Our ProgramThe sleep medicine program within the USC Tina and Rick Caruso Department of Otolaryngology – Head and Neck Surgery at Keck Medicine of USC in Los Angeles is uniquely poised in its ability to provide relief for individuals with snoring and sleep apnea. Snoring and obstructive sleep apnea are important problems that can affect social relationships, health and the ability to get a good night of sleep. Snoring is an important problem that may affect the sleep of others. Obstructive sleep apnea is a more-serious condition. It often involves snoring but also includes intermittent blockage of breathing that can cause health problems and can prevent individuals from achieving deep and restful sleep, thus impacting daily life.
Advances in Sleep Apnea Treatment
Eric Kezirian, MD, MPH
Surgery is generally reserved for treating snoring and sleep apnea in patients who have not benefited from conservative treatments such as weight loss and positive airway pressure therapy. Sleep surgery has evolved beyond the one-size-fits-all approach, and our surgeons are highly skilled in the latest, state-of-the-art procedures and treatments.
Sleep medicine experts within the USC Caruso Department work collaboratively with the USC Sleep Disorders Center that also includes pulmonologists, neurologists and sleep technologists. The center offers comprehensive sleep disorders evaluations and sleep studies either at home or the sleep laboratory.
We offer targeted, effective surgical treatment of snoring and obstructive sleep apnea through a comprehensive approach that is unique in Southern California. Using the most advanced evaluation techniques, we provide a custom treatment plan for each individual patient and offer a variety of options, from minimally invasive office procedures to more-involved surgeries. We are recognized internationally for our expertise and innovative research that directly improves patients’ results. Our surgeons were among the first in the country to perform the Pillar Procedure, a minimally invasive in-office procedure for snoring. Additionally, Keck Medical Center of USC is the only location in Los Angeles offering the Inspire® Upper Airway Stimulation™, recently approved by the Food and Drug Administration, for the treatment of obstructive sleep apnea.
Snoring is a sound produced during sleep caused by vibration of the structures inside the throat and narrowing of the breathing passages. Some studies suggest snoring alone may carry some health risks, although these risks are probably low. Snoring can also negatively impact social relationships as it may disrupt the sleep of others.
Patients with loud, disruptive snoring may have obstructive sleep apnea, a more-serious condition that can have health risks and interfere with the patient’s ability to get restful sleep. A key part of successful treatment is a careful, detailed evaluation that is used to determine the cause of snoring and guide treatment.
Obstructive Sleep Apnea
Obstructive sleep apnea is a condition involving blockage of breathing and can include snoring. The throat is surrounded by soft tissues and muscles., which relax during sleep, and especially, deep sleep. Muscle relaxation during deep, restful sleep allows the muscles and soft tissues around the throat to flutter around and cause snoring or to collapse the space for breathing, resulting in sleep apnea.
Patients with moderate to severe sleep apnea and who have other risk factors, such as obesity, high blood pressure or diabetes, have an increased risk of developing various health problems. These problems might include heart attack, stroke or diabetes, among others.
Patients with sleep apnea may have symptoms such as sleepiness, fatigue or decreased quality of life as a result of disrupted sleep. These symptoms are not related to the severity of obstructive sleep apnea. Some people with mild sleep apnea might feel very tired, while some people with severe sleep apnea may not be tired at all.
Other Sleep Disorders
Many other sleep disorders can occur in combination with snoring or obstructive sleep apnea. The most common sleep disorders are:
- Restless legs syndrome
- Insufficient sleep
- Circadian rhythm disorders (advanced or delayed sleep phase syndrome)
Recognizing other sleep disorders is essential to understanding the benefits of snoring and sleep apnea treatments — as well as treating these other disorders.
