Center for Sleep Disorders

Treating Sleep Disorders

The Center offers several surgical and non-surgical treatments for sleep disorders, depending on your particular condition. These treatments include:

  • Implants that reduce or cure soft-palate obstructions
  • Removing the excess tissue that causes blockages
  • Electrical muscle stimulators of the throat and tongue muscles to keep the airway open during sleep
  • Non-surgical solutions such as therapy, custom-fitted masks, straps, oral appliances and dental devices

The treatment of sleep apnea begins with an accurate diagnosis, as some forms of apnea are due to brain disorders and not blockage of the airway. The Center for Sleep Disorders has the most advanced sleep labs for monitoring many aspects of the patient during sleep. Also available are in-home sleep studies, which provide an accurate OSA diagnosis without the inconvenience and expense of staying overnight in a hospital sleep lab.

The in-home sleep study is yet another example of the Center's use of cutting-edge technology in diagnosing and treating sleep disorders.

Nasal Obstruction

Complete medical and surgical treatment of nasal and sinus disorders that play a role in loud snoring or obstructive sleep apnea (OSA) is provided by physicians at The Center for Sleep Disorders at the New York Head and Neck Institute of North Shore-LIJ Health System. We use state-of-the-art advances including video, computer and laser technology.

Nasal obstruction, congestion, pressure around the eyes and headaches are all symptoms of nasal and sinus (the air-filled cavities in the facial bones) disease. We treat these symptoms using endoscopic (a small fiberoptic telescope passed into the nostril) techniques, washing, cleansing and medicines.

Those patients who do not respond to medical treatment may benefit from a variety of office procedures done with fiberoptic laser methods.

These procedures include:

  • Reduction of the turbinate (the scroll-like bones that project into the nostrils, lined by membranes that may swell obstructing the nasal aiway)
  • Septal (the cartilage dividing the nose into nostrils) spur removal
  • Reduction of polyps (benign growths of the lining tissues of the nose)
  • Release of scar tissue between the side walls of the nose and the cartilage dividing the nose into nostrils (septal cartilage)

Almost all of these procedures may be done in the office under topical anesthesia (medication that numbs the area where it is applied) or on an outpatient basis with sedation.

Our goal with minimally invasive nasal operations is to improve nasal breathing, which opens the first part of the airway -- the nose. This improves the quality of sleep, allowing patients to adjust to different masks if they are being treated with CPAP (continuous positive airway pressure) or APAP (automatic positive airway pressure) ventilation during sleep.

In some cases, the nasal airway obstruction may be the only part of the airway obstructed. With removal of the obstruction, the patient begins to breathe through the nose in a normal fashion and loud snoring or mild obstructive sleep apena may be cured.

Laser-Assisted Endoscopic Septal Surgery (LESS)

Deviation or bends of the large cartilage dividing the nose into nostrils is a very common cause of nasal obstruction or blockage of the airflow through the nostrils. Instead of the traditional surgery using a scalpel and other instruments, the Center offers laser-assisted endoscopic septal surgery (LESS).

Endoscopic surgery uses a probe with a tiny camera that transmits images from inside the body to a video monitor. This allows a surgeon to see images of the body's internal structures through very small incisions or through a natural body opening like the nostril. The surgeon uses the laser to perform the actual surgery. Since the incisions are shorter with endoscopy and made with the laser, there is a decreased risk of losing feeling at the tip of the nose.

Many endoscopic procedures can be performed on an outpatient basis under local anesthesia with sedation. Be sure to discuss this possibility with your doctor.

There are several advantages to LESS over traditional surgery:

  • It's an in-office procedure
  • It requires topical and local anesthesia
  • The patient is in sitting position in an ENT chair
  • Discomfort is minimal
  • No bleeding
  • No packing
  • No adhesions (scar tissue after surgery going across the nostril)
  • No perforations (holes in the septal cartilage between the nostrils)
  • Nasal airway improvement
  • Complete healing in two to three weeks
  • Symptomatic improvement in 92 percent of patients (patients report that their breathing through the nose is greatly improved)
  • Rhinometric improvement in 96 percent of patients (using an instrument that measures airflow through the nose)
  • Increased mean nasal cavity volume (a measure of how open the nostrils are)
  • Decreased mean nasal airway resistance (a measure of how easily air flows through the nostrils, or nasal congestion) 

 Laser Ablation of Inferior Turbinate

The scroll-like bones inside the nose are called the inferior turbinates or nasal concha (meaning "like a sea shell"). The swelling of these bones can be a major cause of nasal obstruction. Laser ablation of inferior turbinate is a method that decreases the amount of swelling of the tissues over these bones.
The laser apparatus includes a catheter for guiding the laser beam through the nostril of the patient. The catheter is placed beneath the tissues of the turbinate bones. The heat from the laser beam causes a tissue reaction, so that after the procedure, the lining tissue of the bones no longer swells resulting in nasal obstruction.

