Shift in Diagnosis, Treatment of Obstructive Sleep Apnea A Challenge for Otolaryngologists

The downside, said Dr. Shangold, is that if patients don’t do well with an APAP in the beginning of their treatment, they’re less likely to be compliant. Patients who’ve never used these machines before might go through several masks during a titration study in the lab until they find one they’re comfortable with, he added. However, if a durable medical equipment company sets them up with APAP at home during the day, they will make their best guess at the ideal mask or interface. “That first night at home using APAP, the patient may turn to the side and the mask will shift creating a leak. They may take it off and never put it back on,” he said. “I tell patients who go to the sleep lab for a titration study that by the time they leave the lab in the morning, I want them to have the most comfortable mask and an understanding of how to work with it.”

Many otolaryngologists have successfully adapted to this new paradigm, but the key is being aware of which patients don’t do well with APAP, said Dr. Wardrop. “Otolaryngologists need to review the downloaded data from APAP machines to determine if patients are being successfully treated,” she said. “If physicians have questions, they should advocate for a titration study and check to make sure there isn’t an undiagnosed condition, such as uncontrolled hypertension.”

“As long as patients are willing to be treated, we will be able to successfully treat them. However, it’s our responsibility to follow up,” added Dr. Shangold. “You can’t just give patients an APAP and then never see them back. The onus is on us as physicians to see that OSA patients are properly treated long-term for this chronic illness.”

Surgical Options

There have been shifts in surgical treatment of OSA as well, with the realization that most adults need multilevel sleep surgery for successful therapy, including both palatal and base-of-tongue procedures.

In a recent study published in The Laryngoscope (published online ahead of print August 8, 2013; doi: 10.1002/lary.24346), Dr. Ishman looked at patterns in the types of surgery used to treat OSA and found that most were undergoing base-of-tongue surgery, that there was a significant increase in nasal and hypopharyngeal surgery, and a decrease in tracheostomy use. “Surgery performed on the uvula and tonsils can help adults with OSA, but only 40 percent were helped by performing a uvulopalatopharyngoplasty. We found that base-of-tongue surgery in combination with palatal surgery or by itself was very helpful.”