Diagnosing Sleep Disorders
Because obstructive sleep apnea often includes loud snoring, a sleep study is used as part of a larger evaluation to help distinguish between the two conditions. Sleep studies can be performed in a sleep laboratory or in a patient’s own bed at home. Home sleep studies generally monitor breathing patterns, oxygen levels and heart rhythms. Studies in the sleep laboratory are more detailed and include brain wave and eye movement monitors, which are used to determine the type of sleep someone is getting and to check for other sleep disorders. A sleep study will determine whether someone has snoring alone or combined with obstructive sleep apnea, which is important in making treatment decisions.
Often, a drug-induced sleep endoscopy is needed to determine the area where the blockage is occurring.
Drug-induced sleep endoscopy
We are leaders in drug-induced sleep endoscopy, an evaluative technique that helps identify the type of breathing obstruction experienced by the patient during sleep. Using this technique, we are able to determine the areas in which blockage or narrowing occurs.
During this procedure, conducted in an operating room, the patient receives just enough sedation to drift off, creating an experience similar to sleep. The physician then uses an endoscope to view the patient’s throat.
Drug-induced sleep endoscopy is not a substitute for a sleep study that evaluates breathing patterns. A sleep study is required to diagnose obstructive sleep apnea. The drug-induced sleep endoscopy shows where the blockage in breathing is occurring, improving the selection of the appropriate surgical approach.
Treatment options for both snoring and obstructive sleep apnea can be separated into four main categories:
Behavioral changes can be very helpful for some patients. These include:
- Weight loss for those who are overweight or obese
- Sleeping on one’s side
- Avoiding alcohol, especially within three to four hours of bedtime
Positive airway pressure therapy (CPAP, BPAP, APAP)
Positive airway pressure therapy – in its various forms such as continuous (CPAP), bilevel (BPAP) or automatic positive airway pressure (APAP) – is the first-line treatment for almost all patients with moderate to severe obstructive sleep apnea.
This treatment uses a machine that functions something like an air compressor with tubing and an interface. This treatment can work very well and has relatively low risks. Positive airway pressure can improve health and sleep quality, and it can improve or eliminate snoring as well. However, positive airway pressure therapy does not work if someone is not able to wear it or sleep comfortably.
Inspire® Upper Airway Stimulation™
Keck Medicine of USC was the first center in Los Angeles to offer Upper Airway Stimulation™ for treatment of sleep apnea. The Upper Airway Stimulation™ system uses a device that is placed inside the body during a surgical procedure. The system analyzes breathing patterns and delivers mild stimulation to key airway muscles to open the airway for breathing during sleep. Read more
Our highly skilled surgeons are able to perform a full range of snoring and sleep apnea procedures. We work with our patients to make decisions that work best for them. We understand that the key to getting the best results for patients is not just the ability to perform a wide range of procedures but also the ability to customize the approach to each patient.
Determining the parts of the nose and throat that cause snoring or sleep apnea is critical to selecting the most appropriate surgical procedures or other options, such as oral appliances. Our surgeons are able to determine the areas in which blockage or narrowing occurs through a careful evaluation of each patient, which includes a thorough patient history, physical examination and drug-induced sleep endoscopy.
The three major regions where blockage or narrowing of the breathing passages can occur are the nasal region, palate region and tongue region. Treatments for each area are presented below:
Nasal blockage, also known as nasal obstruction, is one cause of snoring and obstructive sleep apnea. Nasal obstruction can also make it more difficult for patients with sleep apnea to tolerate positive airway pressure treatment.
Successful treatment of nasal blockage depends first on determining the specific cause. Anything from the tip of the nose through the entire nasal cavity and sinuses can be a source of nasal obstruction. A wide range of treatments is possible once the cause of blockage is determined.
A blocked nasal region may be treated using medications such as nasal saline, corticosteroid or antihistamine sprays, or decongestants. Nasal strips may also be an option.
