What is the approach to assessing sleep issues on physical exam?

Assessing Sleep Issues on Physical Examination

The physical examination for sleep disorders should focus primarily on identifying anatomical features suggesting obstructive sleep apnea through detailed head and neck evaluation, while recognizing that the clinical history remains far more important than physical findings for most sleep disorders. 1

Initial Screening Approach

Begin with two screening questions before proceeding to comprehensive assessment 2:

• "Do you have problems with your sleep or sleep disturbance on average for three or more nights a week?" 3
• "Does the problem with your sleep negatively affect your daytime functioning?" 3

If both answers are yes, proceed with focused physical examination and comprehensive sleep history. 2

Key Physical Examination Components

Head and Neck Evaluation (Critical for Sleep Apnea)

Oropharyngeal assessment should include 1:

• Mallampati classification of tongue size relative to oropharynx
• Tonsillar size and position
• Soft palate length and thickness
• Uvula size
• Presence of retrognathia or micrognathia

Nasal examination for 1:

• Septal deviation
• Turbinate hypertrophy
• Nasal polyps or masses

Neck circumference measurement - larger neck circumference increases sleep apnea risk 1

Body Habitus Assessment

• Body mass index (BMI) calculation - obesity is a major risk factor for obstructive sleep apnea 1
• Distribution of adipose tissue, particularly central obesity 1

Neurological Examination

For patients with suspected hypersomnias of central origin, perform 3:

• Thorough neurologic evaluation
• Cognitive assessment (valuable for diagnosis and monitoring treatment response) 3

Cardiovascular and Respiratory Assessment

• Blood pressure measurement (hypertension associated with sleep apnea) 1
• Signs of right heart failure (cor pulmonale from chronic sleep apnea) 1
• Ankle swelling, which may indicate underlying cardiac or renal conditions affecting sleep 4

Essential Collateral Information from Bed Partner

Obtain bed partner observations whenever possible - they may identify critical findings the patient is unaware of 4:

• Snoring patterns and loudness 3
• Witnessed breathing pauses or apneas 3
• Gasping or choking episodes 3
• Limb movements during sleep 4
• Parasomnias or unusual behaviors 4

Required Objective Documentation Tools

Beyond the physical exam, mandate these assessments 5:

• Two-week sleep diary documenting bedtimes, wake times, sleep onset latency, awakenings, total sleep time, napping, daytime impairment, medications, evening meal timing, caffeine/alcohol consumption, and stress levels 3, 4
• Epworth Sleepiness Scale to quantify daytime sleepiness 3, 5
• General medical/psychiatric questionnaire 5

Specific Physical Findings by Sleep Disorder Type

Obstructive Sleep Apnea Indicators

• Crowded oropharynx (Mallampati class III or IV) 1
• Enlarged tonsils 1
• Retrognathia 1
• Neck circumference >17 inches (men) or >16 inches (women) 1
• Obesity, particularly central 1

Restless Legs Syndrome

• Physical examination is typically normal 3
• Diagnosis relies on clinical history of urge to move legs with uncomfortable sensations during rest 4

Narcolepsy/Hypersomnia

• Cognitive impairment may be evident on mental status examination 3
• Otherwise physical exam typically unremarkable 3

Critical Pitfalls to Avoid

Do not rely solely on physical examination findings - the clinical history is the most important diagnostic element for most sleep disorders 1. Physical findings may suggest sleep apnea but cannot rule out other sleep disorders. 1

Failing to obtain bed partner input leads to missed critical observations about snoring, breathing pauses, and limb movements 2, 4

Overlooking the need for objective measures - physical exam alone is insufficient; always obtain sleep diaries and validated questionnaires 2, 4

Missing medication side effects or substance use as contributors to sleep disturbance during the medication review portion of assessment 2

When to Pursue Polysomnography

Reserve overnight polysomnography for 5, 1:

• Suspected obstructive sleep apnea (particularly with high pretest probability) 1
• Suspected periodic limb movement disorder 5
• Treatment failure of insomnia 5
• Suspected narcolepsy (followed by Multiple Sleep Latency Test) 3

Polysomnography is not routinely indicated for uncomplicated insomnia evaluation alone. 3