Tu, Xinhang

Obstructive sleep apnea (OSA) is a common, heterogeneous disorder managed through a multidisciplinary pathway that connects recognition, physiologic testing, treatment selection, specialty referral, insurance coverage, and longitudinal reassessment. This narrative review provides a clinically oriented, system-level overview of the adult OSA care ecosystem in the United States for an international clinical audience, with particular emphasis on the evolving role of otolaryngology. We describe the organization and complementary functions of sleep physicians, otolaryngologists, dentists, and allied health professionals. We also outline the roles of polysomnography and home sleep apnea testing, along with major therapeutic pathways including positive airway pressure, oral appliance therapy, weight management, upper-airway surgery, and neurostimulation. Otolaryngology provides an important interface between physiologic diagnosis and airway-specific treatment by integrating anatomic evaluation, sleep-state airway phenotyping, intervention selection, and post-treatment reassessment. Recent advances in neurostimulation, pharmacologic weight management, wearable and home-based monitoring, airflow analysis, and artificial intelligence are expanding opportunities for accessible and phenotype-informed care. Important challenges include underdiagnosis, treatment attrition, fragmented transitions, variable coverage, and reliance on the apnea–hypopnea index. Although health-care structures differ internationally, multidisciplinary coordination, individualized treatment selection, and longitudinal reassessment provide broadly applicable principles for developing patient-centered OSA programs.

Abstract Introduction Insomnia is a common sleep disorder in pediatric patients with neurodevelopmental disabilities. There are no FDA approved medications for insomnia in the pediatric population, and treatment can be challenging. We present a case of successful treatment of sleep maintenance insomnia in a 15-year-old male with doxepin with supportive actigraphy data. Report of case(s) A 15-year-old male with a past history pertinent for a genetic neurodevelopmental disorder, autism spectrum disorder (ASD) and attention deficit hyperactivity disorder (ADHD) was evaluated in Pediatric Sleep Medicine Clinic for long standing difficulties with sleep maintenance. He experienced frequent, prolonged nocturnal awakenings and early morning awakenings. Previous polysomnogram was negative for sleep disordered breathing. He previously trialed clonidine, guanfacine, trazodone, melatonin, and mirtazapine without significant benefit. Baseline actigraphy demonstrated frequent and prolonged nocturnal awakenings and early morning awakenings. He was initiated on doxepin 3 mg at bedtime, and it was subsequently increased to 6 mg at bedtime. Parental report and repeat actigraphy 4 months later (on doxepin 6 mg) demonstrated improvement in nocturnal awakenings and early morning awakenings. Conclusion Up to now, there are no FDA approved medications for the treatment of insomnia in the pediatric population. A prior study of patients with ASD and ADHD demonstrated the use of doxepin provided clinical improvement in sleep onset and maintenance insomnia based on subjective evidence with parental report. In this case, doxepin improved subjective report of insomnia and correlated with objective findings on actigraphy. Support (if any) NA

Abstract Introduction Kleine-Levin Syndrome (KLS) is a rare disease with intermittent episodes of hypersomnia with behavioral abnormalities. We present a case of KLS with successful symptomatic treatment with modafinil and eventual remission. Report of case(s) A 19-year-old healthy male with no prior sleep disorders was referred for evaluation of hypersomnia. He developed leg cellulitis requiring antibiotic therapy. Shortly afterwards, he developed abnormal behaviors --quitting school, estrangement from friends, sleeping 20 hours a day, irritability, and suppressed appetite. He also demonstrated hypersexuality and disinhibited behaviors. After 10 days, he abruptly returned to baseline and had limited recall of the prior events. Three months later, he had a second episode with similar behavioral and sleep changes, again followed by spontaneous return to baseline after 10 days. Two months later, a similar spell occurred, prompting arrangement for psychiatric admission and initiation of quetiapine for a proposed diagnosis of rapid-cycling bipolar disorder. His symptoms again resolved spontaneously. Diagnostic tests including liver function tests, thyroid function tests, ammonia level, urine drug screen, Lyme disease, MRI brain, EEG, and CSF analysis were unremarkable. He was eventually referred to the Sleep Medicine clinic for evaluation. There were no symptoms suggesting other comorbid sleep disorders, and he had a normal neurologic and physical exam at time of presentation. A clinical diagnosis of KLS was made. The patient and family deferred prophylactic or abortive treatment (such as lithium, carbamazepine, or steroids) due to potential for side effects. Modafinil provided symptomatic benefits during the three milder episodes he had over the next few years. Episodes subsequently resolved and the patient is currently in remission (over 5 years) without sequalae. Conclusion KLS is a rare disease with typical onset during young adulthood, manifesting with abrupt onset of recurrent episodes of hypersomnia and prolonged sleep duration, lasting from days to several weeks. The diagnosis is clinical and requires at least one additional feature including: cognitive dysfunction, derealization, major apathy, or disinhibited behaviors. Patients revert to baseline between the episodes. Stimulants such as modafinil can promote wakefulness during the episodes. Support (if any) N/A

Abstract Introduction The definition of respiratory events has evolved over decades. The current American Academy of Sleep Medicine scoring manual recommends hypopneas be defined by a ≥ 30% airflow reduction with either ≥ 3% desaturation or an arousal, while the prior “recommended” criteria of a ≥ 30% airflow reduction and associated ≥ 4% oxygen desaturation (with no requirement of arousal) was changed to “optional”. Consequently, events previously characterized as a respiratory effort related arousal (RERA) may now be defined as a 3% hypopnea. We hypothesized that while the 3% apnea-hypopnea index (3%AHI) will be higher than the 4%AHI, the 3%AHI will be similar to the 4% respiratory disturbance index (4%RDI), and that the measurement of RERAs under 3% scoring criteria will be clinically insignificant. Methods We prospectively collected 70 consecutive in-lab polysomnography results in 4 adult age groups. We re-scored the respiratory events utilizing the 3% hypopnea rule, and compared the differences between 3% and 4% scoring criteria. Results Among the 70 studies (mean age 50, males 46%), the 3%AHI was significantly higher than the 4%AHI (+9.247 ± 1.161, p< 0.001). This was mainly due to increased hypopnea events (+10.313 ± 1.617, p< 0.001). The 3%AHI was significantly different from the 4%RDI (+7.096 ± 1.133, p< 0.001). There were no significant differences between the 3% and 4% RERA indices, with both values being minimal. Results were similar in both diagnostic and titration phases of testing. Conclusion As previously shown, utilizing the 3% hypopnea rule results in an increased AHI. Most of this difference is related to hypopneas with negligible influence of RERAs. This may lead to increased diagnosis and severity of sleep-disordered breathing in the adult population, and potentially be associated with payer ramifications. Our findings demonstrated negligible RERA indices on average with either rule, thus calling into question the clinical significance of this index in most patients. Support (if any) NA