The following surgical procedures are also options:
Septoplasty is performed when the blockage is related to septal deviation or septal spurs. In septal deviation, the septum is positioned toward one side of the nose. A septal spur is a thickening or bowing of the area where septum cartilage meets the bone or where trauma or a fracture has occurred. In this procedure, the septum is straightened and the cartilage and bone that blocks breathing is removed.
Rhinoplasty and nasal valve surgery are used to treat breathing obstruction that originates in the outwardly visible area of the nose. Obstruction in this part of the nose may have originated at birth or have been caused by previous trauma or surgery. In nasal valve surgery, which is usually performed with septoplasty, pieces of cartilage are used to support the sidewall of the nose and support the narrowed or collapsed area of the nose.
Sinus surgery is an option for patients who have frequent short-term infections or chronic sinusitis but find little relief with nonsurgical treatments. Sinus surgery involves widening the passageways that connect the sinuses to the nose. This procedure aims to reduce the number and severity of sinus infections and make them easier to treat.
Inflammation of the inferior turbinate is a common cause of nasal obstruction. Inflammation may be caused by allergies or exposure to pollution. Reducing the size of the turbinate may be performed via the following techniques: submucous resection and radiofrequency reduction.
- Submucous resection involves making a small incision in the inferior turbinate and removing part of the small bone that supports the turbinate. The procedure allows the nasal lining to shrink thereby increasing the size of the nasal passage.
- Radiofrequency reduction is performed with local anesthesia and without general sedation. Energy is delivered to the turbinate in a controlled manner. The healing process allows the lining to shrink thereby opening the nasal passage.
These procedures may be combined with outfracture, a procedure in which the small bone within the inferior turbinate is broken in order to move the inferior turbinate toward the side of the nose. This creates more space for breathing.
The palate region is the most common area involved in snoring and obstructive sleep apnea.
Surgical Treatment for Snoring:
For snoring, less aggressive procedures can work well because there is less breathing obstruction. The most common procedures for snoring involve stiffening the soft palate, including the Pillar® Procedure, and a few technologies that treat the soft palate with a controlled type of cauterization, or radio frequency.
The Pillar® Procedure
Our surgeons were among the first in the country to perform the Pillar® Procedure in the treatment of snoring. In this minimally invasive, in-office procedure, implants are inserted into the soft palate (the back of the roof of the mouth) to stiffen the soft palate and reduce tissue vibration.
Palate radiofrequency is performed in the office using local anesthesia. This procedure is used to stiffen the soft palate by a controlled cauterization that creates scar tissue. The tissues tighten, creating more space for breathing and reducing tissue vibration. Patients can expect two to three treatment sessions.
Surgical Treatment for Obstructive Sleep Apnea
For obstructive sleep apnea, most patients require more-involved procedures to treat the palate region. The physician will work with you evaluate which treatments will work best for you.
Expansion sphincter pharyngoplasty is an innovative and advanced procedure in which the soft palate is pulled forward by repositioning the muscle that normally sits behind the tonsil. The muscle is moved closer to the front of the mouth creating a space for breathing behind the soft palate. This procedure involves tonsillectomy. Typically, the uvula is not removed.
Lateral pharyngoplasty is a newer procedure that is only performed by a few surgeons in the world. It is used for patients who have thicker tissues of the palate and sides of the throat. This procedure involves a combination of tonsillectomy plus tissue removal and repositioning in the soft palate and side of the throat. It helps to increase the size of the airway.
Uvulopalatopharyngoplasty, also known as U-triple P or UP3, involves tonsillectomy for those patients who have not previously had their tonsils removed, followed by removal of the uvula and a portion of the soft palate. Although it is the most common surgical procedure performed in the United States to treat sleep apnea, our surgeons perform expansion sphincter pharyngoplasty and lateral pharyngoplasty in the majority of our patients who have palate surgery for two reasons:
- They work better. Randomized clinical trials have shown better results with these two procedures, compared to the UP3 procedure.
- These procedures likely carry lower risks than UP3 because they entail tissue repositioning and less tissue removal.
