Ear Nose Throat | Mount Sinai Today

Is the Sore in My Mouth an Oral Lesion?

Updated on May 2, 2024 | Dental and Oral Health, Ear Nose Throat, Your Health

Have you noticed a wound in your mouth that is not healing? Maybe you also noticed it has a bump or area that seems unnaturally firm to the touch? If these symptoms sound familiar to you, you may have an oral lesion.

Mohemmed Nazir Khan, MD

In this Q&A, Mohemmed Nazir Khan, MD, an Assistant Professor at the Department of Otolaryngology at Mount Sinai-Union Square and a surgeon at Mount Sinai’s Head and Neck Institute—Center of Excellence for Head and Neck Cancer, explains the importance of detecting oral lesions early. While regular dental appointments are important, anything that looks or feels suspicious should be checked out immediately.

“Even if it turns out to be nothing, it is better to be safe than sorry,” he says. “I know the thought of a consultation can be scary, but the earlier we intervene, the better your outcomes will be.”

What is an oral lesion?

An oral lesion is an abnormal cell growth in your mouth, which has the potential to become cancerous. There are several telltale signs that you should look for, including:

A cut or sore in the mouth that becomes painful and has an underlying bump. This may be accompanied by bumps on the neck, but they are rare.
Unusual white or angry-looking red patches; an ulcerated, or cratered, lesion that is painful.
An unusually firm area of your mouth.
Numbness or loss of function, such as your tongue deviating to one side when you stick it out.

What is the difference between an oral lesion and a canker sore?

You may mistake some signs of oral lesions for a canker sore, formally known as an ‘aphthous ulcer.’ However, there are several key differences. For one, an oral lesion is not usually painful when it first appears, unlike a canker sore. Also, canker sores tend to be flat, with edges that appear angry and red. Most important of all, a canker sore will usually heal in two to three weeks. An oral lesion will not.

Usually, an oral lesion is easy to spot because it is front and center, such as on the tongue. If you have a wound or area of firmness in your oral cavity that does not get better over the course of a month, you need to have it examined because that is an indicator of an oral lesion.

Oral lesions are not commonly associated with the human papillomavirus (HPV). Furthermore, the signs are similar for both adults and children. However, the lack of risk factors among young people suggests that there is a genetic predisposition at play. This does not rule out environmental triggers, such as scratching from a misaligned incisor. But the hypothesis is that the irritation is the spark that lights the match for the genetic predisposition.

What are the most common types of oral lesions?

There are six different kinds of oral lesions:

Oral lichen planus, a chronic inflammation that often appears as white patches on your inner cheek or other parts of your mouth, which has no known cause.
Candidiasis, a fungal infection caused by candida, a type of yeast, which often appears as white patches in your mouth with some degree of redness or soreness.
Leukoplakia, white patches typically caused by constant injury or irritation.
Erythroplakia, which appears as red lesions in the mouth, bleeds when irritated, and is linked to alcohol and tobacco use.
Oral cavity cancer, which often appears as a sore or lump on the lips or in the mouth, and is also linked to alcohol and tobacco use.
The herpes simplex virus, which often appears as a cluster or a single small painful blister in the mouth, but may also look like a sore.

What should I do if I think I have an oral lesion?

You should make an appointment with a dental professional for a physical examination. In cases where your doctor has a high clinical suspicion of oral lesions, such as angry red patches, a biopsy may be performed, which will be done in the office. This involves numbing the area before removing a small sample for analysis. For patients who present with enlarged lymph nodes, a doctor normally collects a sample using a needle biopsy. The biopsy is invaluable because it establishes the diagnosis so the doctor can proceed with treatment. It also gives us the ability to reassure patients who have a premalignant lesion that just requires monitoring.

In cases involving cancerous or moderate-to-high risk precancerous lesions, doctors may recommend surgical removal. This is typically done using open surgery as most patients present with oral lesions on the tongue. However, at Mount Sinai’s Head and Neck Institute—Center of Excellence for Head and Neck Cancer, we are typically able to remove most oral lesions with few incisions. But we will remove the lymph nodes from the neck on the ipsilateral—or the same side—as the lesion if the tumor has a thickness of four millimeters or more. In cases involving bone structure, such as the jaw or midface, we will remove the lesion in collaboration with oral and maxillofacial surgeons. This allows us to better reconstruct boney structures and also achieve the best outcomes for your dental rehabilitation.

