A 43-year-old man comes to the office with his wife for evaluation of his snoring. His wife reports that he snores loudly most nights and keeps her awake, but she has not observed him choke, gasp, or stop breathing while asleep. The patient is unaware of his snoring and reports no morning headaches, memory loss, or poor concentration. He occasionally falls asleep after lunch while seated at his desk. He reports no fatigue, weight gain, or constipation. His medical problems include seasonal allergies and hypothyroidism. The patient's medications include intranasal fluticasone and levothyroxine. He drinks 12-24 ounces of beer daily, usually 1-2 hours before going to bed. He does not use tobacco or illicit drugs. Both his parents have hypertension. Temperature is 36.8 C (98.2 F), blood pressure is 125/75 mm Hg, pulse is 65/min, and respirations are 16/min. BMI is 26 kg/m² and neck circumference is 39.4 cm (15.5 in). Physical examination reveals an alert, oriented, and cooperative man in no distress. Oropharyngeal examination is normal. No nasal polyps or septal deviation is seen, and the nares are normal in appearance. Cardiac examination reveals normal first and second heart sounds and no jugular venous distension. The lung fields are clear bilaterally. No edema or rashes are present. Laboratory results are as follows: Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: Snoring is a common phenomenon caused by respiration-induced soft tissue vibrations in the setting of a relaxed upper airway during sleep; it can be an isolated finding or a sign of more serious upper airway pathology such as obstructive sleep apnea (OSA). This patient is most likely experiencing habitual snoring in the absence of OSA; although snoring is usually present in patients with OSA (high sensitivity), >50% of patients who snore do not have OSA (low specificity). Surveys, such as the STOP-Bang questionnaire, have poor positive predictive value but high negative predictive value for OSA; patients with a score <3 are unlikely to have OSA and do not require diagnostic testing. Other than habitual snoring and male sex, this patient does not have other characteristics suggestive of OSA, including observed apneas, elevated blood pressure, BMI >35 kg/m², age >50, and neck circumference >43 cm (17 in). Occasionally falling asleep while sitting quietly after lunch is not unusual and does not meet criteria for excessive daytime sleepiness. Although not included in the STOP-Bang survey, absence of either morning headaches or poor concentration during the day also makes OSA less likely. STOP-Bang questionnaire Both smoking (due to an unknown mechanism) and alcohol consumption before bedtime (likely due to relaxation of pharyngeal muscles) are associated with increased snoring. The best initial management of this patient's isolated habitual snoring is to eliminate alcohol intake prior to bedtime. When appropriate, smoking cessation and weight loss are also suitable initial management strategies. (Choices B and C) Monitoring of nocturnal oxygen saturation is a preliminary diagnostic test for OSA, and polysomnography is the gold standard diagnostic test for OSA. Diagnostic testing is not needed in this patient with low clinical probability of OSA. (Choices D and E) Oral appliances are effective at reducing snoring by physical manipulation of the upper airway (eg, mandible advancement, tongue retraction), and uvulopalatopharyngoplasty may reduce snoring through surgical removal of upper airway tissue. However, lifestyle changes to reduce snoring should be pursued prior to these more invasive and costly therapies. Educational objective: Many patients who snore do not have obstructive sleep apnea (OSA); in the absence of other evidence suggesting OSA (eg, hypertension, excessive daytime sleepiness), snoring is not an indication for diagnostic testing for OSA. Smoking cessation and elimination of alcohol intake before bedtime are preferred initial management strategies for snoring. References: Does this patient have obstructive sleep apnea?: The Rational Clinical Examination systematic review. (http://www.ncbi.nlm.nih.gov/pubmed/23989984) Bedtime ethanol increases resistance of upper airways and produces sleep apneas in asymptomatic snorers. (http://www.ncbi.nlm.nih.gov/pubmed/3064641)

A 43-Year-Old Man Comes to the Office with His Wife