Multidisciplinary Management of Sleep Disorders — MCQs
A 56-year-old woman with diabetes, hypertension, and hyperlipidemia is found to have an A1C of 11 despite her best attempts at diet and faithfully taking her metformin and glyburide. She reports severe fatigue and sleepiness in the daytime, which has limited her ability to exercise. On examination, she is obese, has a full appearing posterior pharynx, clear lungs, a normal heart examination, and trace bilateral edema. Her TSH is 2.0 m/L (normal). Before adding another oral agent or switching to insulin, what is the best next step?
A 32-year-old man comes to the physician complaining of excessive sleepiness for the past several months. He reports falling asleep while dealing with customers and had a near accident when he fell asleep while driving. The patient reports that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move upon awakening. Which of the following is the most appropriate treatment for this patient?
Which of the following is not typically performed during septoplasty?
Laser uvulopalatoplasty is indicated for which of the following conditions?
Which of the following statements about obstructive sleep apnea is false?
What is the minimum number of apnea episodes required for the diagnosis of obstructive sleep apnea?
A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
All of the following are correct about the image shown except:
In which condition is Young's operation performed?
Which is incorrect about the instrument shown?
Multidisciplinary Management of Sleep Disorders Indian Medical PG Practice Questions and MCQs
Question 1: A 56-year-old woman with diabetes, hypertension, and hyperlipidemia is found to have an A1C of 11 despite her best attempts at diet and faithfully taking her metformin and glyburide. She reports severe fatigue and sleepiness in the daytime, which has limited her ability to exercise. On examination, she is obese, has a full appearing posterior pharynx, clear lungs, a normal heart examination, and trace bilateral edema. Her TSH is 2.0 m/L (normal). Before adding another oral agent or switching to insulin, what is the best next step?
- A. Arrange for a sleep study to check the patient for obstructive sleep apnea. (Correct Answer)
- B. Consider prescribing a sleep aid to help her sleep better and increase her energy to exercise during the day.
- C. Assess for possible depression as a contributor to her fatigue.
- D. Educate the patient on sleep hygiene as a supportive measure to improve her overall well-being.
Explanation: A 56-year-old woman with diabetes, hypertension, and hyperlipidemia is found to have an A1C of 11 despite her best attempts at diet and faithfully taking her metformin and glyburide. She reports severe fatigue and sleepiness in the daytime, which has limited her ability to exercise. On examination, she is obese, has a full appearing posterior pharynx, clear lungs, a normal heart examination, and trace bilateral edema. Her TSH is 2.0 m/L (normal). Before adding another oral agent or switching to insulin, what is the best next step? ***Arrange for a sleep study to check the patient for obstructive sleep apnea.*** - The patient's presentation with **severe fatigue**, **daytime sleepiness**, **obesity**, and a **full-appearing posterior pharynx** are highly suggestive of **obstructive sleep apnea (OSA)** [1]. - OSA can lead to **insulin resistance** and worsen glycemic control, making it a critical factor to address before escalating diabetes medications. *Consider prescribing a sleep aid to help her sleep better and increase her energy to exercise during the day.* - Prescribing a sleep aid without investigating the cause of her sleep disturbances could mask a serious underlying condition like **OSA**, which requires specific treatment [1]. - While improved sleep might transiently boost energy, it would not address the **pathophysiology of OSA** or its impact on diabetes. *Assess for possible depression as a contributor to her fatigue.* - While **depression** can cause fatigue and impact exercise, her physical findings (obesity, full pharynx) and the specific symptom of **daytime sleepiness** point more strongly towards a primary sleep disorder like OSA [1]. - A definitive diagnosis of OSA would better explain the combination of her symptoms and poor glycemic control. *Educate the patient on sleep hygiene as a supportive measure to improve her overall well-being.* - **Sleep hygiene** is important for overall health, but it is unlikely to resolve severe daytime sleepiness and fatigue caused by a mechanical obstruction like in **OSA** [1]. - This intervention would be insufficient to address the potential link between her sleep disorder and uncontrolled diabetes.
Question 2: A 32-year-old man comes to the physician complaining of excessive sleepiness for the past several months. He reports falling asleep while dealing with customers and had a near accident when he fell asleep while driving. The patient reports that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move upon awakening. Which of the following is the most appropriate treatment for this patient?
