How a Muti Disciplinary Sleep Clinic Work
Updated: Sep 14
Following is a brief outline of a recent clinic day at CSSC.
Patient 1: Young/ overall mild sleep apnoea but predominant when lying flat in REM sleep according to the sleep study. Endoscopic examination of the airway showed there was base of tongue collapse with no soft palate collapse, no side wall collapse, and previous tonsil surgery. Patient was considered best suited for a mouth guard, less suited for surgery. CPAP would be over-treatment. Patient was referred for a 3D printed nylon mouth guard (MAS). The patient understood the reasons and was very happy with the outcome.
Patient 2: BMI of 40. Very sleepy. The sleep study showed severe sleep apnoea. Endoscopy showed severe collapse of soft palate, sidewall of airway and broad base of tongue collapse and reflux-related changes. The primary treatment modality will be APAP trial (automated pressure CPAP) for four weeks. If failure, surgery could be second-line option with combination therapy (combined with weight loss, a side position device, or a mouth guard). Reflux that we diagnosed will be managed with diet and medications. Weight loss surgery was also was considered appropriate. We plan to review in 4 weeks after trial APAP.
Patient 3: Young with a high-intensity job. Very tired and very sleepy. Sleep study showed sleep apnoea in all sleep positions. The endoscopic assessment showed tonsil collapse, severe soft palate and midline base of tongue collapse. The patient was considered moderately suitable for surgery. The plan was CPAP trial for four weeks and if not tolerant to offer surgery.
Patient 4: Young, high-intensity job and extremely sleepy (sleepiness score -18/24). Severe sleep apnoea. Found to be a good candidate for surgery from endoscopic findings. However, recommended to trial CPAP first. When symptoms are worse than expected, as in this case, CPAP can also help determine if all the symptoms are related to sleep apnoea or if there is another cause (such as narcolepsy). If this level of sleepiness was only related to sleep apnoea, the patient should feel much better during the CPAP trial. Plan to Review in four weeks, and if intolerant of CPAP, modern sleep surgery to be offered.
Patient 5: young and fit but overweight (BMI 29). Severe supine position sleep apnoea, small jaw, underbite and severe tongue collapse. Trialled CPAP in the past and failed. Disappointed by that, not trialled any other treatment.
The endoscopic assessment showed a predominant base of tongue collapse with no sidewall collapse and some soft palate collapse. Found to have ideal anatomy for treatment with a 3D printed mouthguard followed by repeat split sleep study (1/2 the night's sleep assessed with the mouth guard on). The patient was happy with the plan.
Patient 6: Seen a sleep doctor/sleep psychologist and failed to use CPAP due to anxiety and insomnia. Referred for surgery, but had some medical co-morbidities. We noted in the sleep study that restless legs syndrome was causing insomnia, which was then causing intolerance to CPAP. We also noted that the patient was vegan with possibly low iron levels, which can cause restless legs. Planned for iron studies and medication for restless legs and insomnia and re-trial of CPAP. If still failed, to plan for modern sleep surgery after optimising general health, as the patient had suitable anatomy. Review in 4-6 weeks.
Patient 7: Trialled CPAP and failed. The patient had a very small jaw and difficult surgical anatomy but preferred surgery over a device and completed surgery five weeks ago. Recovering well with no complications. Already symptoms are 30% better, and likely will be 50% or more when fully recovered. Will be seen in a sleep clinic in two months with a follow-up sleep study. Will obtain a side positioning device due to residual tongue collapse when lying flat.
Patients 8/9 are two weeks after modern sleep surgery. No complications. No deviation from the expected pathway for an excellent outcome.
Patient 10: Had severe sleep apnoea and was intolerant of CPAP due to nasal obstruction. Diagnosed of severe nasal polyps. Had surgery and recovered with excellent nasal function. Sleep Symptoms have improved significantly. The patient wished not to repeat the sleep study or use CPAP due to improved symptoms. GP was notified and will be managed by GP here on with advice to repeat sleep study when the patient is ready and re trail CPAP.
This once again is a typical sleep clinic day. This holistic approach to treating sleep apnea stems from the two doctors desire to combine their knowledge and skill to bring best possible care for the patient. This level of care, assessment, education and tailored treatment has resulted in high patient satisfaction and very high overall success.
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