Residual Sleepiness in Patients with Obstructive Sleep Apnea a Treatment Challenge for Otolaryngologists

It is vital to take a complete sleep history that includes a wide range of questions addressing habits, health, and family history. The largest culprit in daytime sleepiness, in OSA patients and in the general population, is insufficient sleep. When questioned, many patients report that they are in bed for eight hours, yet they are still tired during the day. In these cases, it is important to probe deeper with questions like:

• Do you sleep through the night? Many patients wake in the middle of the night and watch TV for two hours before falling back to sleep.
• Do you have any pets? According to the CDC, 56% of dog owners and 62% of cat owners report sleeping with their pets, who may disturb their owners with movements and crowding.
• Do you keep any electronics in your room? A TV, computer, cell phone, or tablet can be particularly problematic for children and adolescents.
• Do you nap during the day? A two or three hour nap in the afternoon may prevent patients from being tired enough to fall asleep at bedtime.

The answers to these questions may uncover bad sleep habits that are the real cause of their RES. According to Dr. Shangold, “People sleep four hours and wonder why they are tired. They are tired because they sleep four hours.” These patients may be able to resolve their symptoms by improving their sleep hygiene.

Interestingly, younger patients are more likely to suffer from RES. Although the reason for this is not known, Annelies Verbruggen, MD, otolaryngologist in the department of head and neck surgery at Antwerp University Hospital in Antwerp, Belgium, suggested, “Younger patients often have a more active life: They experience more professional stress and have young children who interrupt their sleep. This could make them more tired.”

Not all RES is behaviorally induced. Many OSA patients have more than one sleep disorder contributing to their symptoms. A careful sleep history can uncover a circadian rhythm disorder. Asking people what hours they would like to sleep if they had no work responsibilities, or what time they rise on weekends or on vacations, can provide a clue to how well they are responding to environmental cues.

If the sleep history fails to uncover the cause, more aggressive testing may be in order. A multiple sleep latency test can identify narcolepsy or hypersomnolence, but only if it is performed under the proper conditions. Patients who are not on regular sleep cycles, who did not get at least six hours of sleep the night before, or who have stimulant or sedating medications in their systems will not obtain valid results.