Before laser surgery was developed, the procedure usually involved cutting out the bones, resulted in a very dry nose with dry crusting of the mucus, which was very uncomfortable for the patient. Laser surgery to reduce turbinate size delivers less tissue damage, a very high cure rate and few if any changes in the function of the nose.

Testing:
Take the Sino-Nasal Outcome Test (SNOT-20) »
Download the Functional Outcomes of Sleep Questionnaire (FOSQ) 
Download the sleep study form (pdf) for the Center for Sleep Disorders 

Treating Obstructive Sleep Apnea (OSA)/Snoring

Evaluation of the nasal airway, soft palate, base of tongue, lateral pharyngeal walls (the sides of the throat), hyoid position (horseshoe-shaped bone situated in the front of the neck between the chin and the Adam’s apple) and mandibular (jaw) projection is essential. This includes studies such as nasal endoscopy, radiologic studies and cephalometric exams (X-ray studies that measure the size of the airway and relationship of the structures of the airway).

If the history and physical exam suggests evidence of sleep apnea, then an overnight split Sleep Study, or Polysomnogram (PSG) with CPAP (Continuous Positive Airway Pressure) titration (the measure of how much air pressure through a breathing mask is needed to keep the tissue from collapsing and obstructing the airway) is necessary. If you are found to have OSA, the sleep specialist at The Center for Sleep Disorders will work with you and your doctor to plan appropriate treatment.

Patient evaluations include:

  • History
  • Questionnaire
  • Body weight
  • Height
  • Body Mass Index
  • Neck circumference
  • Blood pressure

Non-Surgical Treatment Options

Diet and Fitness

One of the first approaches in the treatment of obesity-related snoring/obstructive sleep apnea is to try to revise the diet and exercise program of the patient. Weight loss and exercise can be one of the best initial, non-surgical solutions to reduce or eliminate snoring/sleep apnea.

Tips on how to stay healthy

Nothing is better for good health than a good night's sleep. Here is some advice regarding sleep hygiene:

  • Avoid alcohol, caffeine, heavy food and exercise in the hours before going to bed.
  • Try to unwind earlier in the evening.
  • Allow yourself to be totally relaxed when your head hits the pillow.
  • Hot tea and a bath will help.
  • Keep the arguments and disputes for the morning.
  • Make a real effort to go to bed at approximately the same time every night.
  • Avoid TV, reading, eating in bed.
  • Keep the bedroom dark, quiet and cool.
  • In order to have a healthy morning, you need to have 7-8 hours quality sleep per night.
  • If you snore, wake up with heart palpitations or choking, or if you have high blood pressure, ask your doctor about sleep apnea, and get tested.

The CPAP (Continuous Positive Airway Pressure) Machine

The CPAP machine is primarily used by patients at home for the treatment of obstructive sleep apnea (OSA). When a patient has obstructive sleep apnea, their airway becomes restricted as the patient's muscles relax naturally during sleep. This causes an awakening episode resulting in the muscles stiffening so the person begins breathing again. The CPAP machine stops the airway collapse by delivering a stream of compressed air through a face mask and hose, keeping the airway open under air pressure so that unobstructed breathing becomes possible. CPAP is very effective at keeping the airway open and reducing the number of times the airway collapses and breathing stops during sleep.

The CPAP machine blows air at a prescribed pressure, the amount of air pressure needed to keep the patient's airway open, which is determined during a sleep study. This titration or measurement allows the machine to be set at the right pressure to keep the airway open most of the time. It is determined by a physician after review of the data from the sleep study done in a sleep laboratory.

CPAP treatment is considered to be highly effective (up to 90 percent) in the treatment of obstructive sleep apnea.

Oral Appliances

There are a number of oral appliances on the market today designed to help reduce snoring/mild sleep apnea. Depending upon how bad the patient's OSA is, these appliances may help to keep the airway open or in the case of loud snoring prevent the fluttering of the soft palate against the back wall of the throat. Some of the oral appliances keep the jaw forward to allow for more airflow, and some keep the tongue from moving back.

Once a doctor examines a patient, and a sleep study is done, it can be determined whether this could be a viable solution. Usually, these devices are effective only for mild OSA or mild to moderately loud snoring.

Surgical Procedures

Pillar™ Palatal Implant System

The Palatal Implant System is an effective treatment for mild to moderate obstructive sleep apnea and snoring. It is a minimally invasive procedure, during which tiny polyester inserts are placed in the tissues above the uvula and soft palate (the arches and little "punching bag" looking structure at the back of the mouth). The threads promote a local tissue reaction that stiffens the soft palate, preventing it from vibrating against the back wall of the throat and producing snoring or airway obstruction.