Our experts have unmatched experience with performing tongue region procedures. Two-thirds of patients who have sleep apnea experience obstructed breathing in the tongue region, according to research. Until recently, it had not been possible to treat blockage of this type with surgery. Over the past 20 years, a number of procedures specific to treating this region have been developed. Studies show that combining these procedures with palate surgery improves results.
Blockage in the tongue region can be caused by different structures, including the tongue itself, the sides of the throat and the epiglottis (a structure that functions like a trap door covering the windpipe so that food and liquids do not enter the lungs).
The most common procedures to treat structural issues in the tongue region are:
An epiglottidectomy involves partial removal of the epiglottis. This is a structure in the throat that covers the windpipe so food does not enter the lungs. The procedure is performed through the open mouth without any skin incisions and may involve use of a laser or other method to remove a portion of the epiglottis.
In a genioglossus advancement procedure, the section where the genioglossus – the largest muscle of the tongue – attaches to the lower jaw is moved forward. This procedure creates more room for the tongue to relax during sleep without obstructing the throat. The surgery also enlarges and stabilizes the airway.
The hyoid bone (U-shaped bone in the neck located above the thyroid cartilage) is not firmly anchored, and it may collapse more easily during sleep, causing breathing obstruction. The hyoid suspension procedure secures the hyoid bone to the thyroid cartilage reducing airway obstruction.
In some patients, the lingual tonsils (tonsil tissue located on the back of the tongue) may be enlarged, which may contribute to obstruction of the airway during sleep. In a lingual tonsillectomy, the lingual tonsil is removed to enlarge the airway behind the tongue.
Midline glossectomy (using various techniques including submucosal lingualplasty) is performed in patients with large tongues wherein the size of the tongue contributes to obstruction in sleep apnea. This procedure involves removing portions of the middle and back of the tongue. For extensive procedures, the major blood vessels and nerves are identified via ultrasound prior to the procedure and are protected during the procedure.
Tongue radiofrequency is used to tighten and shrink tongue tissues by a controlled cauterization that creates scar tissue. The procedure makes the tongue less likely to fall backward and block breathing during sleep. It may be performed in two to four treatment sessions in an operating room or outpatient clinic without requiring general anesthesia or sedation.
This procedure is often performed in patients who have not obtained relief from other procedures for sleep apnea. In this procedure, the upper and lower jaws are moved forward enlarging the airway in both the palate and tongue regions. It may also be a first-line treatment for patients who have jaw abnormalities.
USC Sleep Disorders Center
Staffed by board-certified sleep specialists and registered polysomnographic technologists, the USC Sleep Disorders Center delivers a high-quality patient experience.
The center offers sleep studies performed in the four-bed sleep laboratory or in a patient’s own bed at home. Home sleep studies generally monitor breathing patterns, oxygen levels and heart rhythms. Studies in the sleep laboratory are more detailed and include brain wave and eye movement monitors. Sleep studies are necessary to diagnose snoring, obstructive sleep apnea and numerous other sleep disorders. Individuals with sleep irregularities manifested by excessive daytime sleepiness, excessive snoring, witnessed apneas, morning headaches, insomnia and/or abnormal nocturnal movements or behaviors would benefit from a comprehensive sleep evaluation.
Our sleep specialists conduct studies and provide treatments for numerous disorders, including:
- Sleep apnea
- Hypnotic dependent sleep disorder
- Idiopathic hypersomnia
- Kleine-Levin syndrome
- Circadian sleep rhythm disorders
- Delayed and advanced sleep phase syndrome
- Shift-work sleep disorder
- Jet lag
- Irregular sleep wake pattern
- Periodic leg movement disorder
- Restless leg syndrome
- Sleep walking
- Sleep eating
- Sleep paralysis
- REM behavior disorder
- Sleep bruxism
- Pulmonary hypertension with sleep apnea
- Heart failure with sleep apnea