CASE STUDY 4

48 year old man who was diagnosed to have Severe OSA (AHI of 78, mostly hypopneas) with PSG at UBC 5 years ago and who did well for the first 3 years with CPAP. In recent years, he consumed excessive amounts of alcohol and gained substantial weight. He began to complain of increasing fatigue and cognitive dysfunction. An overnight oximetry showed clusters of desaturation while on CPAP of 10. The CPAP was increased to 11 and he was advised to abstain from alcohol, exercise and he was referred for dietary counselling. He weighed 156 kgs and his BMI was 48. His Epworth score was 8.

Dynamic Nasopharyngoscopy

Narrow velopharynx showing marked lateral collapse with Muller's maneuver. Airway dilates with jaw thrust.

He returned for follow - up 4 months later, having lost 28.7 kgs. He had substantially reduced his alcohol intake and was exercising for 1 hour 3 - 4 times a week. His Epworth score was 5.

The nasopharyngoscopy was repeated.

There was widening of the velopharynx and more airway dilation with jaw thrust. He continued to show marked lateral collapse with Muller's maneuver.

In view of the improvement in his airway, he was offered the option of using a dental appliance in place of the CPAP. He decided to proceed with dental appliance therapy. An overnight oximetry was obtained while wearing the dental appliance (called the "Silencer") and sleeping on a foam wedge that elevates the trunk to ~ 20 degrees above the horizontal.

The ODI was 3. With further weight loss, he will be able to sleep without the wedge and maintain his airway satisfactorily using just the dental appliance.