COMMON SENSE FOR COMMON PROBLEMS
| OBSTRUCTIVE SLEEP APNEA: MODERN THERAPEUTIC CONCEPTS —Erich P. Voigt, MD, Assistant Professor,
Department of Otolaryngology, Weill Cornell Medical College, New York, NY
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| Definitions: apnea—cessation or near-cessation (90% decrease) in airflow for >10 sec in adults, >3 sec in children;
central apnea—caused by lack of respiratory effort, usually due to central nervous system problem; obstructive
apnea—caused by upper airway obstruction; mixed apnea—combination of both types of apnea; hypopnea—airway
reduction lasting >10 sec with 30% reduction of airflow and 4% oxygen desaturation; respiratory effort-related
arousals—obstructive events that do not meet above criteria, but arouse individual from sleep
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| Diagnosis: apnea-hypopnea index (AHI; number of apneas and hypopneas over total sleep time); respiratory distress
index (RDI; all respiratory-related events over time); mild sleep apnea—RDI of 5 to 15 per hour;
moderate—RDI of 15 to 30 per hour; severe—RDI >30/hr
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| Impact of obstructive sleep apnea (OSA): negative effects on cardiovascular and neurocognitive systems; increased
risk for neuropsychologic deficits, hypertension, ischemic heart disease, stroke, and arrhythmia; toll on relationship
with bed partner; loss of work productivity; increased risk for job accidents; United States Department of
Transportation estimates sleep disorders responsible for ≈200,000 motor vehicle accidents, including 1500 deaths,
annually; ≈50 million Americans snore, ≈20 million have sleep-disordered breathing
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| Anatomic sites of obstruction and abnormality: nasal airway—internal and external nasal valves; lateral nasal
wall, eg, hypertrophy of inferior turbinate or adenoids; OSA may improve with surgical correction; tongue—
consider intrinsic and extrinsic musculature; tonsils—lingual and palatine; abnormalities of palate and uvula also
possible
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 | Dental relationships: class II occlusion with retrognathia associated with posterior tongue position and occlusion of
posterior airway; bony manipulation may increase narrowed posterior airway space, alleviating OSA
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| Pharynx: divided into nasopharynx (obstruction due to choanal atresia or adenoidal hypertrophy), oropharynx (obstructed
by palatal abnormalities), hypopharynx (obstructed by toungue-base abnormalities); laryngopharynx;
further subdivisions
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| Pathophysiology: neuromuscular tone maintains waking pharyngeal patency; sleep associated with loss of muscle
tone and increased airway collapsibility; tonsillar hypertrophy, laxity of pharyngeal muscles, craniofacial abnormalities,
and retroposed mandible may worsen compression
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| Other factors: alterations in sleep stages, muscle tone, and central nervous system activity; oxygen and CO2 receptor
abnormalities; changes in pharyngeal mechanoreceptors; hormonal and neurotransmitter abnormalities; cardiopulmonary
disease; blood flow changes due to different body positions
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| Polysomnography: chief tool for assessing patients with OSA; indications—diagnosis of OSA or sleep-disordered
breathing; titration of continuous positive airway pressure (CPAP); assessment of response to medical or surgical
treatment; following disease course
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| Levels: gold standard measures at least 7 parameters; level 1 polysomnography least reliable (only 1-2 variables
recorded); portable studies—advantages include easy access, greater patient convenience (can be done at
home); disadvantages include lack of trained attendant, greater long-term costs (often followed by inpatient
studies)
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| Patient evaluation: history, objective measurement of sleepiness (eg, Epworth Sleepiness Scale [ESS]), thorough
physical examination; cephalometrics, sedated endoscopy, and clinical staging optional; ideally should include
bed partner’s observations; evaluate sleep hygiene; check for other sleep disorders, limb movements, and drug
use; consider OSA systemic disease, and obtain chest x-ray, echocardiography; order full medical examination
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| ESS: completed by patient; assesses likelihood of dozing off during activities of daily living; score >9 correlates
with sleep disorder (can also evaluate therapeutic outcomes)
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| Examination of oral cavity: determine modified Mallampati score according to amount of pharynx visualized
and tonsil size
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| Treatment: clinical staging system devised by Friedman et al; correlates modified Mallampati score with tonsil size
