Shelby Stockton speaks with otolaryngologist Dr. Frank Pernas. They discuss common sleep disorders, how to diagnose them, treat them, and what patients can do about snoring issues and sleep apnea.
Shelby Stockton (00:00):
Welcome to the South Florida ENT audio blog. I'm Shelby Stockton, and today I spoke with otolaryngologist Dr. Frank Pernas. We discussed common sleep disorders, how to diagnose them, treat them, and what patients can do about snoring issues and sleep apnea. If you are a bedmate, suffer from sleep-related issues, take a few minutes to listen to Dr. Pernas's advice about what you can do to get a good night's sleep.
Hello, Dr. Pernas, how are you today?
Dr. Francisco Pernas (00:27):
Hi. Good. Good morning. How are you doing?
Shelby Stockton (00:30):
I am great. I'm excited to talk to you today about sleep, one of my favorite subjects in the world to talk about. I have a few questions for you, so thanks for your time.
Dr. Francisco Pernas (00:39):
Thank you. Thank you for having me.
Shelby Stockton (00:41):
Of course. My first question is, as an ENT specialist, can you give us an overview of your experience in treating sleep related issues?
Dr. Francisco Pernas (00:50):
Yeah. So I think as ENT specialists we're pretty good at identifying sleep issues. We have additional tools. Sleep medicine is divided between ENT specialists and sleep medicine doctors that are pulmonary training based. And as ENT specialists, we have the additional tools that we can look in the back of the nose, look inside the nose, look at the back of the tongue with nasal endoscopy, laryngoscopy, and for obstructive sleep apnea issues as they relate to sleep problems. We are better adapt to identify where the level of obstruction is occurring for these patients, whether it be in the nose, back of the nose, back of the throat. And so identifying the site of the obstruction is really important because then you can really target the therapies better in that sense.
Say somebody has OSA or obstructive sleep apnea, you could look at their nose. And if their nose is congested for example, then you would treat their nasal congestion, which would really help to at least have the patient sleep with their mouth closed, which is sometimes part of the reason that people may snore or have mild sleep apnea. We have special set of unique tools as ENTs that allow us to do those additional tests, whereas a general sleep medicine doctor might order a sleep study and tell you, "You have sleep apnea and here's your CPAP Machine." We can do the same thing, but we can also at the same time to try to identify the level obstruction that this is occurring at and try to give targeted treatments for that level of obstruction.
Shelby Stockton (02:28):
What are the most common sleep disorders related to ENT issues and how do you diagnose and treat them?
Dr. Francisco Pernas (02:34):
Right. So as an adjunct to that first question, while we are very good at taking care of patients that have obstructive sleep apnea, that is where the limit of our expertise ends because we're not really going to treat people that have insomnias or that have other parasomnias or difficulties with sleep. We're really queued in to taking care of patients that have sleep apnea that is caused by obstruction, usually big tonsils, big adenoids, especially in kids and in pediatric population. And in adults it can be redundant tongue, redundant cell palate, nasal obstruction. So we really focus as ENTs on the obstructive sleep apnea, not so much the other types of conditions people can develop with their sleep. We do sometimes treat central sleep apnea, which is the kind of sleep apnea patients get, not when they have an obstruction as the word would indicate, but central indicates that the brain is not telling the body to take a breath. And so we treat those patients the same way we treat our typical OSA patients by putting them on a CPAP or an auto PAP machine.
Shelby Stockton (03:38):
How do you approach your patient's diagnosis and treatment of snoring and sleep apnea?
Dr. Francisco Pernas (03:43):
So the way we approach the patients is usually by taking a good history and physical, trying to really identify, because sometimes patients will come in and say, "I snore," and between snoring and having sleep apnea, there's a spectrum. You can have very mild snoring. The snoring gets louder, gets louder, progressively gets louder, and at a certain stage you start having some obstructions as a result of limitation of space usually in the oral pharynx or hypopharynx. So we try to get a good history of physical identify if the patient might be at risk for having sleep apnea. We have a scale that's called the Sleep Epworth Scale, and that scale we do for all the patients that come in with this kind of complaint gives us a good idea if we have a high threshold for ordering a sleep study.
And once we do, then we order a sleep study. Nowadays, we're doing a lot of home sleep studies, which is very convenient for the patient. They don't have to go to a center and sleep anymore. They can now go and do the test at home. They get the machine at home, they get sent back to the manufacturer, we get the results, and then we review these results in the office. If they have sleep apnea, then we talk about the treatments and if they don't, then we move on to any other complaints that the patient may have.
Shelby Stockton (05:01):
Yeah. Doing the at-home sleep treatments is a game changer for a lot of people because from what I've heard, a lot of people didn't want to go into an overnight facility that wasn't at home to do their sleep testing.
