The Complex Sleep Patient
Otolaryngologists who dual board in sleep medicine already have an obvious advantage in working with sleep-disordered patients: They’re otolaryngologists. “The etiology of sleep-disordered breathing is found in the airway, and otolaryngologists are the only specialists trained in the evaluation and treatment of the airway,” Dr. Wardrop said. “Our training allows us to address anatomic issues that affect the successful treatment of our patients. Some patients have issues, such as nasal obstruction, that preclude CPAP compliance. Many patients are intolerant of CPAP or prefer a surgical approach to their issue that will free them from the need to wear CPAP. We offer treatment options that patients need and demand.”
Explore This IssueDecember 2020
Dual-boarded otolaryngologists also view their training in sleep medicine as an essential piece of the diagnostic and treatment puzzle when dealing with disorders. “My sleep medicine training allows me to give my patients a more comprehensive approach to their care,” said Dr. Heubi. “Instead of focusing only on what surgeries I can offer, I can evaluate and manage poor sleep architecture, circadian rhythm disorders, parasomnias, periodic limb movements, narcolepsy, and insomnia. I can read polysomnograms, which in turn helps me better understand the pathophysiology of sleep disorders. I have a depth of sleep knowledge that goes beyond what’s obtained in otolaryngology training.”
Dr. Takashima believes that advanced sleep training is invaluable for otolaryngologists who plan to treat the more complex sleep patient, especially those with OSA. “In order to be an expert in treating patients with OSA, we should know more about the pathophysiology of this disease rather than just be a ‘technician’ doing the surgery,” he said. “There are many nuances of a sleep study that can be analyzed, such as sleep position, to treat patients. Assessing the adequacy of a polysomnography is also important.”
Patients with OSA who aren’t CPAP compliant may require simple machine titration, but often the problem is more complex and multifaceted. Dr. Woodson sees many such patients and reports relatively few whose only problem is sleep apnea. “Often, we find ourselves trying to integrate treatment for a patient who has multiple sleep disorders—sometimes multiple complex sleep disorders,” he said. “Today I saw an elderly gentleman with apnea of greater than 60 events per hour, with predominantly central apnea but also some obstruction. He has a profound but asymptomatic nasal septal deviation and is failing CPAP. In his case, we could be looking at everything from a phrenic nerve neurostimulator implant and trying to address his nasal airway with one of the more complicated CPAP devices, to other interventions, such as positional therapy and addressing underlying medical conditions such as heart failure.
“Complex patients may have a combination of sleep disorders, such as narcolepsy and sleep apnea, or central sleep apnea and insomnia,” Dr. Woodson continued. “Determining how surgery may be part of an integrated treatment isn’t something you can easily do with just one of those two hats on. It comes down to knowing how to integrate the care of the complex patient.”