A 45-year-old overweight man with no medical history is referred to you for evaluation of obstructive sleep apnea (OSA). He complains of loud snoring, excessive daytime fatigue & sleepiness. Physical exam is unremarkable except for a BMI of 29 and a crowded oropharynx. His primary care physician ordered a home sleep study that demonstrated mild OSA, with an apnea-hypopnea index (AHI) of 12 events per hour. Treatment with nasal continuous positive airway pressure (CPAP) was initiated, but the patient could not tolerate CPAP despite multiple mask changes, CPAP device adjustments and educational interventions. The patient wants to pursue treatment but cannot tolerate having a mask on his face. In fact, he finds CPAP more disruptive to his sleep.
What is the next appropriate recommendation?
A) Evaluation by sleep dentistry for mandibular advancement device
B) Continuing CPAP with the addition of a sleeping aid such as zolpidem
C) Referral to otolaryngology for hypoglossal nerve stimulator evaluation
D) Stop treatment since the AHI is less than 15 and is considered mild
E) Try a new modern “sleep hack” that has gained recent popularity called “mouth taping”
A) Evaluation by sleep dentistry for mandibular advancement device
Clinical trials have shown that treatment of mild OSA improves daytime symptoms and quality of life. An oral appliance designed to advance the mandible during sleep is an important consideration in patients with mild to moderate OSA. These devices can be used as a first-line treatment option, and it should definitely be considered in those who cannot tolerate CPAP therapy.
Hypoglossal nerve stimulation (HNS) is only approved for patients with moderate to severe OSA who have a BMI <32. Patients who are interested in HNS need to undergo drug-induced sedation endoscopy (DISE), typically performed by an otolaryngologist. DISE is performed under the supervision of an anesthesiologist with infusion of propofol to induce sleep. The goal of DISE is to ensure the patient has anteroposterior narrowing of the upper airway during sleep. This is important because patients who have concentric narrowing of the upper airway on DISE tend not to respond to HNS.
Key Learning Point
For patients with mild to moderate obstructive sleep apnea, dental appliances or oral mandibular advancement devices that prevent the tongue from blocking the throat and/or advance the lower jaw forward can be made. These devices help keep the airway open during sleep
