Inter-examiner agreement of the systematic physical examination in patients with obstructive sleep disorders Danilo Anunciatto Sguillar, Tatiana de Aguiar Vidigal, João Paulo Mangussi, Lia Bittencourt, Luiz Carlos Gregório, et al. Sleep and Breathing International Journal of the Science and Practice of Sleep Medicine ISSN 1520-9512 Sleep Breath DOI 10.1007/s11325-016-1356-6
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Author's personal copy Sleep Breath DOI 10.1007/s11325-016-1356-6
SLEEP BREATHING PHYSIOLOGY AND DISORDERS • ORIGINAL ARTICLE
Inter-examiner agreement of the systematic physical examination in patients with obstructive sleep disorders Danilo Anunciatto Sguillar 1,2 & Tatiana de Aguiar Vidigal 1 & João Paulo Mangussi 1 Lia Bittencourt 3 & Luiz Carlos Gregório 1 & Sergio Tufik 3 & Fernanda Louise Martinho Haddad 4
&
Received: 11 November 2015 / Revised: 10 February 2016 / Accepted: 9 May 2016 # Springer-Verlag Berlin Heidelberg 2016
Abstract Purpose The goal of this study was to investigate the agreement between examiners who were or were not trained in the physical examination of the upper airway (UA) and the craniofacial skeleton of individuals with obstructive sleep disorders (OSD). Method A systematic assessment of the UA and craniofacial skeleton was performed on 55 individuals with OSD. The participants were consecutively assessed by three otorhinolaryngologists who specialized in sleep medicine for at least 1 year (trained examiners) and two doctors who were attending a residency program in otorhinolaryngology (untrained examiners). Results When analyzing all of the parameters assessed, the concordance was better in the trained group (k = 0.694, which is considered Bgood^) compared to the untrained group (k = 0.475, Bfair^) (p < 0.001). The inter-examiner agreement The study was conducted at the Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo and Discipline of Rhinolaryngology, Federal University of São Paulo/São Paulo School of Medicine (UNIFESP/EPM). * Danilo Anunciatto Sguillar
[email protected]
1
Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo—UNIFESP, São Paulo, Brazil
2
Rua Maestro Cardim 770, Bela Vista, São Paulo, SP CEP 01323 001, Brazil
3
Discipline of Sleep Medicine and Biology, Department of Psychobiology, Federal University of São Paulo—UNIFESP, São Paulo, Brazil
4
Department of Psychobiology, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo—UNIFESP, São Paulo, Brazil
was also better in the trained compared to the untrained group, as follows: craniofacial (k = 0.643 vs. 0.349), nasal (k = 0.657 vs. 0.614), and pharyngeal (k = 0.729 vs. 0.276) abnormalities (p < 0.05). Conclusion The overall concordance of the physical examination of the UA and craniofacial skeleton was Bgood^ among the trained specialists and Bfair^ among examiners without appropriate training, despite its subjectivity. Keywords Physical examination . Upper airway . Obstructive sleep apnea . Snoring . Reproducibility
Introduction The obstructive sleep disorders (OSD) include upper airway resistance syndrome (UARS) and obstructive sleep apnea (OSA) [1–3]. Although the pathophysiology of OSD is not yet fully elucidated, it is thought that anatomical and functional abnormalities increase the susceptibility of the pharynx to collapse in affected individuals [4, 5]. Indeed, previous studies found an increased prevalence of nasal, pharyngeal, and craniofacial abnormalities in individuals with OSA upon physical examination [6–8]. In this regard, the abnormalities most frequently found include a posteriorized, thick, or Bweb^ soft palate, medialized tonsillar pillars, ogival hard palate, retrognathia, abnormal dental occlusion, and others [6–8]. Clinical findings such as nasal or oropharynx or craniofacial changes are highly relevant for the diagnostic screening of individuals with OSD, as performed by general practitioners, and for the therapeutic management of such patients [9]. However, the main objection to this type of exam cites the subjectivity of physical examination. Indeed, although this type of evaluation has been standardized in several studies [6, 8], physical examination of the upper airway (UA) and
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the craniofacial skeleton might exhibit a wide variability among different examiners. Some studies have addressed the reproducibility of diagnostic evaluations of individuals with OSA. For example, a study by Terris and colleagues (2000) assessed the correlation between the Muller maneuver as performed by a resident in an otorhinolaryngology program and a faculty member in 180 consecutive patients. The collapse of three areas, identifiable by the Muller maneuver, was assessed; specifically, the soft palate, lateral pharyngeal wall, and base of the tongue were examined. The inter-examiner concordance varied from 83.9 to 91.1 % as a function of the collapsed area assessed [10]. Furthermore, concerning the physical examination of the UA and the craniofacial skeleton, 95 individuals with OSD were examined by residents and an otorhinolaryngology professor who specialized in sleep medicine in a study by Fischer and colleagues (2006). The inter-examiner variability was low, and the correlation between examiners for the evaluation of the uvula, position of the tongue base, and Angleclassification was rated Bgood^ [9]. The number of studies examining the inter-examiners agreement of the physical examination of the UA and the craniofacial skeleton is small. Therefore, the aim of the present study was to establish the level of concordance between trained and untrained examiners regarding the systematic physical examination of the UA and craniofacial skeleton that is typically performed in individuals with OSD. The accurate diagnosis allows definition of treatment as surgical or nonsurgical.
