1288 Primary Epiglottic Collapse: An Unusual Presentation of Obstructive Sleep Apnea Requiring Multidisciplinary Management

Abstract Introduction Among different upper airway anatomic sites that can contribute to obstruction in patients with obstructive sleep apnea (OSA), primary epiglottic collapse has been one of the most understudied entities. Epiglottic collapse has been associated with milder OSA severity, lower BMI, and higher rates of failure with PAP therapy. Despite a growing understanding of this pattern of obstruction, a drug-induced sleep endoscopy is typically needed to make the diagnosis. In patients with primary epiglottic collapse, the epiglottic stiffening procedure can be an effective treatment for OSA. Report of case(s) We report the case of a 33-year-old male patient with a history of mild OSA with an apnea hypopnea index of 10.7 diagnosed via an in-lab polysomnography (PSG) in 2019. The patient was unable to tolerate a continuous positive airway pressure machine. He additionally had a custom-made adjustable oral appliance that did not control his symptoms, primarily snoring, waking up gasping for air, globus, choking, and non-refreshing sleep. He developed comorbid insomnia inadequately treated by pharmacotherapy (melatonin, zaleplon, and trazodone). Due to the refractory nature and severity of his obstructive symptoms, he was referred to ENT for evaluation. He underwent a DISE, which showed complete independent anteroposterior epiglottic collapse. To address the primary site of obstruction, he subsequently underwent the epiglottic stiffening procedure and had an uneventful recovery. At his clinic follow-up, he reported significant improvement in obstructive symptoms of choking and snoring. His 3-month postop PSG showed an AHI of 3.6. Sleep quality improved; however, his insomnia symptoms persisted despite resolution in OSA. Cognitive behavioral therapy for insomnia was initiated. Conclusion Patients with OSA who have primary epiglottic collapse may have a unique presentation and can be quite symptomatic despite milder severity of OSA. The epiglottic stiffening procedure can effectively treat obstructive sleep apnea in a subset of patients where the epiglottis is the primary site of airway collapse. Comorbid insomnia may also need to be addressed separately. This case report highlights the importance of multidisciplinary management in the workup of refractory obstructive sleep apnea. Support (if any)