 4: After mandibulectomy, which muscle prevents the tongue from falling back?
- A. Genioglossus
- B. Hyoglossus (Correct Answer)
- C. Palatopharyngeus
- D. All of the options
Explanation: ***Hyoglossus*** - The **hyoglossus muscle depresses and retracts the tongue**, attaching to the **hyoid bone**. - Following mandibulectomy, the **hyoid bone** becomes a crucial anchor, as it is often spared, and the hyoglossus aids in preventing the tongue from falling back into the pharynx. *Genioglossus* - The **genioglossus muscle protrudes and depresses the tongue**, attaching to the **mandible**. - After **mandibulectomy**, its primary attachment point is removed, significantly impairing its function in preventing the tongue from falling back. *Palatopharyngeus* - The **palatopharyngeus muscle elevates the pharynx and larynx** and aids in swallowing, but it primarily affects the soft palate and pharynx. - It does not have a direct role in actively preventing the **tongue from falling backward** into the oropharynx. *All of the options* - This option is incorrect because, as explained above, the **genioglossus** is compromised, and the **palatopharyngeus** has a different primary function. - Only the **hyoglossus** maintains its crucial role in this specific post-surgical scenario.
Question 5: Laser uvulopalatoplasty is indicated for which of the following conditions?
- A. Obstructive sleep apnea (Correct Answer)
- B. Pharyngotonsillitis
- C. Cleft palate
- D. Stammering
Explanation: ***Obstructive sleep apnea*** - **Laser uvulopalatoplasty (LUP)** is a surgical procedure that reshapes the **uvula** and **soft palate** to enlarge the airway in patients with **obstructive sleep apnea (OSA)**. - OSA is characterized by repetitive episodes of upper airway obstruction during sleep, leading to snoring, daytime sleepiness, and other health issues. *Pharyngotonsillitis* - This condition involves inflammation of the **pharynx** and **tonsils**, usually caused by bacterial or viral infections. - Treatment typically involves antibiotics for bacterial infections or symptomatic relief for viral infections, not surgical reshaping of the palate. *Cleft palate* - **Cleft palate** is a congenital birth defect where the roof of the mouth does not fully close during fetal development. - The primary treatment involves **surgical repair** to close the opening, which is a different procedure from LUP and focuses on reconstructing normal anatomy. *Stammering* - **Stammering** is a **speech disorder** characterized by disruptions in fluency, such as repetitions, prolongations, or blocks in speech. - It is managed through **speech therapy** and behavioral interventions, and is unrelated to airway obstruction or surgical procedures on the palate.
Question 6: Emergency tracheostomy is not indicated in
- A. Bilateral vocal cord paralysis
- B. Foreign body larynx
- C. Acute severe asthma (Correct Answer)
- D. Stridor due to laryngeal growth
Explanation: ***Acute severe asthma*** - While life-threatening, acute severe asthma is primarily managed with **bronchodilators**, **steroids**, and potentially **non-invasive or invasive ventilation**. - **Tracheostomy** is generally reserved for situations involving upper airway obstruction that cannot be managed by other means, which is not the primary issue in asthma. *Bilateral vocal cord paralysis* - This condition can cause severe **upper airway obstruction** due to the adduction of both vocal cords. - In an emergency setting, a tracheostomy may be life-saving to bypass the obstructed larynx. *Foreign body larynx* - An obstructing **foreign body in the larynx** can lead to immediate and complete airway compromise. - If efforts like the **Heimlich maneuver** or direct laryngoscopy with removal fail, an emergency tracheostomy might be necessary. *Stridor due to laryngeal growth* - A laryngeal growth causing **stridor** indicates significant airway narrowing, which can acutely worsen and lead to respiratory distress. - In cases of severe or rapidly progressive obstruction, an **emergency tracheostomy** is needed to secure the airway below the level of the growth.
Question 7: Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?
- A. Absence of snoring
- B. Bradycardia during sleep episodes (Correct Answer)
- C. Normal oxygen saturation throughout sleep
- D. Decreased neck circumference
Explanation: ***Bradycardia during sleep episodes*** - While patients with **obstructive sleep apnea (OSA)** commonly experience various cardiovascular complications, **bradycardia** during apneic episodes is *less typical* than **tachycardia**. - The body's initial response to apnea and **hypoxia** usually involves a sympathetic surge leading to tachycardia upon arousal, followed by bradycardia if the apnea is prolonged. However, the dominant pattern is often elevated heart rate variability. *Normal oxygen saturation throughout sleep* - Patients with OSA frequently experience intermittent **hypoxemia** due to repeated apneas and hypopneas, leading to significant drops in **oxygen saturation** [1]. - A *normal oxygen saturation throughout sleep* would effectively rule out significant OSA, as desaturation is a hallmark of the condition [1]. *Absence of snoring* - **Snoring** is a classic and highly prevalent symptom of OSA, caused by the vibration of upper airway tissues as air struggles to pass through an obstructed pharynx. - While not all snorers have OSA, the *absence of snoring* makes OSA less likely, although it can occur in some subsets of patients, particularly those with central sleep apnea or certain anatomical variations. *Decreased neck circumference* - A **large neck circumference** is a well-established anatomical risk factor for OSA, indicating increased soft tissue in the neck that can contribute to upper airway collapse. - A *decreased neck circumference* would generally be protective against OSA, making it less likely for an individual to have the condition.