and body mass index (BMI); stage I—favorable Mallampati score; associated with 80% chance for improvement
after tonsillectomy or uvulopalatopharyngoplasty (UPPP), defined as >50% reduction in AHI; stage III—poor
Mallampati score; success rate of surgery ≈8%
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| Therapeutic approach: treat comorbidities; counsel patients on importance of diet, exercise, and avoiding alcohol,
sedatives, and extreme fatigue; encourage use of sleep pillows for sleeping on side
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| CPAP: gold standard for treating OSA; indicated for RDI >30/hr; improves AHI, ESS, maintenance of wakefulness,
and quality of life; long-term compliance poor (≈60%) despite good outcomes; improve compliance through autotitrating
CPAP, patient education, and close follow-up
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| Oral appliances: pull mandible and tongue forward to open posterior airway; indicated for snoring, mild to moderate
sleep apnea, CPAP failure, CPAP adjuvant; contraindicated for central apnea, disorders of temporomandibular
joint, dental disease, and edentulous patients
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| Nasal surgery: does not cure sleep apnea; may improve CPAP compliance by opening nasal airway
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| Tonsillectomy and UPPP: success defined as 50% decrease in AHI and AHI <20/hr; overall success rate 41% (≤75% in
patients with palatal obstruction and ≤21% in patients with mixed obstruction); success rates depend on cause of
sleep apnea; can reduce mortality and cardiovascular morbidity; improve survival, compared to CPAP and no treatment
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| Hypopharyngeal procedures: include radiofrequency ablation, genioglossus advancement, and hyoid suspension;
success rates of 30% to 60% reported from case series; no controlled studies
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| Mandibular-maxillary advancement: excellent choice for patients with severe OSA or CPAP resistance; tracheostomy
option for severe cases
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| Partial tonsillectomy: in speaker’s experience, no complications, good OSA resolution in 30 adult patients
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| TASTE AND SMELL: THE NEGLECTED SENSES —Timothy Smith, MD, Professor and Chief, Division of Rhinology
and Sinus Surgery, Oregon Health and Science University, Portland
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| Terminology: anosmia—complete loss of olfaction; hyposmia—partial loss of olfaction; hyperosmia—enhanced
olfaction; dysosmia—distorted olfaction; 2 basic forms (parosmia [item smells like something else] and phantosmia
[smelling something despite lack of stimulus])
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| Causes of olfactory disorders: sometimes difficult to discern (eg, is problem caused by patient’s long-term hypertension
or by antihypertensive drug?); head injuries involving shearing of olfactory fibers—prognosis poor (<10%
of patients recover normal olfactory function); viral infection—most common cause; diagnose by history of upper
respiratory tract infection followed by loss of smell; may involve direct viral insult to olfactory neuroepithelium; full
spectrum of olfactory disorders seen in these patients; about one-third of patients recover completely, remaining
two-thirds make mild to moderate recovery over several years; conductive loss—most common cause encountered
by otolaryngologists; common etiologies include obstruction of olfactory cleft by polyps and edema; underlying
neuroepithelium usually remains intact, but inflammation thought to be involved; oral steroids indicated; antibiotics
and other medications—may be difficult to distinguish long-term consequences of medical condition from medication
side effect; toxic exposure; age-related olfactory loss—often early symptom of neurodegenerative disease; imaging
studies and further tests indicated if associated neurologic symptoms present; neoplasms—on either side of
cribriform plate; perception of loss of taste—often accompanies all these conditions, despite little measurable loss
on chemosensory tests; patients usually experiencing loss of flavor perception (combination of smell and taste)
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| Chemosensory tests: identification—University of Pennsylvania Smell Identification test (UPSIT) multiple-
choice, scratch-and-sniff test; patient’s correct answers compared to normative data; patient should get ≥10 of 40
correct; threshold—more sophisticated and less common; stimulus (eg, butanol) presented to patient in escalating
concentration to determine olfactory threshold; results compared to normative data
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| Indications for imaging studies: no discernible cause found from history or physical examination; perform computed
