Diagnosis and Treatment of Sleep Disorders

The Emory Clinic Sleep Disorders Center offers a complete range of diagnostic procedures to identify specific sleep disorders, as well as the latest treatments and therapies to manage the patient's condition. From simple snoring to more severe conditions such as obstructive sleep apnea, the center works with patients to tailor an individualized treatment plan.

Diagnostic Services

The Emory Clinic Sleep Disorders Center uses among the most sophisticated and technologically advanced diagnostic tools available to diagnose patients with sleep disorders. These include:

Polysomnogram

A polysomnogram records information about an individual’s sleep. Sensors are gently attached to a patient’s body which obtain, while the patient sleeps, a continuous recording of brain waves, eye movements, muscle tone, and oxygen levels in the blood, heart rate and rhythm, leg and body movements, sounds made while sleeping, breathing effort, and airflow through the nose and mouth. If other disorders are suspected, additional information is recorded.

The recording is painless, however patients with sensitive skin may notice mild irritation from the sensor adhesive. This equipment can be disconnected during the night, to enable a patient to get out of bed or use the bathroom.

A polysomnogram generally takes place during an overnight stay in the Sleep Center. If you routinely sleep during the day or evenings, your testing hours can be customized with advanced planning. Each of the Sleep Center’s bedrooms are private with an adjoining private bathroom and shower, and patients are monitored from an adjacent control room by an experienced sleep technologist.

Positive Airway Pressure (PAP) Titration Study

If Polysomnography testing shows that an individual demonstrates sleep apnea, a PAP titration study will be ordered to initiate treatment. If the sleep apnea is severe, this may take place during the first overnight sleep study. Otherwise, the individual will need to return for a second all-night sleep study before starting CPAP (Continuous Positive Airway Pressure) therapy.

During the titration study, as the patient sleeps using the CPAP machine, the sleep technologist will record data including the patient’s breathing and make adjustment to the CPAP machine during the night. These adjustments do not require the technologist to awaken the patient. The technologist will use this information to find the level of air pressure that keeps the  airway open and helps the patient to  breathe easily and to reduce the number of times breathing stops to allow better and safer sleep.

Multiple Sleep Latency Test (MSLT)

The MSLT is the standard way to quantify sleepiness and diagnose disorders of excessive sleepiness. Generally used to evaluate for Narcolepsy, this type of polysomnogram is conducted after an overnight polysomnogram to investigate other possible causes of excessive sleepiness (e.g. sleep apnea or periodic limb movements during sleep) and to make sure the patient is not lacking REM (rapid eye movement) sleep. The MSLT begins one-and-a half to two hours after awakening in the morning, with the patient being encouraged to sleep five more times, once every two hours.

Multiple Wakefulness Test (MWT)

This polysomnogram is used to evaluate the ability to stay awake during the day. This is a variation of the MSLT, in which the patient is instructed to attempt to stay awake sitting up in bed, rather than napping, every two hours. MWT testing is available for testing required by the Dept. of Transportation, Federal Airway Adminsitration, and as required by other organizations and employers.

Treatment Services

Our center provides a full range of diagnostic capabilities to manage all types of sleep disorders. Our respected clinical quality is signified by our American Academy of Sleep Medicine (AASM) accreditation. Our board-certified sleep experts provide consultation, treatment coordination and follow-up care with your primary care physician, and work closely with specialists in the fields of cardiology, pulmonology, and neurology.

Our physicians include those named among the “BEST DOCTORS IN AMERICA” and our sleep specialists have performed groundbreaking research on restless legs syndrome, periodic limb movement disorders, sleep apnea, narcolepsy, and excessive daytime sleepiness. Board certified sleep physicians and nurse practitioners utilize medication, CPAP, positioning therapy, weight loss therapy, and oral appliance therapy in the management of sleep disorders.

The current “gold standard” for the treatment of sleep apnea is use of a Continuous Positive Airway Pressure (CPAP) machine. This machine, used with a mask specifically selected by the patient, provides aire pressure that prevents the airway from closing and interrupting breathing. Many types and styles of masks are available, and our staff will work with the patient to determine which works best and is most comfortable for the patient. Consistent use of CPAP for the treatment of sleep apnea is important not only for better sleep, but to avoid more serious consequences of untreated sleep apnea such as:

• Hypertension (high blood pressure)
• Myocardial Infarction (heart attack)
• Stroke
• Arrhythmia (irregular heartbeat)

Everyone has a different experience when using CPAP for the first time. Some find that CPAP is comfortable and easy to use; others find it requires a period of adjustment. Emory Sleep Center is committed to ensuring you receive the education and support required to make your experience with CPAP as successful as possible. Our Center sleep specialists will determine if CPAP is an appropriate treatment method, or whether other treatment methods for sleep apnea should be considered.