- A. Melatonin
- B. Modafinil (Correct Answer)
- C. Clonazepam
- D. Continuous positive airway pressure
Explanation: ***Modafinil*** - The patient's symptoms of **excessive daytime sleepiness** (EDS), **hypnagogic hallucinations** (hearing voices while falling asleep), and **sleep paralysis** are classic signs of **narcolepsy**. - **Modafinil** is a **non-amphetamine stimulant** that promotes wakefulness and is a first-line treatment for narcolepsy, improving alertness and reducing EDS. *Melatonin* - **Melatonin** is a hormone involved in regulating the **sleep-wake cycle** and is primarily used for **insomnia**, **jet lag**, or **circadian rhythm disorders**. - It is not effective for treating the hallmark symptoms of narcolepsy, such as cataplexy or excessive daytime sleepiness. *Clonazepam* - **Clonazepam** is a **benzodiazepine** that acts as a central nervous system depressant, primarily used for **anxiety disorders**, seizures, and some sleep disorders like **REM sleep behavior disorder**. - While it can help with some parasomnias, it would worsen daytime sleepiness in a patient with narcolepsy and is not a primary treatment for its core symptoms. *Continuous positive airway pressure* - **Continuous positive airway pressure (CPAP)** is the standard treatment for **obstructive sleep apnea (OSA)**, a condition characterized by recurrent upper airway collapse during sleep. - Although OSA can cause excessive daytime sleepiness, the patient's additional symptoms of hypnagogic hallucinations and sleep paralysis are not typical of OSA, making narcolepsy and its specific treatments more appropriate.
Question 3: Which of the following is not typically performed during septoplasty?
- A. Surgical removal of nasal polyps (Correct Answer)
- B. Throat pack
- C. Nasal packing at the end of surgery
- D. Submucosal resection of deviated cartilage
Explanation: ***Surgical removal of nasal polyps*** - Septoplasty is a surgical procedure specifically designed to correct a **deviated nasal septum** by repositioning or removing obstructing cartilage and bone. - **Nasal polyps** arise from the mucosa of the nasal cavity or sinuses and require a separate procedure, typically **functional endoscopic sinus surgery (FESS)** or polypectomy. - While septoplasty and polypectomy may sometimes be performed together, polyp removal is **not part of standard septoplasty**. *Submucosal resection of deviated cartilage* - This is the **core component of septoplasty** - removing or repositioning deviated septal cartilage while preserving the mucosal lining. - The submucosal approach maintains structural support while correcting the deviation. *Throat pack* - A **throat pack** is routinely placed during septoplasty to **prevent aspiration of blood and secretions** into the pharynx and esophagus. - It protects the airway and is removed at the end of the procedure. *Nasal packing at the end of surgery* - **Nasal packing** (splints or packs) is commonly placed after septoplasty to **control bleeding, support the septum, and prevent hematoma formation**. - Modern techniques may use absorbable or non-absorbable packing materials.
Question 4: Laser uvulopalatoplasty is indicated for which of the following conditions?
- A. Obstructive sleep apnea (Correct Answer)
- B. Pharyngotonsillitis
- C. Cleft palate
- D. Stammering
Explanation: ***Obstructive sleep apnea*** - **Laser uvulopalatoplasty (LUP)** is a surgical procedure that reshapes the **uvula** and **soft palate** to enlarge the airway in patients with **obstructive sleep apnea (OSA)**. - OSA is characterized by repetitive episodes of upper airway obstruction during sleep, leading to snoring, daytime sleepiness, and other health issues. *Pharyngotonsillitis* - This condition involves inflammation of the **pharynx** and **tonsils**, usually caused by bacterial or viral infections. - Treatment typically involves antibiotics for bacterial infections or symptomatic relief for viral infections, not surgical reshaping of the palate. *Cleft palate* - **Cleft palate** is a congenital birth defect where the roof of the mouth does not fully close during fetal development. - The primary treatment involves **surgical repair** to close the opening, which is a different procedure from LUP and focuses on reconstructing normal anatomy. *Stammering* - **Stammering** is a **speech disorder** characterized by disruptions in fluency, such as repetitions, prolongations, or blocks in speech. - It is managed through **speech therapy** and behavioral interventions, and is unrelated to airway obstruction or surgical procedures on the palate.
Question 5: Which of the following statements about obstructive sleep apnea is false?
