Pell Ann Wardrop, MD, an ENT Today editorial board member, is Assistant Professor of Surgery in the Division of Otolaryngology-Head and Neck Surgery at the University of Kentucky. She is board certified in both otolaryngology and sleep medicine. Her practice in Lexington, KY, encompasses all aspects of pediatric and adult sleep medicine.
The general otolaryngologist’s office practice is full of patients with sleep disorders-the hypertensive male with epistaxis, the snoring child with ADHD, the woman with fatigue and restless sleep. As otolaryngologists, we are often the physicians who recognize and initiate evaluation of sleep disorders in our patients. Given the high prevalence of sleep disorders in the population, it is likely that we fail to diagnose some of these patients with sleep disorders who pass through our offices. A negative sleep test, particularly a type III or IV home test, does not rule out all sleep disorders.
Scope of the Problem
The April 2006 Institute of Medicine report, Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem, contained the following summary:
It is estimated that 50 to 70 million Americans chronically suffer from a disorder of sleep and wakefulness, hindering daily functioning and adversely affecting their health and longevity. The cumulative effects of sleep loss and sleep disorders represent an under-recognized public health problem and have been associated with a wide range of health consequences including an increased risk of hypertension, diabetes, obesity, depression, heart attack, and stroke. Almost 20 percent of all serious car crash injuries in the general population are associated with driver sleepiness. Hundreds of billions of dollars a year are spent on direct medical costs related to sleep disorders such as doctor visits, hospital services, prescriptions, and over-the-counter medications.
Daytime sleepiness is a frequent complaint of those with sleep disorders. While many of these patients have sleep-disordered breathing, some have other sleep disorders causing or contributing to this complaint. Sleep disorders involve abnormalities of the upper and lower airway, central and peripheral nervous system, endocrine system, and cardiorespiratory system. A familiarity with the most common sleep-related causes of daytime sleepiness or fatigue is helpful in evaluating and treating these patients. In addition to sleep disordered breathing, these include restless leg syndrome (RLS), inadequate sleep time, and narcolepsy. Patients who may have sleep disorders other than obstructive sleep apnea are not appropriate candidates for type III or type IV home testing.
Initial Evaluation
For most patients, the evaluation begins with the initial intake questionnaire in the physician’s office (see ENT Sleep Questionnaire sidebar). This general questionnaire should include a few sleep-specific questions such as snoring, witnessed apneas, daytime sleepiness/fatigue, nonrestorative sleep, and frequent awakenings. A positive response to these questions, or the presence of any of the risk factors listed below, could trigger the completion of a more complete sleep-specific questionnaire. The suggested questions listed in the sidebar will help the practitioner assess the patient’s sleep symptoms more accurately. A patient may deny daytime sleepiness, but may be self-medicating with large doses of caffeine. A middle-aged woman may attribute her poor sleep to symptoms of menopause rather than the onset of sleep-disordered breathing. A sleepy patient may lack the insight into the fact that his poor sleep habits and inadequate time in bed are contributing to his symptoms.
Sleep-Disordered Breathing
Sleep-disordered breathing (SDB) is the most common sleep disorder, and it does frequently present with daytime sleepiness. SDB includes obstructive sleep apnea syndrome (OSAS), upper airway resistance syndrome (UARS), snoring, Cheyne-Stokes respiration, and central sleep apnea. The Wisconsin Sleep Cohort study concluded that 82% of men and 93% of women with moderate-to-severe sleep apnea have not received a diagnosis, so OSAS continues to be underdiagnosed.
OSAS is defined as collapse of the airway with physiologic sequelae including excessive daytime sleepiness (EDS), hypertension, stroke, myocardial infarction, cardiac arrhythmia, and congestive heart failure. Patients with OSAS may also complain of difficulty concentrating, memory impairment, chronic fatigue, chronic pain, morning headaches, and difficulty initiating sleep or staying asleep. Patients with SDB can also present with kicking during sleep, which is a response to the airway obstruction. Risk factors for OSAS include hypertension, body mass index (BMI) >25, male gender, age >65, menopause, increased neck circumference, craniofacial abnormalities, and family history. Patients with hypothyroidism, particularly women, can present with OSAS. Home sleep testing can be successfully used in adults for whom there is a high pretest probability of OSAS based on the evaluation and examination. For those patients who become surgical candidates for OSAS, it is not clear how home testing results will be viewed by third-party payers.
The first line of treatment for OSAS is CPAP. Many patients are successfully treated with CPAP if they receive appropriate education and close initial follow-up. Some patients, despite apparently adequate treatment of OSAS, continue to experience daytime sleepiness. For these patients, further evaluation for additional sleep disorders is warranted.