Medication

A wide variety of medications are available to manage conditions such as narcolepsy, insomnia, and apneas. Our physicians will develop an individualized medication therapy plan for each patient.

Behavioral Therapy

Behavioral therapies treat the root causes of some sleep disorders. Depending on the type of disorder, recommended programs include:

• Weight loss

• A change in sleep habits

• An exercise regimen

Surgical Options for Obstructive Sleep Apnea

Emory Sleep Center is pleased to announce the arrival of its Director of Sleep Surgery, Raj Dedhia, MD, MS. He is one of a handful of otolaryngologists (ENTs) in the country to be fully trained in sleep medicine. His practice focuses on surgical options for the treatment of obstructive sleep apnea (OSA) as outlined below. Please call 404-778-3381 if you are interested in scheduling a comprehensive evaluation with him.

Am I a Candidate?

In order to be a candidate, you should have tried positive airway pressure (PAP) as this is the first-line treatment for OSA. If you are not able to consistently use PAP therapy, we can look at other treatment options, including oral appliance and surgery.

As a general rule, patients who are 1) obese and/or 2) have more severe sleep apnea will have fewer treatment options available to them.

What are the Surgical Options?

Upper airway surgery to directly treat OSA is not “one size fits all”. There are numerous types of throat surgery for OSA, and it is critical to choose the procedure that corrects the individual’s source(s) of obstruction. Studies have shown that determining the location of the obstruction site can significantly increase success rates. Generally speaking, there are 2 main sources of obstruction: the soft palate and the tongue (Figure 1 - seen at left. “X” marks obstruction behind the soft palate; “O” marks obstruction behind the tongue base). OSA In each patient, I attempt to identify whether there exists a single site of obstruction or double-obstruction. This identification is done with a fiberoptic telescope exam performed through one of the nostrils. The exam can be done in the clinic with the patient awake or with the patient under sedation in the endoscopy suite or operating room. The sedated exam is called drug-induced sleep endoscopy (DISE) and is intended to recreate natural sleep. There are 4 different classes of surgery to improve blockage in the throat. chart

Each of these surgery classes can address both soft palate and tongue-based obstruction. Choosing amongst the 4 options requires consideration of each patient’s OSA severity, throat anatomy, body weight, medical problems and personal preference. Of note, it may take more than 1 procedure to satisfactorily address OSA; thus, the above surgery classes may be performed in a staged manner.

A. Soft tissue surgery

The most common type of soft tissue surgery for OSA is uvulopalatopharyngoplasty (UPPP). I do not perform a traditional UPPP given the risk of certain unwanted side effects; instead, I generally perform a modified UPPP, known as expansion sphincter pharyngoplasty. This version of the procedure is reconstructive as it repositions the throat muscles to open the airway without removing significant tissue. Removal of lingual (i.e. tongue) tonsils and removal of portions of the tongue base can address tongue-based obstruction.

Modified UPPP

Reasons for surgery: soft palate obstruction

Procedure: Surgery is performed in the operating room and you will be under general anesthesia (completely unconscious) with a breathing tube in place. If palatine tonsils are present, they will be removed at the beginning. Next, the soft palate muscles are incised and reattached to a location such that the breathing space is increased. The muscles are set in place with dissolvable sutures. Total operative time is roughly 1.5 hours.

Main risks: Bleeding (3-4%), difficulty swallowing, residual OSA

Recovery: Most patients will spend at least 1 night in the hospital. You will experience a severe sore throat for 2-3 weeks. I recommend patients plan to take at least 2 weeks off from work. You will return for a checkup 3-4 weeks after surgery. More information is available in the handout “Post-operative Instructions after Palate, Tonsil or Tongue Surgery”.

B. Skeletal Surgery

There exist several skeletal surgeries, each designed to address single obstruction (palate or tongue) or double-obstruction. Most commonly, I perform maxillomandibular advancement (MMA), also known as double-jaw surgery. This procedure is designed to treat double-obstruction. MMA has been shown to be very effective in treating OSA. Given the significant recovery time, however, MMA is reserved for motivated patients with limited health problems. 