Question 8: 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 9: In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
- A. Surgery
- B. Radiotherapy
- C. Chemotherapy
- D. CECT to stage disease (Correct Answer)
Explanation: ***CECT to stage disease*** - **CECT (Contrast-Enhanced CT) of chest, abdomen, and pelvis is the essential next step** after histological confirmation of colon adenocarcinoma. - **Staging is mandatory** before any treatment decision to determine: - **Local extent** of tumor (T stage) - **Lymph node involvement** (N stage) - **Distant metastases** (M stage - liver, lungs, peritoneum) - **Resectability** and surgical planning - Even with the "apple core" appearance indicating an advanced primary tumor, **treatment decisions cannot be made without knowing the overall disease burden**. - **CEA (Carcinoembryonic Antigen) levels** are also typically obtained during staging. *Surgery* - **Surgical resection is the definitive treatment** for localized, resectable colon cancer and would be performed **after staging**, not before. - Surgery involves removing the tumor with adequate margins and regional lymphadenectomy. - However, **staging must precede surgery** to: - Determine if the disease is metastatic (which would change surgical approach) - Plan the extent of resection - Counsel the patient appropriately - Decide on neoadjuvant therapy if indicated - The "apple core" appearance suggests an advanced primary but does not indicate acute obstruction requiring emergency surgery in this stable patient who has already undergone barium enema and colonoscopy. *Chemotherapy* - **Chemotherapy** is typically given as: - **Adjuvant therapy** after surgery for stage III (node-positive) or high-risk stage II disease - **Palliative therapy** for metastatic (stage IV) disease - **Neoadjuvant therapy** is not standard for colon cancer (unlike rectal cancer) - Chemotherapy is not the immediate next step; staging and then surgery (if resectable) come first. *Radiotherapy* - **Radiotherapy has limited role in colon cancer** (unlike rectal cancer where it is commonly used). - It may be used for: - **Palliation** of symptoms (pain, bleeding) in advanced disease - Rare cases of **locally advanced unresectable disease** - It is not a primary treatment modality and is not the next step in this case.
Question 10: A patient has carcinoid tumour of appendix of size more than 2.5 cm. The management of choice is:
- A. Appendectomy
- B. Right hemicolectomy (Correct Answer)
- C. Appendectomy and 24 hour urinary HIAA
- D. Appendectomy and abdominal CT scan
Explanation: **Right hemicolectomy** - For **carcinoid tumors of the appendix** larger than **2.0 cm (or 2.5 cm by some guidelines)**, a right hemicolectomy is the recommended management due to the increased risk of **lymph node metastasis** and distant spread. - This procedure ensures adequate tumor clearance and regional lymphadenectomy, which is crucial for staging and preventing recurrence in larger tumors. *Appendectomy* - An appendectomy alone is usually sufficient for **small carcinoid tumors (<1-2 cm)** that are **confined to the appendix**, without evidence of mesoappendiceal invasion or lymph node involvement. - For tumors exceeding 2.5 cm, the risk of metastasis is considerably higher, making appendectomy alone inadequate for complete oncological control. *Appendectomy and 24 hour urinary HIAA* - While a **24-hour urinary 5-hydroxyindoleacetic acid (5-HIAA)** measurement is useful for diagnosing and monitoring **carcinoid syndrome**, it does not influence the primary surgical management decision for an appendiceal tumor of this size. - The surgical approach is dictated by **tumor size** and the risk of metastasis, not by biochemical markers alone, unless the patient presents with symptoms of carcinoid syndrome. *Appendectomy and abdominal CT scan* - An abdominal **CT scan** is valuable for **staging** and detecting distant metastases or nodal involvement, especially in larger tumors, but it is a diagnostic tool, not a treatment itself. - While a CT scan would likely be performed as part of the work-up, an appendectomy alone is insufficient as the definitive surgical management for a tumor of this size without addressing the high risk of regional spread.
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