Children and adolescents frequently present with SDB; their presentation can be quite different from that of their adult counterparts. Snoring in children, even those with normal polysomnograms (PSGs), has been associated with hyperactivity, inattention, learning disabilities, lower IQ, attention deficit/hyperactivity disorder, and excessive daytime sleepiness. The cause of these deficits is not yet clear, but treatment of the airway obstruction with tonsillectomy and adenoidectomy does improve the quality of life and behavior of many of these children.
Restless Leg Syndrome
Restless leg syndrome (RLS) is a clinical syndrome that does not require a PSG for diagnosis. The diagnostic criteria are listing in the second sidebar. If a PSG is preformed, 80% to 90% of patients with RLS will have frequent leg movements, also called periodic limb movements. RLS can be caused or aggravated by pregnancy, antidepressants, renal disease, iron deficiency, caffeine, antihistamines, and neurologic lesions. These movements cause frequent arousals from sleep and daytime sleepiness. Type III and IV home sleep testing does not monitor leg movements or EEG, so arousals and limb movements cannot be detected with this testing modality.
Narcolepsy
Narcolepsy is a neurologic disorder of unknown cause, which affects one in 2000 Americans. The cardinal symptom is profound sleepiness, with involuntary sleep attacks during daily activity. The onset of symptoms is usually in the teenage years, but it can arise from childhood to middle age. In addition to daytime sleepiness, a triad of symptoms characterizes narcolepsy: cataplexy, a sudden loss of voluntary muscle tone with emotion; vivid hallucinations during sleep onset or on awakening; and brief episodes of total paralysis at the beginning or end of sleep. The diagnosis of narcolepsy is made with PSG and the multiple sleep latency test (MSLT). PSGs in these patients show disruption of the sleep-wake cycle with early onset REM sleep. The MSLT demonstrates short sleep latency and REM sleep during two or more daytime naps. Only a full PSG can be used to diagnose narcolepsy.
Sleep Deprivation
Surveys have shown that most people are sleeping less than they were 20 years ago. In adults, research has demonstrated many deleterious effects of inadequate sleep on cognitive ability, motor skills, and judgment. People with acute sleep deprivation have slower reaction times, increased cognitive errors, impaired memory and learning, and more volatile emotional responses. Failure to inquire about the amount of sleep may contribute to treatment failures. Despite the best treatment of sleep apnea, a sleepy patient who sleeps only six hours a night will likely remain sleepy and impaired. It is important to caution our patients with inadequate sleep, no matter what the cause, to avoid driving until their sleep disorder is adequately treated.
Children, adolescents, and young adults are particularly at risk for sleep deprivation. While adults need 7.5 to eight hours of sleep, school-age children need 10 hours of sleep each night. In children, short sleep time has been shown to be associated with cognitive dysfunction, behavior disorders, and increased anxiety. Adolescents and young adults need about 9.2 hours of sleep each night, according to studies conducted by Mary Carskadon at Brown University. Unfortunately, sleep duration in this age group averages about seven hours a night, so many high school and college students are significantly sleep-deprived. This contributes to the high rate of motor vehicle accidents and fatalities in teens and young adults. In addition to sleepiness, sleep deprivation in this age group has been correlated with school dysfunction, risk-taking behavior, poor dietary choices, and disciplinary problems.
As otolaryngologists serve as the gateway for diagnosis and treatment of many patients with sleep disorders, increased knowledge of sleep medicine will enhance our ability to provide comprehensive care for our patients. The airway plays a major role in sleep disorders, so otolaryngologists have a major role to play in management of sleep disorders. Failure to adequately educate ourselves about these disorders will narrow the treatment options available to our patients.
ENT Sleep Questionnaire
The one-page questionnaire includes the following:
- Previous evaluation/treatment for OSAS
- Results of CPAP treatment-if cannot tolerate, why?
- Snoring severity
- Witnessed apneas
- Awaken gasping for air
- Nasal obstruction at night
- Sleepwalking, talking, dream enacting
- Difficulty falling/staying asleep
- Hours in bed/asleep each night
- School/work performance issues
- Leg symptoms-urge to move, kicking
- Caffeine, ETOH intake
- Epworth Sleepiness Scale
Diagnostic Criteria for RLS
- Urge to move the legs, with uncomfortable sensations in the legs
- These symptoms are worse during periods of rest
- Urge to move or uncomfortable sensations are relieved by walking/stretching
- Symptoms are worse in the evening or at night
- Not caused by another sleep or medical disorder
Resources
Institute of Medicine. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington DC: National Academies Press, April 2006.
American Academy of Sleep Medicine. International Classification of Sleep Disorders, 2nd Ed. (ICSD 2). Chicago: American Academy of Sleep Medicine, 2005.
National Sleep Foundation: www.nationalsleepfoundation.org
©2008 The Triological Society