If the diagnosis reveals that the lesion is a stage two or higher cancer, we will recommend radiation therapy post-surgery. We will also recommend chemotherapy if there are positive margins following surgery—meaning that not all of the cancer could be removed—or if there is extranodal extension of the tumor, which means that the cells have spread beyond the lymph nodes.

For tumors that are located low on the tongue, or close to the floor of the mouth, we recommend microvascular reconstruction using skin and fat from other parts of the body. This allows us to preserve essential functions, such as your ability to eat and talk.

What should I expect following treatment?

Recovery differs based upon the extent of the surgery. For example, patients who undergo primary tumor removal without reconstruction are often discharged the same day and are started on a soft diet to promote healing. Patients who undergo lymph node removal are normally discharged the next day with a drain. Patients who undergo bone reconstruction are fitted with a nasogastric tube for a week to promote healing. In all cases, the goal at Mount Sinai is to get you back to eating and drinking as quickly as possible.

After surgery, we consult with patients every two months for the first year and conduct a surveillance scan at three months to ensure that all looks well. If subsequent scans show no signs of lesions, we gradually reduce the number of consultations to once a year after year five.

How can I prevent oral lesions?

You can take several steps to reduce your risk of developing an oral lesion:

Maintain a healthy diet
Practice proper oral hygiene by brushing and flossing daily
Avoid betel nut chewing, which can lead to significant scaring and increased risk for oral cancer
See a dental professional twice a year

To make an appointment with Dr. Khan, call 212-844-8775.

Make an appointment with Dr. Khan online.

Is My Stuffy Nose Congestion or Nasal Polyps?

Updated on Jul 20, 2023 | Ear Nose Throat, Your Health

An occasional stuffy nose due to allergies or infection can be annoying or difficult to manage. But if you are experiencing chronic nasal congestion that is also impacting your sleep and ability to breathe, it may be a sign of something more serious—nasal polyps. However, it is easy to mistake the symptoms of nasal polyps for other conditions, including allergies, a deviated septum, or chronic sinusitis.

Madeleine Schaberg, MD, Director of Rhinology and Skull Base Surgery

In this Q&A, Madeleine Schaberg, MD, Director of Rhinology and Skull Base Surgery at New York Eye and Ear Infirmary of Mount Sinai, defines nasal polyps, the indications you might have them, and why it’s important to seek a diagnosis and treatment quickly.

“There is a lot of overlap between symptoms,” explains Dr. Schaberg, who is also Assistant Professor of Otolaryngology at the Icahn School of Medicine at Mount Sinai. “Furthermore, polyps tend to grow gradually, which means the symptoms can be somewhat insidious until you reach a tipping point. Many people live with nasal polyps for years before receiving a diagnosis.”

What are nasal polyps?
Nasal polyps are benign, inflammation-related growths that occur in the nose and sinuses. One of the most common causes is environmental allergies, but they are also associated with diseases such as aspirin exacerbated respiratory disease and eosinophilic granulomatosis with polyangiitis. In some cases, nasal polyps can also be the result of caustic environmental exposures, such as construction sites or toxins exposures. Although nasal polyps are often soft and painless, they can become swollen or irritated and result in sinus blockages that can have serious impacts on your quality of life.

How do I know if I have nasal polyps?
Two prominent symptoms are associated with nasal polyps: congestion and loss of smell. The degree of congestion is often serious enough that it becomes difficult to breathe through the nose. Human beings are obligate nasal breathers, which means we are much more comfortable breathing through the nose. Polyps create an obstruction, which typically leads to breathing through the mouth, which is very uncomfortable. It can also lead to several issues that can affect your overall health and well-being, such as sleep apnea, frequent sinus infections, and increased frequency of asthma attacks.

How are nasal polyps diagnosed?
If you think the symptoms that you are experiencing are associated with nasal polyps, see an ear, nose and throat (ENT) specialist for a consultation. This will typically involve an examination, a review of your medical history, and a nasal endoscopy. Endoscopy is the best in-office diagnostic tool we have to determine what is going on. It enables us to evaluate all the structures of the nasal cavity in a safe, easy manner without causing discomfort and then proceed based on what we find.

What are my treatment options for nasal polyps?
There are several treatment options depending on the severity of your polyps:

For mild cases, a steroid spray is often effective in reducing polyp size and relieving symptoms.
For more severe cases, oral steroids may be prescribed.
If topical and oral steroid treatments are not effective, and the nasal polyps are extensive, surgical removal may be recommended as a therapeutic approach. This is typically done in an outpatient center through minimally invasive endoscopic surgery.
There is also the option of treatment with a biologic medication, such as Dupixent® (dupilumab), which is administered by injection under the skin once every two weeks.

