Which specialty to refer a patient for obstructive sleep apnea (OSA)?

From the Guidelines

Patients with obstructive sleep apnea should be referred to a sleep medicine specialist, who may be a pulmonologist, neurologist, otolaryngologist (ENT), or another physician with specialized training in sleep disorders. The initial referral is typically to a sleep medicine specialist who can order and interpret a sleep study (polysomnography) to confirm the diagnosis and assess the severity of the condition 1. If the sleep apnea is related to anatomical issues such as enlarged tonsils or adenoids, a subsequent referral to an ENT specialist may be appropriate. For patients with obesity contributing to their sleep apnea, consultation with a bariatric specialist or nutritionist might also be beneficial 1.

The sleep medicine specialist will develop a treatment plan that may include continuous positive airway pressure (CPAP) therapy, oral appliances, lifestyle modifications, or surgical interventions depending on the patient's specific situation. Key considerations in the decision to refer to a specialist include:

• The presence of major upper airway anatomic abnormalities, such as tonsillar hypertrophy or maxillomandibular deficiencies
• The patient's ability to tolerate and adhere to CPAP therapy
• The potential benefits and risks of surgical interventions, including upper airway surgery and bariatric surgery
• The patient's overall medical history and personal preferences

Early referral is important as untreated sleep apnea can lead to serious complications including cardiovascular problems, metabolic disorders, and neurocognitive impairment 1. The American Academy of Sleep Medicine recommends that clinicians recommend PAP as initial therapy for adults with OSA and a major upper airway anatomic abnormality prior to consideration of referral for upper airway surgery 1. However, the decision to discuss referral for initial surgical therapy should be based on the clinician’s judgment of the patient’s medical history.

From the Research

Specialty Referral for Obstructive Sleep Apnea

The following specialties may be considered for referral:

• ENT (Ear, Nose, and Throat) specialist or otolaryngologist for surgical options such as septoplasty, tonsillectomy, adenoidectomy, uvulopalatopharyngoplasty, mandibular advancement procedures, tongue reduction surgery, hyoid bone suspension, maxillofacial surgery, and bariatric procedures 2
• Dentist or orthodontist for oral appliances such as mandibular advancement devices (MADs) or tongue retaining devices 2, 3
• Sleep specialist or pulmonologist for continuous positive airway pressure (CPAP) therapy and other non-surgical treatments 3, 4, 5
• Surgeon for bariatric procedures or other surgical interventions 2, 3, 5

Considerations for Referral

When referring a patient for obstructive sleep apnea, consider the following:

• Severity of symptoms and apnea-hypopnea index (AHI) 3, 5
• Patient's ability to tolerate CPAP therapy 3, 6
• Presence of other health conditions, such as obesity or cardiovascular disease 3, 5
• Patient's preferences and lifestyle 3, 5

Alternative Treatment Options

Alternative treatment options may be considered for patients who are intolerant to CPAP or have incomplete response to MAD, such as:

• Combination therapy of MAD and nasal CPAP 6
• Hypoglossal nerve stimulation for select patients with a body mass index less than 32 5
• Weight loss and exercise 3, 5
• Oral appliances that hold the jaw forward during sleep 3, 5