When it Comes to Sleep-Disordered Breathing, Be Sure to Evaluate the Whole Patient

CHICAGO-If at first you don’t succeed, try, try again. Perhaps nowhere in medicine does that age-old axiom apply more appropriately than in the treatment of patients with sleep-disordered breathing (SDB). Even though the etiology of SDB may be airway obstruction or collapse, it might encompass the entire upper airway. So, before rushing these patients into the operating room, it is important to evaluate the patient, the whole patient, and nothing but the patient.

A panel of experts-convened by the Triological Society here at the 2006 Combined Otolaryngology Spring Meetings (COSM)-discussed some of the intricacies and issues involved in the presurgical evaluation of the SDB patient. The panel included Michael Friedman, MD, Professor of Otolaryngology at Rush Medical College in Chicago, Ill.; Regina P. Walker, MD, Clinical Associate Professor of Otolaryngology at Loyola University in Chicago, Ill.; and Brent A. Senior, MD, Associate Professor of Otolaryngology at the University of North Carolina in Chapel Hill.

Panel moderator B. Tucker Woodson, MD, Professor and Chief of the Division of Sleep Medicine and Surgery in the Department of Otolaryngology and Communication Sciences at the Medical College of Wisconsin in Milwaukee, presented the panelists with two cases representing symptoms and situations commonly seen by otolaryngologists. The panelists then offered their thoughts on what to look for-and what to look out for-when diagnosing and determining treatment approaches for SDB patients.

Case #1

Dr. Woodson: A 66-year-old male came to see me with non-refreshing sleep. His wife reported that she had noticed him choking during sleep. He had a sleep study and apnea-hypopnea index (AHI) is 30 events per hour. Pretty significant desaturation of 78%, not terribly unusual as people get older, but a little on the low side. He has only been able to tolerate CPAP [continuous positive airway pressure] for about two and a half hours per night, frequently dislodges the mask, and is pretty miserable. He complains of pretty significant daytime sleepiness and another doctor has actually started him on Ritalin to address this. He’s not one of those people who just hates the CPAP and doesn’t want to wear the device, he’s just unhappy with the outcome. He is otherwise pretty healthy and on no other medications. Upon examination, the patient displays marked septal deviation, the nasal cavum is small, and internal nasal valves are slit-like.

A huge problem, and we see this all the time, people get diagnosed with apnea-even by board-certified sleep doctors-who have symptoms but don’t actually have the disorder. – -B. Tucker Woodson, MD