In many cases, patients will receive some combination of these treatments, and then continue treatment with a topical steroid or biologic medication following surgical removal. It is best to think of nasal polyps as a kind of long-term problem, like having high blood pressure. It will be different for every patient, but many require topical steroids, oral steroids, and surgery as an adjunct, along with a biologic medication.

How can I prevent nasal polyps from recurring?
For the most part, maintenance medications, such as topical steroids and biologics, provide the best protection against recurrence. However, nasal polyps are a chronic condition, one that requires regular follow-ups with an ENT specialist to check for signs of regrowth. Furthermore, patients who use topical steroids for maintenance should also be assessed annually by an ophthalmologist for changes in eye pressure related to their medication. As with any condition, early detection and treatment of nasal polyps is ideal. However, a later diagnosis or extreme severity in disease should not ultimately affect the outcomes that you can achieve. The medications, treatments, surgery—everything we offer for polyps—works well at many stages in the course of the disease. The important thing is to see your primary care provider or an ENT specialist if you think you have symptoms.

Learn more about Your Health.

Is Dry Air Causing Your Nosebleeds?

Updated on Nov 17, 2022 | Ear Nose Throat, Your Health

Nosebleeds are common—nearly 60 percent of us have had to deal with one at some point in our lives—and the pesky problem usually comes out of nowhere. You may be enjoying a walk on a brisk day or wake up in the morning and suddenly your nose starts dripping red. As the seasons change and the weather becomes colder and dryer, nosebleeds are more likely to occur.

“As we head into winter, the change in temperature and humidity has a significant effect on our overall well-being,” says Isaac Namdar, MD, Assistant Professor of Otolaryngology-Head and Neck Surgery at the Icahn School of Medicine at Mount Sinai. “One of the more common side effects that we see from the cold, dry winter months is nosebleeds.”

Nosebleeds are normally not serious and stop on their own within about ten minutes. Still, stopping the bleeding is an important first-aid skill everyone should know in case it happens to you—or someone in your family. And you may be surprised to learn that experts say don’t tilt your head back.

What causes nosebleeds?

The nose is one of the most common areas of the body for spontaneous bleeding to occur. “There is a very rich blood supply to the nose, which allows the nose to change the humidity and the temperature of the air you breathe, and the vessels are more close to the surface than other places in the body,” explains Dr. Namdar. This makes the vessels in the nose more delicate and susceptible to damage.

Nosebleeds are particularly problematic in the winter when the weather is cold and dry; when there is less heat, there is usually less humidity and moisture. This dryness can damage or crack the delicate nasal membrane lining the nose, resulting in a bleed.

The environment inside our homes also makes this dryness worse. Central heating is the source of heat for most people in the United States. This type of heat further dries out the air as it is warmed.

Trauma is another major cause. When the nose is scraped or banged up, the small blood vessels inside it can burst. That is why young children who pick their nose or stick objects into their nostrils are more susceptible to nosebleeds.

Allergy sufferers are also at risk since anything that causes inflammation to develop in the nose can cause it to bleed. People with allergies also commonly use nasal sprays, which can make matters worse.

“Inserting the nasal spray tip into the nostrils can scrape the inside of the nose. Or if the medication is not evenly dispersed when it is sprayed, it can accumulate in the front of the nose and cause irritation,” says Dr. Namdar.

Some individuals with certain medical conditions are prone to nosebleeds. Patients with uncontrolled high blood pressure or genetic conditions such as Von Willebrand disease or hemorrhagic telangiectasia are more likely to bleed. People who take blood thinners, such as aspirin or warfarin, are also more likely to have nosebleeds.

How do I stop a nosebleed?

Even if you know the reason behind the nosebleed, getting one can be disconcerting. Follow these simple steps to stop the bleed:

Stay calm. Breathe through your mouth. Remind yourself—or the person you are helping—that the bleeding will stop soon.
Pinch the nostrils. Use two fingers to apply firm pressure to the fleshy part of the nostrils below the bridge of the nose. This pressure will allow the blood vessels to form a clot over the leak. Continue to hold this position for about ten minutes.
Sit up tall and lean forward. Do not lie down or tilt your head back. Avoid blowing your nose. If you need to remove a blood clot, wipe gently with a tissue.
Use an ice pack. Take a bag of frozen peas or something similar in the freezer and place it on top of the nose. The cold will shrink the blood vessels and reduce the bleeding.
Make a plan. If the bleeding continues after 15 minutes or begins to spurt, go to the emergency room.

