Is CPAP the best therapy for all phenotypes of OSA? A case of complete epiglottic collapse treated with CPAP

Different studies estimate the prevalence of epiglottis complete or near-complete collapse among patients with Obstructive Sleep Apnea (OSA) between 11.5 to 26.6%. (1)(2) Treating OSA with Positive Airway Pressure (PAP) therapy in patients with complete or near-complete epiglottis collapse could worsen the severity of disease and cause further suffering for the patient.

73 years old man with medical history of PTSD and severe OSA who is intolerant to CPAP. Multiple attempts for adjusting pressure settings were unsuccessful in improving his tolerance. Possibility of claustrophobia was also considered (particularly due to history of PTSD) but switching full face mask to nasal mask and then nasal pillow was not helpful. Eventually he was evaluated for alternative treatment options for severe OSA and elected to proceed with hypoglossal nerve stimulation therapy. As part of the work up for this procedure, he underwent Drug Induced Sleep Endoscopy (DISE) which showed multilevel obstruction was observed during the procedure including partial concentric collapse at oropharynx, and partial AP collapse at the velopharynx but the most prominent finding was complete Antro-Posterior (AP) epiglottic collapse (EC). This finding likely explains his CPAP intolerance as positive airway pressure would worsen epiglottic collapse.

Variety of underlying mechanisms cause OSA. As discussed for EC, CPAP might not be the optimal treatment for some OSA phenotypes. Current diagnostic approach for OSA does not emphasize the phenotypical varieties among patients. Further diagnostic evaluation, such as utilization of DISE might be helpful in personalized approach to OSA in individual patients.

We are presenting this case to illustrate the importance of more personalized approached for diagnosis and treatment of OSA.