Methods ThepresentprospectivestudywasconductedattheSleepDisorders Outpatient Clinic, Department of Otorhinolaryngology and Head and Neck Surgery, Federal University of São Paulo/São Paulo School of Medicine Universidade Federal de São Paulo/Escola Paulista de Medicina—UNIFESP/EPM from March to December 2013. The study was approved by the institutional research ethics committee—Brazil Platform, ruling no. 226,524. All participants signed an informed consent document. Adult individuals, older than 18 years of age, whose main clinical complaint was suggestive of OSD, including usual snoring (every day or almost every day), witnessed pauses in breathing during sleep, and excessive daytime sleepiness (score on Epworth Sleepiness Scale over nine) were consecutively recruited during the study period [11]. The study protocol included questionnaires and physical examination of the UA and craniofacial skeleton. Epidemiological and anthropometric data, including age, gender, body mass index (BMI), and neck circumference (NC), were collected first. Next, the protocol for the
systematic physical examination of the UA and craniofacial skeleton that is routinely used for the assessment of individuals with OSA, as by Zonato and colleagues, was performed [6, 7]. The physical examination was performed by three otorhinolaryngologists who specialized in sleep medicine for at least 1 year and have had previous specific training in this type of assessment (trained examiners) and two residents in an otorhinolaryngology program who were properly acquainted with the standard otorhinolaryngological examination (evaluation of ear, nose, and oropharynx), but were not trained on the aforementioned specific evaluation (untrained examiners). The residents were interchanged every 2 months so that they would not become acquainted with the physical examination that focuses on OSD and thus become specifically trained in that procedure. Trained examiners were not exchanged. All of the examinations were performed in a blinded manner, such that the examiners had no contact with one another by any means throughout the duration of the study. Craniofacial evaluation The assessment of the craniofacial skeleton was performed relative to the Frankfurt horizontal plane, with the participants in a sitting position. First, the distance between a virtual line starting at the anterior margin of the lower lip and perpendicular to the ground and the most prominent point on the chin was measured; the occurrence of retrognathia (posterior positioning of the mandible) was established when that distance was equal to or longer than 2 mm. The hard palate was assessed by an inspection of the oral cavity, and it was defined as ogival when its appearance was narrow and deep. Occlusion was classified according to Angle’s system [12] as follows: class I (normal occlusion), class II (suggestive of retrognathia), class III (suggestive of prognathism or maxillary hypoplasia), or edentulous. The individuals who exhibited at least two out of the three investigated abnormalities (ogival hard palate, retrognathia, and Angle’s class II or III) were classified as exhibiting a craniofacial abnormality [7]. Nose evaluation The nose assessment was based on the investigation of subjective complaints and anterior rhinoscopy. The participants were questioned regarding the presence of nasal obstruction and complaints suggestive of rhinopathy (coryza, itching, and sneezing). Only the participants who reported daily or almost daily occurrence of these symptoms in the past 3 months were classified with rhinopathy. Nasal septum deviation, as detected on anterior rhinoscopy, was classified as follows: grade I (septum does not contact the inferior turbinate), grade II (septum contacts the inferior
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turbinate), or grade III (septum contacts the lateral wall). Turbinate hypertrophy was categorized as present or absent. Participants were classified as exhibiting an abnormal nose when one of the following conditions was present: (1) grade II or III septum deviation, (2) grade I septum deviation combined with nasal obstruction and/or rhinopathy complaints, or (3) turbinate hypertrophy combined with nasal obstruction and/or rhinopathy complaints.
