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A 62-year-old obese businessman presents to the primary care physician at the insistence of his wife. She is accompanying him and says, "He snores loudly all night, which keeps me awake. Sometimes he even seems to start choking or gasping and then wakes a little bit himself before falling back to sleep." When asked, the man agrees that he snores and is frequently sleepy during the day, though he attributes this to working too hard and sleeping too little. His past medical history is significant for hypertension, and constipation. Current medications include hydrochlorothiazide and aspirin. What is the most appropriate next step in evaluating this patient?
A) Magnetic resonance imaging of the upper airway
B) Nasopharyngoscopy
C) Medical workup
D) Sleep study
E) Nasal continuous positive airway pressure (CPAP) treatment
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The correct answer is: C
Although there are no specific physical findings consistent with obstructive sleep apnea (OSA), some general observations can contribute to the diagnosis. Truncal obesity and a large neck circumference (collar size > 17.5 inches) are common, and the oropharynx may be visibly "crowded." In some patients, the uvula is enlarged. Systemic hypertension is seen in approximately half of the patients with OSA. Hypothyroidism should be screened for, especially in older patients or those with symptoms suggestive of hypothyroidism (e.g., constipation and hair loss, as seen in this patient). Therefore, physical examination and thyroid function testing (Choice C) should be performed next with this man.
MRI (Choice A) is an imaging modality that offers excellent resolution of the upper airway and surrounding soft tissues. It is often used before performing uvulopalatopharyngoplasty, the surgical procedure performed most often to correct obstructive sleep apnea. There is no indication for using MRI in the diagnosis of OSA.
Nasopharyngoscopy (Choice B) evaluates the airway lumen and may offer some information about the location of an upper airway obstruction. It too may be used before performing uvulopalatopharyngoplasty, but is not indicated in the diagnosis of OSA.
Sleep studies (Choice D) are typically performed to confirm the diagnosis of OSA. Polysomnography in particular is considered the gold standard for diagnosis. After completing the physical and laboratory evaluation of the patient, polysomnography is indicated.
Nasal CPAP (Choice E) is one of the most popular treatments for OSA, but should not be implemented until the diagnosis is confirmed.
Educational Objective:
If the diagnosis of obstructive sleep apnea is suspected, physical examination and laboratory testing to rule out hypothyroidism should be completed before referring the patient for a sleep study.