The Pillar™ Palatal Implant System has a long history of safe use in the body. Some patients report that snoring is reduced almost immediately, and most are able to resume a normal diet and activities the same day as the procedure. This procedure is designed to permanently treat socially disruptive snoring, a serious health and lifestyle problem afflicting more than 27 million Americans and their bed partners.
This procedure, also called palatal restoration, takes only a few minutes in the doctor’s office. After first numbing the area with a local anesthetic, the physician places three tiny Pillar inserts in the patient’s soft palate. Each insert is a thin cord-like device less than an inch long. Unlike other procedures, palatal restoration does not involve heating or removing tissue, which means patients experience minimal discomfort and recovery time is short. Only one treatment is needed, with most patients noting a significant reduction in their snoring within two to four weeks. There is a high probability of a permanent cure of snoring and/or mild to moderately severe OSA with the implant procedure.

To get more extensive information and to see an animated video of this procedure, visit PillarImplant.com

Uvulopalatopharyngoplasty (UPPP)

Uvulopalatopharyngoplasty (UPPP) is surgery to remove the uvula and all, or a part, of the soft palate (see diagram at left, areas of the uvula and soft palate usually removed are highlighted in yellow). The purpose of this procedure is to eliminate snoring or obstructive sleep apnea (OSA). It is most likely that the doctor will also remove your tonsils if they are still present.

Most patients with moderate and severe sleep apnea have experienced great success with this procedure.

Read one of our physicians' recent publication on UPPP.

 Laser Tonsil Ablation

 

Laser ablation of the tonsils (laser cryptolysis) is performed under a local anesthetic and is an outpatient procedure. It is an alternative technique to removal of the tonsils under general anesthesia. Laser cryptolysis or tonsillotomy can effectively ablate (vaporize) up to 80 percent of the tonsillar tissue. It is usually done for patients who have decided not to have a conventional tonsillectomy (tonsil removal), or are unable to have a general anesthetic for medical reasons. This procedure does not completely eliminate all of the tonsil tissue. However, it offers a safe and effective substitute to those patients who would rather have a local procedure (injected anesthesia) done on an outpatient basis. It has been shown to have significant impact on recurrent tonsil stones (rotten food material in the crypts or indentations of the tonsil), causing halitosis (bad breath).

Tongue Suspension

 

Tongue suspension is a surgical technique used in the treatment of airway obstruction due to the back of the tongue falling against the back wall of the throat blocking the airway. The base (back) of the tongue is anchored with a suture, which is then passed through an eyelet screw made of titanium that has been placed into the inside of the middle of the jaw. This is a procedure that prevents the tongue from dropping backwards while the patient is asleep. The phrase "keep them from swallowing their tongue" with regard to helping someone who has lost consciousness (knocked out) describes what this procedure will prevent.

Hyoid Suspension/Laryngoplasy

 

The hyoid suspension is a procedure that was invented to deliver treatment for severe obstructive sleep apnea. This operation brings the tongue base and epiglottis (flap of cartilage that moves down over the voice box when swallowing to prevent food and saliva from going into the lungs) forward, so that the breathing passage is opened and improved. The hyoid bone is located in the neck, and some of the muscles of the tongue attach to it. When the hyoid bone containing the attached tongue muscles is pulled forward and upward toward the jaw, it opens and increases the airway diameter behind the tongue.

The hyoid suspension is performed under either local sedation or general anesthesia. Usually, an overnight hospital stay is required for observation. The vocal cords and the voice should not be affected by this procedure.

Hypoglossal Nerve Stimulation

This procedure, which is a patient-activated, implantable therapy to treat obstructive sleep apnea, looks very promising but is not yet FDA approved. There are currently three U.S. companies developing implantable neurostimulation systems for OSA. These therapy devices function like a heart pacemaker firing a small electrical impulse when the tongue starts to fall backward and block the airway. The tongue muscles tense and the tongue moves forward and upward, thereby preventing airway obstruction during sleep.

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Meet An Expert

Yosef Krespi, MD, FACS

Yosef Krespi, MD, FACS

Yosef Krespi, MD, FACS is the Director, Center for Sleep Disorders, NYHNI, Associate Director, Head & Neck Surgery Service Line, North Shore-LIJ.


Harly Greenberg, MD, FAASM, FCCP

Harly Greenberg, MD, FAASM, FCCP

Harly Greenberg, MD, FAASM, FCCP is Medical Director, North Shore-LIJ Sleep Disorders Center; Program Director, Hofstra-North Shore LIJ Sleep Medicine Fellowship Program; and Professor of Medicine, Hofstra-North Shore-LIJ School of Medicine.