is more specific as a measure of local obesity).
Similarly, TS was irrelevant. Curiously, tonsillectomy performed during childhood did not seem to be preventive but in fact seemed to favor the development of OSAS (Figure 4).
Previous studies have shown a statistical relationship between the FTP (frequently called the modified Mallampati score) and sleep disturbances.9,27,29-33 To our knowledge, our study is the first to quantify the specific weight of these maneuvers in a multivariate regression model. Our results suggest that a patient with an FTP score of 3 or 4 is unlikely to have an AHI value within the normal range. In other words, findings from a correct oropharyngeal physical examination may contradict those from a sleep study considered to be normal. The strength of the association between the FTP scores and the OSAS severity is further illustrated in Figure 3, in which we show the joint distribution of FTP scores and AHI values categorized according to the AASM criteria.12 Note that all patients with an FTP score of 4 had severe OSAS; most of the patients with an FTP scores of 3 (71.6%) also had severe OSAS, and all the remaining patients but 1 had moderate OSAS. Almost all patients with an FTP score of 2 were evenly split between mild and moderate categories, with only 2 cases (1.7%) being normal and 4 cases (3.5%) being severe. Finally, patients with an FTP score of 1 had either normal or mild OSAS but very rarely moderate and hardly ever severe OSAS.
The FTP score is a modification of the Mallampati score, established by Friedman.9 Mallampati et al35 determined that the position of the palate with respect to the tongue was an indicator of the ease or difficulty of endotracheal intubation. Friedman et al9 definitively related the position of the palate and the tongue with the risk of OSAS. Friedman et al9 made changes to Mallampati's procedure: whereas Mallampati et al35 performed the examination with the tongue outside the oropharyngeal cavity, Friedman et al9 maintained the tongue inside the oral cavity in a neutral position. Initially, they called their observations the modified Mallampati grade9 but later adopted the term Friedman tongue position36 because it is, in fact, the position of the tongue in relation to the palate that is assessed. Friedman et al9 believed that this modification provides a natural and physiological tongue position similar to the one achieved during sleep.
The FTP score is assessed with the patient in a sitting position (the supine position increases the Mallampati score, as Tham et al37 observed) by opening the mouth in a natural, nonforced manner, with the tongue inside without swallowing or inspiring. We repeated the maneuver 5 times and took the most frequent result. A correct performance of the examination is time consuming but is necessary to avoid significant errors in determining the FTP score. In our cohort, those with FTP scores of 2 and 3 accounted for 74.1% of the whole population, but the severity of OSAS in the 2 groups was quite different. These results emphasize the importance of correct performance of the maneuver.
Our study has several limitations. First of all, the sleep studies are performed on an ambulatory basis and might underestimate the severity of sleep disorders. Nonetheless, these procedures are accepted in the literature, and our experience shows their reliability in clinical practice.38,39 The second point applies to the target population. Our study was performed in a white population; because some studies have reported higher prevalence and severity levels in Asian and African American populations,22,40 there is no guarantee that our results apply to these populations. Furthermore, because the sleep studies were not full polysomnographic studies, the AHI may have been underestimated. Finally, the oropharyngeal examination was performed by a specialist and may not be so accurate when implemented in primary care. The reproducibility of the examination has to be widely implemented.
Despite increasing awareness of the condition and improvements in diagno