The Sleep Apnea Evaluation

A Trip to the Doctor

If you have concerns after reviewing the signs and symptoms of obstructive sleep apnea, the best course of action is to make an appointment with your general care provider for his or her professional opinion. If your doctor has little experience with sleep disorders, then make an appointment with a credentialed sleep specialist.

During the appointment, the doctor will ask several questions regarding your sleep habits, family history and lifestyle. He will then perform a physical examination of your nose, mouth and throat. The doctor may order some general blood tests and if he or she suspects you may have a sleep disorder, will recommend an overnight sleep study – polysomnogram – to be performed at a sleep clinic credentialed by the American Academy of Sleep Medicine.

What to Expect at the Sleep Clinic

Your first appointment at the sleep clinic will be spent filling out a long questionnaire concerning your health and family with regard to lifestyle and sleep habits. You will then meet with a sleep specialist – a medical doctor with a multidisciplinary credential in sleep science and neurology, psychiatry or pulmonary. You will answer additional questions as your questionnaire is reviewed, then will undergo a physical examination of your nose, mouth and throat. An appointment will be made for an overnight sleep study, the polysomnogram.

What to Expect During an Overnight Stay at the Sleep Clinic.

You will be scheduled to arrive in the evening with other patients who will be undergoing a polysomnogram. Pack pajamas, toiletries and a change of clothes, for you will be there for a minimum of eight hours and may need to go directly to work from the clinic.

You will be taken to a room decorated much like a hotel room to change into night clothing, after which a technician will attach monitors to your head and different parts of your body. The wires connecting you to a computer are lightweight and hardly noticeable. After you are settled into bed, the lights will be shut down and off to sleep you go. During that time, a technician will be monitoring your respiratory variables including oxygen saturation levels caused by air flow from the mouth and nose, brain waves, heart rate, body and eye movements, snore levels, how many times you wake up, time spent in Non REM and REM sleep stages, and positioning of your body during the night. The next morning, you will be gently awakened and disconnected from the wires so you can shower and dress for the day. There will be an appointment set up for you to meet with your admitting sleep doctor after he or she reviews the sleep study.

How Do They Know if I Need Surgery?

When the sleep specialist assesses your report, it will show how your body is resting at night. If you show decreased oxygen saturation, snoring and a number of apneas, hypopneas and arousals, these can be signs of moderate to severe obstructive sleep apnea.

The categories of sleep apnea are mild, moderate or severe based on the apnea and hypopneas frequencies, separate and combined as an AHI (apnea-hypopneas index). Apnea is a period of 10 seconds or more where you stop breathing. Hypopneas are episodes during sleep of at least 30% decreased shallow breathing lasting 10 seconds or more and 4% or more lowered oxygen saturation.

Sleep Apnea Definitions:

Mild	Moderate	Severe
AHI 5 to 14	AHI 15 to 30	AHI 30 plus
O2 86% or better	O2 80 – 85%	O2 79% or less

There are non-surgical treatments for a diagnosis of mild obstructive sleep apnea such as losing weight, exercise, good sleep hygiene or each night sleeping with a continuous positive airway pressure machine with mask (CPAP) and oral appliances. They can be very effective when adhered to. However, therein lies the problem of compliance. If you do not follow the prescription of the non-surgical treatments every night for the rest of your life, you will not achieve optimum health. If you are diagnosed with moderate to severe obstructive sleep apnea and do not or cannot successfully use these methods, your health can become seriously compromised. Untreated obstructive sleep apnea significantly increases the risk of morbidity and mortality.

You will be referred by the sleep-disorder clinic physician for a surgical consultation if the non-surgical methods are ineffective or you find you cannot tolerate using them. Ask for several recommendations. Foremost the surgeon should at minimum be an otolaryngoligist/head and neck surgeon who is experienced in sleep disorders and their treatment options and associated with a major hospital or university. There are several links on this site to assist you in researching that important information. You can also go to your state’s board of licensing Web site for additional background information.

What Happens at the Surgeon’s Office?

You will bring copies of the polysomnogram and doctor’s reports from your general practitioner and sleep specialist. You will fill out paperwork answering questions about your medical background, sleep habits and concerns for the surgeon’s review and records.

After initial questions about your sleep habits and health, the surgeon will perform an initial evaluation of your nose and/or mouth. The surgeon may decide to further examine your nose, mouth and throat with a fiberoptic laryngoscopy, which involves the use of a very small camera and light to see those structures from the inside. A topical anesthetic will be applied to your nostrils to minimize the discomfort. Depending on the severity of your OSA, the surgeon may require some non-invasive tests before a final surgical treatment plan.

Cephalometric radiograph and panoramic radiograph may be performed in the office during the initial visit. They will provide the surgeon with additional information through measurements of your head and neck’s bony and soft tissue structures that may be contributing to your obstructive sleep apnea. Patients with obstructive sleep apnea either have smaller airway dimensions or floppy airway with a greater tendency to collapse. Any sleep apnea surgical procedure is aimed at enlarging and decreasing the collapsibility of your airway. Your surgeon will study all of the tests and records, then offer a surgical treatment option.

MAXILLOMANDIBULAR ADVANCEMENT

Li KK, Guilleminault C, Riley RW, Powell NB. Obstructive Sleep Apnea, Maxillomandibular Advancement and the Airway: An Assessment of Airway Changes Using Radiographic and Nasopharygoscopic Examinations. Journal of Oral and Maxillofacial Surgery; 60(5):526-530, May 2002.

Li KK, Troell RJ, Powell NB, Riley RW, Guilleminault C. Uvulopalatopharyngoplasty, Maxillomandibular Advancement, and the Velopharynx. Laryngoscope; 111(6):1075-1078, June 2001.

Li KK, Riley RW, Powell NB, Guilleminault C. Patient’s Perception of the Facial Appearance after Maxillomandibular Advancement for Obstructive Sleep Apnea Syndrome. Journal of Oral and Maxillofacial Surgery; 59(4):377-380, April 2001.