I perform this surgery with Dr. Gary Bouloux (oral surgeon at Emory) to optimize dental expertise and surgical efficiency.

Maxillomandibular advancement (MMA)

Reasons for surgery: moderate or severe OSA, small upper or lower jaw, double-obstruction

Procedure: Surgery is performed in the operating room and you will be under general anesthesia (completely unconscious) with a breathing tube in place. All incisions are made INSIDE the mouth. The upper jaw is exposed and divided, making sure not to damage the teeth nerves. The upper jaw is pulled forward roughly 10mm and fixated with plates and screws. Next, the lower jaw is exposed and similarly, divided to avoid nerve injury. The lower jaw is pulled forward roughly 10mm (to match the upper jaw) and fixated with plates and screws. Careful attention is given to ensure the bite does not change during the procedure. The incisions are closed with dissolvable suture. Arch bars (i.e. similar to dental braces) are left in place to allow for placement of rubber bands between the jaws. Total operative time is roughly 5 hours.

Main risks: longstanding numbness around the lips, change in dental bite, infection of hardware, residual OSA

Recovery: Most patients will spend 1 night in the ICU for monitoring and another 1-2 nights on the general ward. The rubber bands are removed at the first checkup 1 week after surgery. Over the course of 1-3 months, the amount of jaw opening will continue to increase. Numbness around the lips improves over the course of 3-12 months. Depending upon work type, I recommend patients take off at least 1 month from work. More information is available in the handout “Post-operative Instructions after Maxillo-mandibular Advancement”.

C. Neurostimulatory Surgery

Nerve stimulation therapy represents the most recent advancement in sleep surgery. Currently, the Inspire® is the only device FDA-approved for the treatment of moderate-severe OSA. This therapy works by delivering electrical stimulation, synchronized to the breathing cycle, to the nerve which controls tongue movement (hypoglossal nerve). In essence, electrical stimulation of the tongue prevents falling back of the tongue and soft palate into the airway. Thus, this treatment is designed to treat double-obstruction. In order to qualify for the therapy, however, the patient cannot be obese and must undergo a drug-induced sleep endoscopy (DISE) to ensure a certain type of airway collapse. More information regarding the therapy is available in our office or online at www.inspiresleep.com.

Nerve stimulator implant

Reasons for surgery: moderate or severe OSA, tongue and/or palate obstruction

Procedure: Surgery is performed in the operating room and you will be under general anesthesia (completely unconscious) with a breathing tube in place. A small incision is placed under the jawline on the right side and the hypoglossal nerve is dissected. A stimulation electrode is placed around the nerve. Next, a small incision is made in the right upper chest to place the generator. Finally, a small incision is made along the right rib cage to place the breathing sensor. All incisions are closed with dissolvable sutures. Total operative time is roughly 2.5 hours.

Main risks: longstanding tongue discomfort, infection of hardware, residual OSA

Recovery: Most patients will spend 1 night in the hospital for observation. Soreness over the incisions will be present for 3-5 days. Patients will return for checkup 1 week after surgery. At 1 month, the device will be activated. More information is available in the handout “Post-operative Instructions after Nerve Stimulator Implant”.

D. Tracheostomy

Tracheostomy can be performed as a means of bypassing the upper airway. Tracheostomy is generally highly effective in treating OSA. The main drawbacks of the surgery are aesthetic concerns, maintenance of the stoma (neck opening) and lifestyle change (not able to participate in activities involving submersion in water such as swimming).

Reasons for surgery: persistent OSA despite other interventions, health issues preventing other treatment options

Procedure: Surgery is performed in the operating room and you will be under general anesthesia (completely unconscious) with a breathing tube in place. A small incision is made over the center of the neck. The outside of the trachea is identified. A plastic tube is placed in the trachea and affixed to the skin with non-dissolvable sutures. Total operative time is roughly 1 hour.

Main risks: infection, occlusion of airway, need for revision of stoma

Recovery: Most patients will spend 1 night in the ICU for monitoring and another night on the general ward. Patients will return for checkup and suture removal 1 week after surgery. More information is available in the handout “Post-operative Instructions after Tracheostomy”.

Contact Information 

Dr. Raj Dedhia
Emory University Hospital Midtown
550 Peachtree Street, NE
9th Floor – Suite 4400
Atlanta, Georgia 30308
Phone: 404-778-3381