When should I be concerned about a nosebleed?

Nosebleeds are generally not cause for alarm. However, there are some red flags that could indicate something more serious is happening. If you experience any of the following symptoms, seek medical attention immediately:

A nosebleed that lasts more than 15 minutes
Blood that is squirting rather than dripping from the nose
The amount of blood from the nose could fill an eight ounce cup

When you have a nosebleed, a blood clot may come out of your nose or mouth. These clumps of blood may look concerning, but they are actually the body’s way of trying to stop the bleed. Since the airway is connected, the clot may end up in the throat.

“If the nosebleed starts to form a blood clot, gently spit it out,” advises Dr. Namdar. “When clots are swallowed, they can end up in the stomach and cause discomfort.”

If you suffer from recurrent nosebleeds—more than two in a season—it is probably time to make an appointment with an ear, nose, and throat physician.

When nosebleeds are recurrent, they may require medical attention. Specialists like Dr. Namdar can seal the leaky blood vessels by either packing or cauterizing the area to prevent bleeding.

How do I prevent nosebleeds?

Since dryness is the main culprit for nosebleeds, finding ways to moisturize the nasal passageways are key to prevention.

“These are basically saline solutions, or a mix of salt and water, and some of them have moisturizers built in. I generally recommend using a nasogel spray. Some patients also use bacitracin ointment or petroleum jelly,” says Dr. Namdar.

Hydrating your body and drinking plenty of water is a good start. Dr. Namdar suggests using a humidifier—which puts moisture back into the air—in the bedroom. And if you spend several hours a day in your living room or office, you may want to consider having a humidifier in those spaces as well.

Make an appointment with Dr. Namdar

Treatment Options for Acoustic Neuromas, a Common Brain Tumor

Jun 8, 2022 | Ear Nose Throat

Acoustic neuromas are benign tumors that cause hearing loss, tinnitus, and dizziness. They are one of the most common brain tumors diagnosed in the United States, which translates to about 3,000 new cases each year. Several treatments are available for these tumors, depending on the size of the tumor, symptoms, patient age and overall health.

For more than 20 years, George Wanna, MD, Executive Vice Chair of Otolaryngology – Head and Neck Surgery and Chief of the Division of Otology-Neurotology at the Mount Sinai Health System, has specialized in the surgical management of acoustic neuromas. He has performed approximately 1,000 procedures to treat these unusual tumors and improve the quality of life of his patients.

Acoustic neuromas can be treated surgically in a variety of ways. As a pioneer in the field, Dr. Wanna specializes in several approaches, including removal of the tumor endoscopically through the ear canal. Dr. Wanna was one of the first skull base surgeons to use the exoscope, or a robotically controlled microscope. The exoscope offers surgeons increased visualization with high-definition, real-time imagery.

George Wanna, MD

In this Q&A, Dr. Wanna explains the various treatment options for acoustic neuromas, and he answers common questions about the benefits of endoscopic surgery, the use of radiation, and how the exoscope can improve outcomes for patients.

How is acoustic neuroma removed endoscopically? How is this surgery different from conventional, “open” surgery?

An endoscopic approach allows us to access the tumor through the ear canal without any major incisions. The endoscope is a thin, rigid tool with a light and high-definition camera attached to the end. We use it to look through the ear canal, behind the ear drum and inner ear, and into the brain. It can be our main surgical tool or used in combination with open surgical techniques that require an incision. Often the endoscope will allow for a more minimally invasive approach, even when used as an adjunct in open surgery.

What are the benefits of using an endoscopic approach?

There are no major incisions. The procedure is done entirely through the ear canal. Patients who have endoscopic surgery recover faster and typically go home within 48 hours.

Who is a candidate for endoscopic surgery?

Every case is different, and it is important to individualize the approach to each patient with the goal being to treat the tumor in the safest, most effective way. Patients with small tumors who have lost their hearing are ideal candidates for endoscopic techniques. Conventional, open surgical approaches are used to treat larger tumors in deeper locations. In some cases, a wait-and-see approach is taken for patients with smaller tumors and good hearing, or those with stable tumors. Typically, we do not operate on small, stable tumors (less than 1 cm). However, if the tumor is growing and the patient prefers it to be removed, we may perform surgery earlier than expected.

