CASE STUDY 6

47 year old man investigated at UBC at age 43 and found to have Severe OSA (AHI of 75.5). PSG performed on "Smart CPAP" showed incomplete response with AHI of 30.1. A third PSG with CPAP titration showed elimination of obstructive events at a pressure of 7. He declined CPAP and had a UPPP with minor improvement in symptoms. PSG was not performed to determine if AHI was improved. He was then fitted with a dental appliance that he wore nightly for 3 years. He presented for evaluation because of continued excessive fatigue and sleepiness. He continued to snore, even while wearing the dental appliance. BMI of 27.5. Epworth score of 11.

Dynamic Nasopharyngoscopy

Post - UPPP with excessive lateral collapse, inadequate splinting of the upper airway by the dental appliance.

Oximetry While Wearing the Dental Appliance

Diagnosis - Severe OSA despite use of dental appliance. ODI of 52.

Treatment - Auto - CPAP with base pressure of 6.

Oximetry on Auto - CPAP

Treatment Outcomes - The patient is using the CPAP daily for an average of 6.7 hours each time. He reports increased energy and alertness. ODI of 7.5 on Auto - CPAP of 6, pressure went as high as 8. Epworth score of 5.

This case illustrates the following:

• CPAP non - compliance is common when there is inadequate follow - up. True CPAP failures should be rare.
• Severe OSA does not respond to UPPP.
• Findings on dynamic nasopharyngoscopy must be correlated with findings on oximetry before recommending dental appliance therapy for a patient with OSA. Deep desaturation indicates severe instability of the lateral pharyngeal walls that cannot be treated with a dental appliance. Patients with Severe OSA who do not show deep desaturation may be able to use a dental appliance.

In a UPPP, the tonsils are excised and the palatopharyngeus and palatoglossus are sewed together. This can compromise the beneficial effects of mandibular advancement by:

• Making the hypopharynx shallower
• Pulling the palatoglossus down and back which reduces the tensing effect that this structure has on the soft palate
• Pulling the lateral pharyngeal walls inwards which promotes collapse.

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