- A. Apnea is associated with high respiratory effort
- B. Apnea is associated with fall in SpO2
- C. Apnea is associated with sudden awakening
- D. Contraction of pharyngeal muscles can worsen obstruction (Correct Answer)
Explanation: ***Contraction of pharyngeal muscles can worsen obstruction*** - In **obstructive sleep apnea (OSA)**, the pharyngeal muscles are normally responsible for maintaining airway patency [1]. - A *contraction* of these muscles would *open* the airway, whereas *relaxation* or *loss of tone* leads to collapse and obstruction. *Apnea is associated with high respiratory effort* - During an **apneic episode** in OSA, the airway is *obstructed*, leading to continued but **unsuccessful inspiratory efforts** against a closed airway. - This results in a significant increase in **respiratory effort** as the diaphragm and accessory muscles try to overcome the obstruction. *Apnea is associated with fall in SpO2* - The cessation of airflow during **apnea** prevents **gas exchange**, leading to a progressive decrease in **oxygen saturation (SpO2)**. - This **hypoxia** is a hallmark physiological consequence of apneic events and often triggers arousal from sleep [2]. *Apnea is associated with sudden awakening* - The combination of **hypoxia** and **hypercapnia** (increased CO2), along with the increased respiratory effort, stimulates the central nervous system [2]. - This stimulation causes a **brief arousal or awakening** from sleep, often accompanied by gasping or snorting, to re-establish airway patency.
Question 6: What is the minimum number of apnea episodes required for the diagnosis of obstructive sleep apnea?
- A. AHI ≥ 10 events/hour
- B. AHI ≥ 2 events/hour
- C. AHI ≥ 5 events/hour (Correct Answer)
- D. AHI ≥ 4 events/hour
Explanation: ***AHI ≥ 5 events/hour*** - An **apnea-hypopnea index (AHI)** of 5 or more events per hour of sleep, accompanied by symptoms such as **daytime sleepiness**, snoring, or witnessed apneas, is the diagnostic criterion for obstructive sleep apnea (OSA) [1]. - This threshold signifies a clinically significant frequency of **breathing disturbances** during sleep [1]. *AHI ≥ 2 events/hour* - An AHI of 2 events/hour is generally considered within the **normal range** or indicates very mild, non-pathological sleep disordered breathing. - It is **insufficient** to diagnose OSA in adults, even with associated symptoms. *AHI ≥ 10 events/hour* - An AHI of 10 events/hour would indicate at least **mild to moderate OSA**, well above the minimum diagnostic threshold. - While diagnostic, it is not the *minimum* number required for initial diagnosis. *AHI ≥ 4 events/hour* - An AHI of 4 events/hour is close to the diagnostic threshold but still **below the minimum** required for a formal diagnosis of OSA. - It would typically be considered **mild sleep-disordered breathing** that may not meet diagnostic criteria without other significant factors.
Question 7: A 47-year-old man comes to the physician for a follow-up examination. He feels well. He was diagnosed with hypertension 3 months ago. He has smoked one pack of cigarettes daily for 20 years but quit 4 years ago. He occasionally drinks alcohol on the weekends. He walks for 45 minutes daily and eats three meals per day. His current diet consists mostly of canned tuna and cured meats. He started eating whole-wheat bread after he was diagnosed with hypertension. He drinks 1 to 2 cups of coffee daily. His mother has a history of hyperthyroidism. Current medications include hydrochlorothiazide and a multivitamin pill every night before sleeping. His wife told him that he sometimes snores at night, but he reports that he usually sleeps well and feels refreshed in the mornings. His pulse is 80/min, respirations are 18/min, and blood pressure is 148/86 mm Hg. Physical examination shows no abnormalities. Which of the following is the most appropriate next step in the management of this patient?
- A. Counsel on dietary modification (Correct Answer)
- B. Conduct a sleep study
- C. Add metoprolol
- D. Start a structured exercise program
- E. Measure thyroid-stimulating hormone levels
Explanation: ### Counsel on dietary modification - This patient's diet of **canned tuna** and **cured meats** is likely very high in sodium, contributing to his uncontrolled hypertension despite being on hydrochlorothiazide. [2] - Counseling him on a **low-sodium diet** patterned after the **DASH diet** (Dietary Approaches to Stop Hypertension) is the most appropriate next step to improve blood pressure control. [1] ### Conduct a sleep study - While snoring can be a sign of **sleep apnea**, the patient reports sleeping well and feeling refreshed, making sleep apnea less likely to be the primary concern for his hypertension at this point. - Addressing his likely high-sodium diet has a more direct and immediate impact on his uncontrolled blood pressure. [2] ### Add metoprolol - Adding a second antihypertensive medication (like metoprolol) is an option if **lifestyle modifications** and the current diuretic are insufficient. However, addressing preventable dietary factors first is key. - It's important to optimize non-pharmacological interventions before escalating drug therapy, especially when a clear modifiable risk factor like diet is present. [2] ### Start a structured exercise program - The patient already walks for **45 minutes daily**, which meets recommended exercise guidelines (moderate intensity for at least 30 minutes most days of the week). - While an exercise program is generally beneficial, his current exercise regimen is adequate, and dietary sodium is a more prominent and unaddressed factor for his uncontrolled hypertension. [2] ### Measure thyroid-stimulating hormone levels - Although his mother has a history of **hyperthyroidism**, this patient presents with no symptoms suggestive of thyroid dysfunction, such as weight changes, tremors, or significant fatigue. - His controlled pulse and feeling well do not indicate an immediate need for thyroid function testing as a primary cause for his hypertension.
