Refer to a Neurologist for Suspected Parasomnia
This 19-year-old man with nocturnal moaning, talking, and breathing sounds during early morning hours, combined with frequent nighttime wakings and no anatomical risk factors for obstructive sleep apnea, most likely has a parasomnia and should be referred to a neurologist for evaluation.
Clinical Reasoning
Why This is NOT Sleep Apnea
The clinical presentation argues strongly against obstructive sleep apnea (OSA):
Normal anatomical features: BMI of 23 (normal weight), Mallampati class I airway (low risk), 13-inch neck circumference (well below the 17-inch threshold for men), and non-deviated septum all indicate very low anatomical risk for OSA 1
Atypical symptoms: The girlfriend describes him "moaning and talking" and "trying to breathe out all of his air" - these are not characteristic descriptions of OSA, which typically presents with witnessed apneas (stopping breathing), gasping, or choking sounds 1
Age and demographics: At 19 years old with normal BMI and no medical comorbidities, he falls outside the typical OSA demographic 1
Why This Suggests Parasomnia
The clinical features point toward a parasomnia, specifically a REM-related parasomnia or possibly catathrenia (nocturnal groaning):
Timing: Early morning hours is when REM sleep predominates, which is when REM-related parasomnias and catathrenia typically occur 1
Vocalizations: Moaning, talking, and prolonged exhalations are characteristic of parasomnias rather than sleep-disordered breathing 1
Frequent wakings: Can occur with various parasomnias and sleep disruptions 1
Why Not the Other Options
Home Sleep Apnea Test (Option b)
Home sleep apnea testing is inappropriate because:
- It is designed for patients with high pretest probability of moderate to severe OSA, which this patient clearly does not have 1, 2, 3
- Home testing cannot capture the complex behaviors, vocalizations, or movements that need to be evaluated in this case 2, 3
ENT Referral (Option c)
ENT evaluation is not indicated because:
- There are no anatomical abnormalities identified (Mallampati I, normal neck circumference, non-deviated septum) 1
- The symptoms do not suggest upper airway obstruction 1
In-Laboratory Polysomnography (Option a)
While polysomnography would eventually be needed to characterize the parasomnia, direct referral to neurology is more appropriate because:
- Parasomnias require specialized interpretation and management by sleep medicine specialists or neurologists 4, 2, 3
- The neurologist can determine if polysomnography is needed and what specific montage/protocol should be used 4, 2
- Parasomnias, particularly those with vocalizations and movements, may require extended EEG monitoring to rule out nocturnal seizures 4, 2, 3
Appropriate Neurological Evaluation
The neurologist will assess for:
- REM sleep behavior disorder: Though uncommon at age 19, it can present with vocalizations and dream enactment 3
- Nocturnal seizures: Can present with vocalizations and require specialized EEG evaluation 4, 2, 3
- Other parasomnias: Including sleep terrors, confusional arousals, or catathrenia 1, 4
The neurologist can then order appropriate testing, which may include video polysomnography with extended EEG montage if seizure activity is suspected 4, 2, 3.
Common Pitfalls to Avoid
Don't assume all nocturnal breathing sounds are sleep apnea: Catathrenia (nocturnal groaning) involves prolonged exhalations with moaning sounds and is a parasomnia, not a breathing disorder 1
Don't order sleep studies without considering the differential diagnosis: The symptoms described are not typical of OSA and require specialized evaluation 4, 2
Don't overlook age-appropriate diagnoses: Young, healthy individuals with normal anatomy rarely have OSA but can have various parasomnias 1, 4