Referral Letter (Sleep Surgery/ENT for OSA Alternatives)

Date: [Date of referral]

To: [ENT/Sleep surgery service or surgeon name if known; facility; fax or secure messaging destination]

From: [Referring clinician name, credentials; clinic; direct phone; NPI if required locally]

Patient: [Full name; DOB; MRN; phone; interpreter needs if relevant]

Urgency: [routine / expedited] (If expedited, briefly state the clinical reason)

RE: Sleep surgery/ENT evaluation for OSA treatment alternatives due to PAP intolerance

Summary

[Concise problem representation] (Limit to one paragraph, no more than six lines. Lead with OSA severity classification and AHI or RDI with study date, followed by the key constraint of PAP intolerance or failure. Briefly list high-impact comorbidities if present. State the specific request, such as candidacy assessment for surgical OSA treatments, drug-induced sleep endoscopy, hypoglossal nerve stimulation evaluation, or nasal optimization. If severity or sleep study data are unknown, explicitly state this rather than inferring.)

Referral Questions

1. [Anatomic assessment request, e.g., determine levels and patterns of upper airway obstruction; indicate if DISE is requested] (Remove if already completed.)
2. [Surgical candidacy question, e.g., assess candidacy for surgical OSA treatments and recommend procedure(s) most likely to address the obstruction pattern]
3. [Hypoglossal nerve stimulation evaluation if applicable, including prerequisites or additional testing needed] (Include only if HNS evaluation is being requested.)
4. [Nasal optimization question, e.g., assess whether nasal surgery could enable PAP re-trial or improve oral appliance tolerance] (Include only if nasal obstruction is a concern.)
5. [Treatment plan request, e.g., recommend sequenced approach with expected outcomes and post-treatment testing needs]

(Tailor questions to the specific case. Remove questions that are not applicable.)

OSA Diagnosis

Study: [PSG / HSAT]; [diagnostic / titration]; [Study date]; [Facility]; [Scoring rule if known]

• AHI or RDI (overall): [Value]
• Positional breakdown: [Supine AHI/RDI]; [Non-supine AHI/RDI] (Include if reported and relevant)
• REM vs NREM: [REM AHI/RDI]; [NREM AHI/RDI] (Include if reported)
• Central apnea index: [Value] (Include if elevated or relevant to HNS candidacy)
• Oxygenation: [Nadir SpO2]; [Time below 88%] (Include if reported)

Severity: [Mild / Moderate / Severe / Unknown] OSA based on [AHI/RDI value] from [study date].

Symptoms: [Sleepiness with ESS score and date if available; witnessed apneas; drowsy driving or safety concerns] (Include only if documented.)

Record status: [Report attached / pending; if pending, state where performed and records request status]

Treatment History

PAP Therapy

• Modality and settings: [CPAP / APAP / BiPAP / ASV]; [Pressure or range]; [Other settings if relevant]
• Date range: [Start date – End date or current]
• Interfaces tried: [Mask types and sizes trialed]
• Troubleshooting attempted: [Mask refits, pressure adjustments, humidification changes, desensitization, DME support, other interventions]
• Objective download data: [Average nightly use]; [% nights ≥4 hours]; [Residual AHI]; [Leak metrics]; [Device model]; [Download date range]
• Patient-reported issues: [Specific intolerance factors: discomfort, claustrophobia, nasal obstruction, aerophagia, etc.]
• Outcome: [intolerance / failure] (Intolerance = unable to use adequately despite troubleshooting; Failure = adequate use with residual disease)

Other Therapies

• Oral appliance: [Type; prescribing dentist; dates; efficacy testing results with date] (Include if trialed)
• Positional therapy: [Device/method; response or efficacy data] (Include if trialed)
• Weight management: [BMI trend with dates; interventions tried; weight change] (Include if relevant)
• Prior airway surgeries: [Procedure(s); dates; outcomes; complications] (Include if applicable)

Relevant Findings

Anatomy

• Anthropometrics: [BMI]; [Neck circumference if measured]
• Nasal exam: [Relevant findings: septal deviation, turbinate hypertrophy, valve collapse, etc.] (If not examined, state "not formally assessed—evaluation requested")
• Oropharyngeal exam: [Tonsil size; Mallampati; palate/tongue position; retrognathia if present] (If not examined, state "not formally assessed")
• DISE findings: [Levels and patterns of obstruction including complete concentric collapse if present] (Only include if DISE was performed; otherwise omit this line)

Perioperative Considerations

• [Relevant cardiopulmonary conditions] (Include only if present)
• [Anticoagulation/antiplatelet therapy and indications] (Include only if applicable)
• [Tobacco, alcohol, sedative or opioid use] (Include only if relevant)
• [Implanted devices with MRI considerations] (Include only if applicable)

Patient Preferences

• Primary goals: [Treatment goals: symptom relief, cardiovascular risk reduction, snoring reduction, etc.]
• Surgical willingness: [open to surgery / prefers to avoid / undecided]; [open to HNS / declines HNS / undecided]; [specific concerns or constraints]

Attachments & Coordination

• Attached: [PSG/HSAT report; PAP download; prior ENT notes; oral appliance documentation; relevant imaging/labs]
• Pending: [Records/tests requested; date requested; source] (Include only if records are pending)
• Requested from consultant: [Consult note with recommendations; candidacy determination; DISE scheduling if indicated; post-treatment testing plan]
• Ongoing OSA care: [Clinician/service managing long-term OSA care]; [Who will coordinate follow-up testing]; [Direct contact for questions]

(Remove any sections or bullets that are not applicable. Do not infer data; explicitly state when information is unknown or pending.)

Thank you for your evaluation and recommendations.

Signature: [Referring clinician name, credentials, clinic, direct phone]