A new NIH-funded study at the USC Caruso Department of Otolaryngology – Head and Neck Surgery will try to determine which patients might benefit from a combination of surgery and medication.
By Geoffrey Waring
Anyone who’s been to summer camp, slept in a hostel, or shared a room with family members will be familiar with this scenario. You’re on the cusp of falling asleep, when suddenly, an abrupt sound. A snort, an inhalation, and then it lets loose: the sound of sawing logs.
Snoring is more than an embarrassing habit or a noisy nuisance. It can be indicative of sleep apnea, a sleep disorder that can lead to serious health complications like high blood pressure, stroke, and heart attack. Sleep apnea can make sufferers tired during the day, even after a full night’s sleep, leading to potential trouble at work or car accidents. It is also associated with snoring that can disturb others, of course.
Fortunately, there are ways to treat sleep apnea — and a new 5-year clinical trial funded by the National Institutes of Health to be undertaken by Eric Kezirian, MD, MPH, a sleep surgeon with the USC Caruso Department of Otolaryngology – Head and Neck Surgery, is looking for ways to make treatment for this serious disorder even more effective.
“Surgery is a treatment option for patients with sleep apnea who cannot tolerate positive airway pressure, or CPAP,” said Dr. Kezirian. “Surgery can work very well on its own, but we want to enhance the results by seeing if certain medications to treat other factors important in sleep apnea can enhance the results of treatments like surgery.”
When it comes to surgery, soft palate surgery has generally been the go-to choice for treatment, but it doesn’t always work. An evaluation called drug-induced sleep endoscopy involves a patient receiving sedation for a surgeon to place a telescope into the nose to examine their throat. Surgeons can evaluate the anatomy, learning what kind of surgery may be helpful and whether the patient is a good candidate for surgery.
Dr. Kezirian is one of the world’s experts in this procedure. The problem? It’s expensive for patients and takes time.
“Drug-induced sleep endoscopy is state-of-the-art for surgical evaluation in sleep apnea patients,” said Dr. Kezirian, “but it would be nice to obtain this information without needing to do this procedure.”
The grant will involve collaboration with researchers from Brigham Women’s Hospital in Boston and Michael Khoo, PhD at the USC Viterbi School of Engineering. They will examine the complex breathing patterns on sleep studies, potentially determining who might benefit from soft palate surgery.
“If you could look in a detailed way at the airflow and you could determine what’s going on in the throat to cause the sleep apnea, you would eliminate the need to do the drug-induced sleep endoscopy,” said Dr. Kezirian. “So that would be cool.”
A second part of the trial will involve the combination of medications and sleep surgery. While many cases of sleep apnea are caused by anatomy, there are other reasons for this disorder as well, including how the brain reacts to small obstructions in breathing patterns. This is called “arousal threshold” — how easily one wakes up when airflow is disturbed.
Drugs like acetazolamide and eszopiclone have been shown to help some people with sleep apnea, but on average, the results have not been particularly effective. Dr. Kezirian suspects that this is because these drugs have never been tried in conjunction with sleep surgery.
“The popular saying in real estate is location, location, location,” said Dr. Kezirian. “In treating obstructive sleep apnea, we’re looking at anatomy, anatomy, anatomy. But it might not be that simple. We need to learn more about how to measure and treat other causes of obstructive sleep apnea. There is strong reason to believe that treating a combination of causes should really improve results.”
Dr. Kezirian’s clinical trial will take patients who did not benefit from sleep surgery, giving them the combination of medicines meant to help other factors important in sleep apnea. The results could reveal which types of patients will be helped through surgery, and which may be helped through the use of surgery in combination with medicine.
“Unfortunately, there are many patients with obstructive sleep apnea who cannot tolerate positive airway pressure,” said Dr. Kezirian. “This research is designed to deliver better results for them by improving our ability to select the best candidates for palate surgery and then improve results for those who do not do well by adding inexpensive, well-tolerated medications.”
Dr. Kezirian is a clinician-scientist, meaning he is a doctor who treats patients in a clinical setting while also dedicating a significant portion of his time to research. The USC Caruso Department of Otolaryngology – Head and Neck Surgery places an emphasis on the importance of clinician-scientists, not only through conducting clinical trials like Dr. Kezirian’s sleep study, but also through new education programs like the Clinician-Scientist Training Program (CSTP) for residents and medical students.
“The weak link in the sequence of medical innovation has long been recognized to be translational and clinical research. Bringing a basic science discovery to the point where it improves patient care happens far too slowly and often decades after the original discovery took place,” said Department Chair John S. Oghalai, MD.
“All our faculty and trainees at USC perform research as a part of their daily activities, and what they do changes the way medicine is practiced. This is part of our culture,” said Dr. Oghalai.
“As surgeons treating patients, we see important questions that need to be studied,” said. Dr. Kezirian. “This grant will examine some of these, and I hope this work will improve results for patients.”
To learn more about the exciting research going on at the USC Caruso Department of Otolaryngology-Head and Neck Surgery, click here.