Dr. Francisco Pernas (05:13):
Correct. Some of them were uncomfortable, some of them were not the nicest places, and people have families and they have other obligations that they have to meet and going at 8:00 PM to a sleep center and sleeping there overnight, it's not possible for everybody. Sometimes we do recommend in lab sleep studies. I still order them sometimes, especially for those patients that I suspect have other kind of sleep issues going on because you do get more data from them. You get EEG brainwaves, you get a lot of other data recordings that you don't get with a regular home sleep study. And for very severe patients, we also recommend it too because we need to get a really accurate finding of how often there is cessation of breathing per hour.
Shelby Stockton (05:58):
Oh, that's really good information. Thank you. What surgical and non-surgical interventions do you typically recommend for sleep apnea?
Dr. Francisco Pernas (06:06):
So for sleep apnea, there are many surgeries for sleep apnea, and I always tell my patients when there's so many solutions for one specific problem is that none of those solutions are that good. The key with sleep apnea and figuring out what surgery to offer a patient is to identify again, where we're having the obstruction. If somebody comes in and their nose is completely obstructed with nasal polyps or terminates and they have sleep apnea, you want to really address that first because people that have their nose obstructed or congested tend to open their mouth to sleep at night, and that creates narrowing of the oral pharyngeal space posteriorly. So we try to address that. That's one issue we can potentially address. Somebody comes in and their nose is completely congested, we shrink their turbinates or we remove their polyps and make their nose more open.
Some people have super large tonsils, they're called kissing tonsils. They're basically literally touching in the center, and especially in pediatrics, 20% to 25% of my practice is pediatrics. So for kids, when you have OSA, the gold standard of treatment is to do a tonsillectomy and you cure kids with tonsillectomy. Some adults also have very large tonsils and adenoids, although less commonly, but they can. You take out their tonsils, you take out their adenoids and you trim their palate and you can make a lot of them better. And if they have really mild, you can almost cure the patients. And then there's a lot of other procedures that I don't necessarily do, but that are available for patients out there such as advancement of the genioglossus and hyoid suspension, and they used to have these implants in the soft palette. There's a million things people can do, but generally speaking, the most commonly offered ones are nasal procedures like septoplasty, turbinate reduction or oral pharyngeal procedures such as tonsillectomy and uvulopalatopharyngoplasty, which is abbreviated as UPPP.
Shelby Stockton (08:03):
Are there any recent advancements for sleep related issues that you find to be promising or noteworthy?
Dr. Francisco Pernas (08:10):
The latest and greatest thing that's come out in the market, which a couple of my partners in my practice are doing is the Inspire device. The Inspire device is an implantable, essentially a small pacemaker that goes underneath the skin on the right chest, and there's a wire that goes to the muscle that moves your tongue out and the wire that goes to diaphragm. The concept is that many people that have sleep apnea, their tongue will protrude to the back of their throat and that limits their breathing. So in theory, if you're able to get that muscle, just push it up a little bit forward or it's not in the way anymore, when you take a deep breath, then you're essentially taking care of that obstruction.
So that's what the Inspire machine does, when you go to sleep and there's an external remote that you turn on and you click it on, and then when you take a deep breath, the machine knows you're breathing and it'll push your tongue out by a few millimeters. It's not noticeable, it's not uncomfortable, but it's enough to give you enough space back there so that there's less snoring and there's less sleep out. And that's called the Inspire device.
Shelby Stockton (09:14):
Wonderful. Yes. I've read and heard a lot about that device and it seems to be amazing. I have one more question for you. Have you heard, there's a new trend, it's all over TikTok, mouth taping? What do you think of that?
Dr. Francisco Pernas (09:28):
I don't like mouth taping. I mean, again, if you're a mouth breather and you open your mouth as a habit and there's no obstruction, the other solution to that is a chin strap, which some people wear when they have a CPAP machine just to keep their mouth closed. But I wouldn't recommend doing these things unless somebody's examined you and make sure that your nose is completely open. I mean, imagine if you tape your mouth and you have an allergy and your nose gets blocked, how are you going to breathe? The other thing that some dentists will offer are dental appliances that basically advance your jaw forward for snoring and for mild sleep apnea cases, they work phenomenal.
The only caveat to those dental appliances that they will pull your jaw out slightly and some people can get issues with their temporomandibular joint, they can get some arthritis. So just a word of caution for those mandibular advancement devices, they're good. I usually recommend for some patients that I can tell that they have their jaw fairly posterior just to give them a few extra millimeters back there. But I tell them, if you have any ear pain as a result or any TMJ pain as a result, you should hold off on using them.
Shelby Stockton (10:43):
That's awesome advice. Thank you so much, and thank you for your time. We really appreciate it.
Dr. Francisco Pernas (10:49):
Thank you very much. Thank you for having me. It was a pleasure.
