Sleep apnea secondary to Veteran’s service-connected tinnitus
I opine that it is more likely than not that the veteran’s sleep apnea is caused by and/or aggravated by his service-connected tinnitus.
Lai[i] et al reported in the study Higher prevalence and increased severity of sleep-disordered breathing in male patients with chronic tinnitus: Our experience with 173 cases: “Tinnitus and sleep are closely related. One of the most important aspects of tinnitus is its association with sleep disturbance. According to the literature, up to 71% of patients with tinnitus report sleep problems…” While sleep diseases (SDB) also include insomnia, a large percentage of tinnitus patients suffer from OSA. The Apnea Hypopnea Index (AHI) is the average number of combined apneas and hypopneas per hour. It is most often used to determine the severity of a person’s sleep apnea. Lai et al studied the incidence of sleep apnea as determined by the AHI score in 249 consecutive male patients with chronic tinnitus from August 2015 to August 2016. Of the 173 men enrolled, 16 (9.2%) were normal (AHI < 5), 43 (24.8%) had AHI between 5 and 15, 56 (32.3%) had moderate SDB with AHI between 15 and 30, and 58 (33.5%) had severe SDB (AHI > 30). The group had more overweight patients and less patients with normal BMI; however, the proportion of obese patients was comparable to that of the general population. Hence, BMI may not be considered a main reason for the increase in prevalence of SDB in this study. Lai concluded that SDB is much more common and severe in men with tinnitus. Lai noted that CPAP helps some tinnitus patients by providing better sleep quality and higher oxygenation during sleep. He concluded that tinnitus and SDB may be two sides of the same coin; tinnitus cause OSA and OSA aggravates tinnitus. That is, they are either co-morbidities or etiologically related.
Eysel-Gosepath[ii] et al reported that approximately 60% of patients with tinnitus experience disturbances of the normal sleep pattern. Polysomnography was performed on 26 patients with tinnitus and sleep disturbances. In 17 of 26 patients polysomnography revealed a pathological sleep analysis: 10 patients were diagnosed with obstructive sleep apnea syndrome, 4 with insomnia and an increased index of arousals as well as a reduction of deep sleep and REM phases. Pathological movements of the legs were seen in 3 cases.
In another study, Alster[iii] et al reported:
“Sleep disturbance is a common and frequent complaint reported by tinnitus sufferers. Recent studies have shown that when insomnia and depression are associated with tinnitus there is decreased tolerance and increased discomfort with the tinnitus. The purpose of this study was to assess the reported prevalence and severity of sleep disturbance in chronic tinnitus patients. Patients (n = 80) were military personnel without major psychiatric disturbance and their tinnitus was associated with noise-induced permanent hearing loss (NIHL). Mini Sleep Questionnaire (MSQ) scores for sleep disturbance were found to be higher than those of normal controls in 77% of the patients. Self-rated depressive symptomatology was also highly correlated with sleep disturbance.”
After reviewing all of the veteran’s medical and military records, and an interview with the veteran, it is my expert medical opinion that it is more likely than not (50% or more) that the veteran’s sleep apnea is caused by and/or aggravated by his service-connected conditions of PTSD, migraines and tinnitus. The medical literature supports such a nexus. While each of these conditions solely is sufficient to cause OSA, clearly a combination of these disabilities will cause OSA. The scientific observation that the derangement of REM sleep prominent in the patient with PTSD is the cause for sleep apnea is of particular importance in this case.