Question 8: All of the following are correct about the image shown except:
- A. Omega shaped epiglottis
- B. High pitched expiratory stridor (Correct Answer)
- C. Cry is normal
- D. 10% cases need surgery due to development of OSA or Cor Pulmonale
Explanation: ***High pitched expiratory stridor*** - The image depicts an **omega-shaped epiglottis** and collapsed aryepiglottic folds, consistent with **laryngomalacia**. - Laryngomalacia typically presents with **inspiratory stridor**, not expiratory, resulting from airway collapse during inspiration. - **This is the EXCEPT answer** - high-pitched expiratory stridor is NOT a feature of laryngomalacia. *Omega shaped epiglottis* - The image clearly shows an **omega-shaped epiglottis**, a characteristic feature of **laryngomalacia**. - This anatomical variation contributes to the collapse of supraglottic structures during inspiration. *Cry is normal* - In laryngomalacia, the **vocal cords** themselves are not affected, so the **cry typically remains normal**. - The abnormal sounds (stridor) arise from the supraglottic structures, not the vocal cord function during crying. *10% cases need surgery due to development of OSA or Cor Pulmonale* - While most cases of laryngomalacia are self-limiting, approximately **10% of infants may require surgical intervention** (supraglottoplasty). - This is usually due to severe symptoms like **obstructive sleep apnea (OSA)**, failure to thrive, or the rare development of **cor pulmonale**.
Question 9: In which condition is Young's operation performed?
- A. Allergic rhinitis
- B. Vasomotor rhinitis
- C. Lupus vulgaris
- D. Atrophic rhinitis (Correct Answer)
Explanation: ***Atrophic rhinitis*** - **Young's operation** is a surgical procedure specifically designed to treat severe cases of **atrophic rhinitis**, aiming to narrow the nasal cavity and promote mucosal regeneration. - Involves **closing the nostrils temporarily** for several months to allow healing and reduce crusting and foul odor associated with the condition. *Allergic rhinitis* - This condition is managed primarily with **antihistamines**, **nasal corticosteroids**, and allergen avoidance, not surgical methods like Young's operation. - It is an **inflammatory response** to allergens, causing sneezing, itching, and rhinorrhea, which is distinct from the mucosal atrophy seen in atrophic rhinitis. *Vasomotor rhinitis* - Vasomotor rhinitis is characterized by **non-allergic triggers** like temperature changes or irritants, leading to nasal congestion and rhinorrhea. - Treatment typically involves **topical nasal sprays** (e.g., ipratropium bromide) or lifestyle modifications, not **Young's operation**. *Lupus vulgaris* - Lupus vulgaris is a form of **cutaneous tuberculosis** affecting the skin, primarily treated with **anti-tubercular drugs**, not a nasal surgical procedure. - It presents as chronic, progressive skin lesions and is unrelated to nasal cavity disorders.
Question 10: Which is incorrect about the instrument shown?
- A. Boyle Davis gag
- B. Uses a draffin bipod stand (Correct Answer)
- C. Used in uvulopalatopharyngoplasty
- D. Used to perform procedures on the tongue
Explanation: ***Uses a draffin bipod stand*** - The image shows a **Boyle-Davis mouth gag** being used, which is typically self-retaining and **does not require an additional stand** such as a Draffin bipod. - The Draffin bipod stand is primarily used with a **Draffin mouth gag** or similar instruments to provide stability and hands-free retraction. *Boyle Davis gag* - The instrument shown suspending the tongue and keeping the mouth open is indeed a **Boyle-Davis self-retaining mouth gag**, commonly used in tonsillectomies and other oral cavity procedures. - Its design includes a central part that keeps the jaws apart and a tongue blade to depress the tongue. *Used in uvulopalatopharyngoplasty* - The Boyle-Davis mouth gag provides excellent exposure of the **oropharynx**, making it suitable for procedures like **uvulopalatopharyngoplasty (UPPP)**, which aims to improve breathing by reshaping the soft palate and uvula. - It allows for clear visualization and access to the surgical area in the back of the throat. *Used to perform procedures on the tongue* - While its primary function is to retract the tongue and keep the mouth open, it also provides good access for procedures directly on the tongue, such as **tongue base reduction** or biopsy. - The tongue blade component directly depresses the tongue, facilitating its manipulation for surgical access.
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