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.
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September 2006A 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
Dr. Walker: Does he ever have a good night with CPAP? When he is able to wear it, does he have a good night, does he notice any benefits? That’s one of the first things I will ask. If they come in totally disgusted with CPAP, I might try something else, but if they are still open minded, I would retry CPAP and work on the nose before going into surgery.
Dr. Senior: In a situation like this I will get into a discussion about nasal issues with the patient. If we fix the septum, that might offer some improvement and make CPAP more effective. It’s always a question mark, though. In my clinical experience it’s about a 50-50 shot, but there are certainly individuals who will see significant benefit. I always like to look at hyperthyroid issues and reflux issues as well.
Dr. Friedman: When a patient comes in like this, they have to understand that we can offer them help, but it might not be ideal. If they are committed to getting rid of CPAP, then I would talk to them immediately about two surgical procedures-one directed at the nose and a second one directed at the palate and, in both procedures, I would address the tongue base with radiofrequency reduction. If I’m committed to a plan of surgical correction, not only would I include the septum, but the nasal valve is also crucial to treat.
Dr. Woodson: More and more I do the nose first. Even if, in general, they’re doing okay with the CPAP, we find that they do much better when we’re more aggressive at treating the nose. Probably 95% of my nasal surgeries are done under local anesthesia and the recuperation, even with severe apnea patients, is just so rapid that many of these people can even go home the same day.
I also use positional therapy a lot; it helps their reflux too. Sometimes, if you just elevate the head of the bed 12 inches or so, you might be able to drop the CPAP rate to 2 to 3 cm and they can now tolerate it.
I do endoscopy on every patient; any patient with an airway issue, snoring or otherwise, deserves full endoscopy. – -Michael Friedman, MD
Dr. Walker: I use positional therapy a lot as well. Until I can get a sleep study on them, I tell them they can’t even sleep in bed-they have to sleep in a recliner. And for people who aren’t tolerating CPAP and are waiting for surgery, I tell them they are not allowed to sleep in bed, and many of them really do better. You even see that in the OR. If someone is obstructing after they’ve been extubated, just sit them up, lean them forward, and they start breathing. Positioning is huge.
Case #2
Dr. Woodson: A 56-year-old, non-obese, postmenopausal female comes in complaining of poor sleep. She wakes up a lot; she had a sleep study and the sleep doctor put her on CPAP. She failed CPAP and says it’s the worst thing that she’s ever had any experience with and, in fact, made her problem much, much worse. She does snore, but she’s not really complaining about that; she’s just tired and not feeling well.
Dr. Walker: In looking at her sleep study, I would probably diagnose her as a symptomatic, very mild apneic. I would guess that the menopause is probably what set it off. I really believe in looking very closely at their metabolic system; she could be tired for a whole lot of reasons. You need to talk to patient to get a really good idea of the whole picture. If she never snored before, she definitely didn’t grow a new uvula-she lost her muscle tone.
Dr. Friedman: I treat the snoring patient in the same way, as far as evaluation, as I would treat any other patient with upper airway problems. I look at the entire airway and I think of it as having multiple areas of potential obstruction. I do endoscopy on every patient; any patient with an airway issue, snoring or otherwise, deserves full endoscopy. If it’s just snoring, I might go back and do more tongue-based radiofrequency; it’s not going to work all the time, but very often it will solve the problem. And it might only work for six months or a year, but then I will just do it again.
Dr. Woodson: I find that, both with apnea and with snoring, it is really quite beneficial to go in there and really see what’s going on. Many times I will do a sedated endoscopy, and if it corroborates what I see in the office, then go on and do Pillar implants, injection snoreplasty, radiofrequency, or whatever. Injection snoreplasty, I think has a pretty good track record.
Dr. Senior: Snoring is really a grab bag, but I would definitely work up the nose, making sure it is as open as possible. I would just want to see, on a very objective level, if the snoring improves with management of nasal obstruction. I also find that endoscopy is very, very helpful. I basically look for the final common pathway for the snoring; I want to see if it’s palatal obstruction.
Dr. Walker: And there are times where you fix the deep vibratory sound; then the patient comes back and now they are wheezing or making some other sound, which might be worse than the snoring. You can sometimes unmask different sounds as you treat others. I simply won’t operate on the unrealistic patient who is looking for complete silence. I think that’s a huge problem.
Dr. Woodson: Another 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.
Don’t assume sleep apnea.
©2006 The Triological Society
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