Oropharyngeal evaluation Upon oropharyngeal assessment, the soft palate was classified as Bposterior^ (posterior position relative to the oropharynx), Bthick^ (swollen appearance), and/or Bweb^ (presence of a mucous membrane resulting from the insertion of the posterior pillar of the uvula being too low). The tonsillar pillars were considered Bmedialized^ when they were close to the midline of the oropharynx. The uvula was considered Blong^ when it was close to or contacted the base of the tongue and as Bthick^ when it exhibited a swollen appearance. The palatine tonsils were classified as grade I (obstructing up to 25 % of the oropharyngeal space), grade II (obstructing 25 to 50 % of the oropharyngeal space), grade III (obstructing 50 to 75 % of the oropharyngeal space), grade IV (obstructing more than 75 % of the oropharyngeal space), or grade 0 (participants previously subjected to tonsillectomy) [13]. Participants were classified as exhibiting an Babnormal^ oropharynx when three or more abnormalities were identified in the palate (Bposterior,^ Bmedialized,^ Bthick,^ and/or Bweb^), uvula (Blong^ and/or Bthick^), or palatine tonsils (grade III or IV). The modified Mallampati score was obtained as described by Friedman and colleagues, i.e., the participants were in a sitting position, the mouth was maximally opened, and the tongue was relaxed inside the oral cavity [13]. The scores were classified as follows: class I (the entire oropharynx is visible, including the soft palate, tonsillar pillars, palatine tonsils, and posterior wall of the oropharynx), class II (the upper pole of the palatine tonsils and part of the posterior wall of the oropharynx are visible), class III (part of the soft palate and uvula are visible), and class IV (only the hard palate and part of the soft palate are visible). At the end of data collection, the parameters were compared among the three trained and the two untrained examiners. The inter-examiner agreement was assessed using the kappa concordance test (k) [14]. Concordance was considered Bdismissible^ when k was less than 0.20, Bminimal^ when k was 0.21 to 0.4, Bfair^ when k was 0.41 to 0.60, Bgood^ when k was 0.61 to 0.80, and Boptimal^ when k was equal to or greater than 0.81. Statistical analysis was performed using SPSS v.17 software. The significance level was set at p < 0.05.
Results A total of 55 individuals were assessed at the Sleep Disorders Outpatient Clinic; 35 were male (63.5 %) and 20 were female (36.4 %). The average age was 46.4 ± 13.6 years old. The average BMI and NC were 31.7 ± 6.3 kg/m [2] and 41.9 ± .4.3 cm, respectively. The inter-examiner concordance results for each variable are presented in Tables 1, 2, and 3. The value of k for all of the investigated variables was higher in the group of trained examiners. Joint analysis of the variables together showed that the concordance between the trained examiners was Bgood^ (k = 0.694) and between the untrained examiners was Bfair^ (k = 0.475). Both results were statistically significant (Table 1). Concordance values for all of the parameters corresponding to the craniofacial assessment were higher in the group of trained examiners and were fair or good (p < 0.001), whereas in the group of untrained examiners, the concordance rates were minimal or dismissible (Table 2). The agreement of the physical examination to detect nasal abnormalities performed by the trained examiners was rated Bfair^ for the individual findings (presence and degree of septum deviation and turbinate hypertrophy) and Bgood^ for the combined parameters (septum deviation grade II or III and nasal abnormality). The concordance between the untrained examiners was Bdismissible^ or Bminimal^ for the separate findings and Bgood^ for the combined parameters (nasal abnormality) (Table 3). For the assessment of the pharynx, the correlation among the trained examiners varied from Bminimal^ to Bgood,^ but was Boptimal^ (k > 0.80) when Bclassification of palatine tonsils (grade III or IV)^ and Bmodified Mallampati score (grade III or IV)^ were analyzed together. Among the untrained examiners, the concordance was Bminimal^ or Bdismissible^ for most parameters. It was even negative in the case of the variable Bthick soft palate^ (k = −0.033), meaning that the findings reported by the untrained examiners for this parameter were less than what would be expected by chance. The strongest correlation between the untrained examiners was found
Table 1 Overall reproducibility of the physical examination of the UA and craniofacial skeleton of individuals with OSD between trained and untrained examiners
Overall reproducibility
Untrained examiners
Trained examiners
k
p value
k
p value
0.475