How do you know the size of the tumor?

We assess tumor growth using MRI scans. We measure the tumor in 3 dimensions and compare each dimension and overall volume from scan to scan. These measurements are then used to help guide decision making along with the patient.

Does endoscopic surgery reduce potential side effects like facial paralysis or cerebrospinal fluid (CSF) leak?

At Mount Sinai, our acoustic neuroma surgeons have extremely high success rates with endoscopic surgery and were one of the first adopters of the technology in ear surgery. As one of the highest volume endoscopic ear surgery centers in the world, we have adapted our experience to acoustic neuroma surgery. For example, we have found that packing the Eustachian tube under direct visualization reduces the risk of CSF leaks. In essence, we employ the principles of conventional, safe surgery and use the endoscope to accomplish the same goals in a minimally invasive approach.

Is radiation used after surgery? Does everyone need it?

This is a vibrant discussion in the field of otology-neurotology. Radiation is used in certain patients, If the tumor is large and pressing on the brainstem, surgery is most appropriate. Radiation should only be used when there is MRI documentation of tumor growth and can be the treatment of choice for elderly patients or those with other existing comorbidities. In some cases, the acoustic neuroma cannot be completely removed without causing facial paralysis; in those cases, a very small remnant is purposefully left behind, and if it grows, is radiated.

What is the exoscope? How does it help surgeons visualize the tumor?

The exoscope is a specialized microscope with a robotic arm. It can generate 2D or 3D images and is guided by voice command. It has a built-in surgical GPS which allows us to see in real time on a CT scan or MRI exactly where we are. This exceptional visualization of the patient’s anatomical structures is unprecedented.

What are the benefits of coming to the Ear Institute of New York Eye and Ear Infirmary of Mount Sinai?

While acoustic neuromas are relatively uncommon, we are one of the highest volume centers in the country, giving patients the advantage of seeing providers who have treated the full spectrum of these tumors, including the most complex cases. We work very closely with our colleagues in neurosurgery and radiation oncology to ensure patients receive the most appropriate and optimal treatment for them. Our extensive support staff guides patients through every step of the way.

What are the benefit of collaboration between surgeons and trainees at the Ear Institute?

The exoscope projects a real-time, high quality display of anatomical images that both neurosurgeons and otologists can view simultaneously, rather than individually through a microscope. This creates a true collaborative approach between surgeons and anesthesiologists, as well as for other medical experts (domestic and international), who may be observing the procedure. This technology has also greatly enhanced the educational experience at the Icahn School of Medicine at Mount Sinai for residents, fellows and medical students, as we continuously harness innovative technology for the next generation of surgeons.

To make an appointment with Dr. Wanna at the Ear Institute of New York Eye and Ear Infirmary of Mount Sinai, please call 212-979-4200 or email NYEEentreps@mountsinai.org.

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Could My Snoring Be Obstructive Sleep Apnea?

Mar 11, 2022 | Ear Nose Throat, Sleep, Your Health

Does your bed partner complain that you snore loudly or gasp for air in the middle of the night? Have you been nudged awake or kicked to the couch because your loved one can’t sleep? These are telltale symptoms of obstructive sleep apnea, and if you suspect you may have the condition, the person lying beside you may be your best ally.

Courtney Chou, MD, a sleep surgeon and an Assistant Professor of Otolaryngology at the Icahn School of Medicine at Mount Sinai, urges people to take this feedback seriously.

“Bed partners are an important referral source,” says Dr. Chou. “People with sleep apnea are often unaware of nighttime symptoms like snoring or interruptions in their breathing. And many either do not experience daytime symptoms, like drowsiness and difficulty concentrating, or think something else is to blame.”

What is obstructive sleep apnea?

Affecting as many as 22 million people in the United States, obstructive sleep apnea (OSA) is a serious sleep disorder that causes your breathing to repeatedly start and stop throughout the night. The condition occurs when the muscles of the upper airway relax and block the flow of air, which prevents your body from getting the oxygen it needs and causes you to wake up repeatedly during the night.

These nighttime disruptions can negatively affect the sleep of the OSA sufferer and can put a significant strain on relationships. In fact, frustrated companions are often the reason patients eventually visit a doctor.

“Bed partners end up suffering tremendously,” she adds. “They may struggle to fall asleep or stay asleep. Some couples end up sleeping in separate rooms.”

How do I know if my snoring is obstructive sleep apnea?