tomography (CT) first; consider magnetic resonance imaging (MRI) when other neurologic signs and
symptoms accompany olfactory abnormality; sinus CT best when nasal and sinus disease suspected
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| Treatment of inflammatory nasal and sinus disease: tapering doses of prednisone over 2 wk to “reset” sinonasal
mucosa; antibiotics when bacterial infection suspected; if patient responds to oral steroid, switch to topical
nasal steroid as soon as mucosal inflammation resolved (speaker prescribes prednisolone ophthalmic drops; off-
label use); prednisone burst at holidays and special occasions may allow patient to smell and appreciate flavors;
some of speaker’s patients make informed decision to take low-dose prednisone every other or every third day to
improve olfaction and appreciation of flavors
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| Sinus surgery: some reports of good results, but most studies have limited follow-up and variable postsurgical medical
management; most patients remain hyposmic
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| Counseling patients: warn anosmic patients about hazards, eg, consuming spoiled food
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| MANAGING SNORING —Michael G. Stewart, MD, Professor and Chair, Department of Otolaryngology, Weill
Cornell Medical College, New York, NY
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| Patient evaluation: loud snoring is risk factor for OSA; ask patient and bed partner how much snoring bothers
them; discuss nonsurgical management, eg, weight loss, sleep positioning, trial of oral appliances, alcohol avoidance;
nasal surgery and medical treatment of nasal obstruction often reduce snoring, although seldom helpful in
OSA
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| Surgical and invasive treatments: interventions designed to treat snoring usually not effective for OSA; also,
stiffening of palate probably helps snoring but may make OSA worse; site of snoring—usually uvula and soft
palate, although patient actually snoring from base of tongue or collapse of lateral pharyngeal wall; anatomic
evaluation—use Muller maneuver in office to identify source of obstruction (insert fiberoptic endoscope; ask
patient to reproduce snoring; see where tissue contact occurs; ideally, bed partner present); caveat—patient’s reproduction
of snoring while awake, may not exactly duplicate conditions during sleep when muscle tone less
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| Laser-assisted uvulopalatoplasty (LAUP): effective but painful; must be performed in stages; elevates and tightens
palate, and reduces vibratory portion of uvula; leave some uvula or patients may complain of feeling something
in back of throat
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| Cautery-assisted palatal stiffening operation: remove mucosa from section of uvula and soft palate; palate will contract
and stiffen as wound heals; even more painful than LAUP, but can be done in one stage
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| Injection snoreplasty: injection of sclerosing agent (sodium tetradecyl sulfate [STS]) submucosally to tighten uvula
and soft palate; early results promising, but STS no longer available; other sclerosing agents associated with extreme
pain and fistula formation; procedure rarely performed today
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| Radiofrequency ablation (RFA): radiofrequency waves trim uvula and palate by vaporization; much less painful;
several treatments required; results good; all procedures associated with some risk for relapse, but RFA better
tolerated than more invasive surgeries
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| Pillar implants: pillars injected submucosally at junction of hard and soft palates (minimizes extrusion); pillars become
infiltrated with tissue; not very painful; arbitrary measures of success rate (41% at 3 mo, 22% at 1 yr);
FDA-approved for apnea, but data do not show reduced apnea (RDI increased from 3.7/hr to 5.5/hr)
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| Patient and partner satisfaction: probably best outcome measure; 60% to 80% with many procedures; combination
of procedures may be best
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| PREVENTING MEDICAL ERRORS —Robert M. Wachter, MD, Professor and Associate Chair, Department of
Medicine, University of California, San Francisco, School of Medicine
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| Institute of Medicine (IOM) report: “To Err is Human,” published in 2000; alerted public to problem of medical
mistakes; stated that 44,000 to 98,000 Americans die from medical errors annually; equal to “a large plane
crashing every day”; initiated modern patient safety movement
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| Sample case: “Jane Morrison” hospitalized for cardiac electrophysiology procedure for arrhythmia; “Joan Morris”
admitted for treatment of cerebral aneurysm, which went well; Ms. Morris mistakenly sent next morning for Ms.
Morrison’s cardiac procedure; usual precautions such as consent forms inadequate; error not discovered until ≈2 hr
into procedure, when attending neurovascular physician demanded surgical team recheck patient’s chart; represents
series of errors by several people; “resembles most bad medical mistakes,” ie, good people trying to function
in glitch-prone system with few safety systems
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| Patient safety movement: trying to change view of medical mistakes from individual error, dealt with through
shame and litigation, to problem with system
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| Systems thinking: humans not perfect, therefore use checklists, redundancies, and double-checking to minimize
risk for error
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| “Culture of low expectations”: resignation of nurses and residents to poor communication and poor teamwork; norm of
faulty incomplete information exchange leads to conclusion that red flags reflect poor communication, not possible
catastrophes; more safety-oriented industries insist that staff double-check something when uncertain whether it is
right, not just when they are sure it is wrong; discouraged in health care due to pressure to keep things moving
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| Culture: worst air traffic collision in aviation history occurred because copilot and flight engineer afraid to question
captain’s judgment; after that, industry transformed culture to one in which questions and concerns welcomed, regardless
of rank; in health care, surgeons still often discourage other staff from speaking up; challenge involves
transforming physicians’ views of themselves as professionals (requires change in professional culture)
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Suggested Reading
Bloch KE et al: Ambulatory management of obstructive sleep apnea without polysomnography. Ann Intern Med
147:350, 2007; Doty RL: Olfactory dysfunction and its measurment in the clinic and workplace. Int Arch Occup Environ
Health 79:268, 2006; Duncan HJ, Seiden AM: Long-term follow up of olfactory loss secondary to head trauma
and upper respiratory tract infection. Arch Otolaryngol Head Neck Surg 121:1183, 1995; Ephros HD et al: Developing
a protocol for the surgical management of snoring and obstructive sleep apnea. Atlas Oral Maxillofac Surg Clin
North Am 15:89, 2007; Fleisher KE, Krieger AC: Current trends in the treatment of obstructive sleep apnea. J Oral
Maxillofac Surg 65:2056, 2007; Friedman M et al: Palatal stiffening after failed uvulopalatopharyngoplasty with the
Pillar Implant System. Laryngoscope 116:1956, 2006; Friedman M: Sleep endoscopy versus modified Mallampati
score for OSA and snoring. Laryngoscope 115:2072, 2005; Kern RC et al: Pathology of the olfactory mucosa: implications
for the treatment of olfactory dysfunction. Laryngoscope 114:279, 2004; Kohn LT, Corrigan JM, Donaldson
MS, Eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America,
Institute of Medicine. Washington, DC: National Academy Press, 2000; Shah RK et al: Errors and adverse events in
otolaryngology. Curr Opin Otolaryngol Head Neck Surg 14:164, 2006; Shetty S et al: The management of olfactory
disorders. Br J Hosp Med (Lond) 68:241, 2007; Wise JB et al: Magnetic resonance imaging findings in the evaluation
of traumatic anosmia. Ann Otol Rhinol Laryngol 115:124, 2006.
Educational Objectives
| The goals of this program are to present strategies for diagnosing and managing sleep apnea, snoring, and olfactory
disorders, and to demonstrate the importance of a culture of safety in health care. After hearing and assimilating this
program, the clinician will be better able to:
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| 1. Define the various types of sleep apnea.
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| 2. Diagnose and treat obstructive sleep apnea.
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| 3. Identify the causes of olfactory disorders.
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| 4. Manage a patient who snores.
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| 5. Explain why enhanced patient safety requires a change in professional culture among clinicians.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the following has been
disclosed: Dr. Smith is a consultant for Sinexus. Drs. Voigt, Stewart, and Wachter, and the planning committee reported
nothing to disclose.
Acknowledgements
Drs. Voigt, Smith, and Stewart were recorded at the Otolaryngology Update, held October 25-26, 2007, in New
York, NY, and sponsored by the Weill Cornell Medical College. Dr. Wachter spoke at the UCSF Otolaryngology Update:
2007, held November 8-10, 2007, in San Francisco, CA, and sponsored by the University of California, San
Francisco. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
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