Consistent snoring, pauses in breathing, or gasping for air in the middle of the night are common symptoms of the condition and should be evaluated by a physician. If left untreated, sleep apnea can lead to serious complications. For instance, individuals with OSA are more likely to have high blood pressure, stroke, heart disease, and diabetes.

That being said, it is hard to make a diagnosis from symptoms alone. To know for sure, Dr. Chou explains, you need a sleep study. In the past, patients had to stay overnight at a sleep center for testing. But today, for most patients, a sleep study is performed at home using minimally invasive equipment, sometimes requiring only a special finger and wristband gadget that is connected to a smartphone. Home sleep tests record the number of times your breathing is interrupted throughout the night, revealing if you have OSA and, if so, how severe it is.

“I believe a lot of my patients would have come in sooner if they knew about home sleep studies,” explains Dr. Chou. “I have done it myself, and it was easy and comfortable. I don’t think anyone should be nervous about having a sleep study.”

How is obstructive sleep apnea treated?

If you are diagnosed with sleep apnea, there are three types of treatments that can help. Dr. Chou likes to start with the least invasive treatment.

CPAP (continuous positive airway pressure) therapy has long been the gold standard treatment for OSA. This is a machine that uses air pressure to keep the airway open throughout the night. Patients wear a mask while sleeping—placed over the nose or both the nose and mouth—that connects to this device. Although several options and models are available, research shows that only half of patients can tolerate sleeping with the mask.
Oral appliances are an alternative to CPAP machines or are sometimes used in conjunction with a CPAP device. Oral appliances are worn in the mouth to reposition your lower jaw while you sleep. These appliances are made by a dentist and molded specifically to fit your teeth.
Surgery is recommended when noninvasive therapies fail to provide relief or patients struggle to successfully use CPAP, oral appliances, or both. There are numerous options that open, reshape, enhance, or stimulate the upper airway and eliminate symptoms like snoring and breathing interruptions.

What are the surgical options to treat sleep apnea?

The type of surgery required depends on the severity of your symptoms, the severity of the condition, and your unique anatomy. Dr. Chou works closely with patients to decide what procedure is right for them.

Soft tissue procedures—Dr. Chou likes to compare the upper airway to a house. With soft tissue surgeries, the goal is to make more room by throwing out furniture or making it smaller. This may involve nasal, palate, or tonsil surgery, which creates more room in the passageways for air to flow.
Skeletal surgeries—With skeletal surgeries, the goal is to make the house bigger by building it out as you would by adding a new room. These more extensive operations include widening or forward movement of the jaws and chin advancement. The goal of these surgeries is to improve the position, balance, and movement of the upper airway.
Neurostimulation/Hypoglossal Nerve Stimulator—Inspire ™ therapy is a newer therapy that has been approved by the United States Food and Drug Administration. It stimulates the base of the tongue to expand the airway. Like a pacemaker, the device is surgically implanted into your chest and connected by a wire to the upper airway. You can control the device using a remote device. Mount Sinai’s Division of Sleep Surgery was one of the early adopters of Inspire therapy.

Dr. Chou is currently treating patients at New York Eye and Ear Infirmary of Mount Sinai. To make an appointment, call 212-979-4200.

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I Have Obstructive Sleep Apnea. Should I Get a Drug-Induced Sleep Endoscopy (DISE)?

Sep 9, 2021 | Ear Nose Throat, Sleep, Your Health

Loud snoring. Gasping for air. Feeling tired after getting plenty of sleep. Nearly one in every 15 adults in the U.S. suffer from obstructive sleep apnea, a common sleep disorder that causes the airway to collapse and breathing to be repeatedly interrupted throughout the night.

The first line of defense for individuals with this condition is a treatment known as continuous positive airway pressure (CPAP), a machine that helps push air into the lungs and keep the airway open. Unfortunately, as many as half of those who use the machine do not have success, and look to surgery as an alternative to CPAP to treat their sleep apnea. But what surgery is the right one for the patient? Drug-induced sleep endoscopy helps to answer this question.

Known as DISE, this advanced diagnostic tool allows sleep surgeons to assess the anatomy of the upper airway in 3D under sleep-like conditions. Studies have shown that the evaluation technique, which has become increasingly popular over the last 10 years, improves surgical outcomes in patients that do not respond to CPAP.

How does DISE help patients with sleep apnea?

Courtney Chou, MD

“Every individual’s anatomy is different,” explains Courtney Chou, MD, a sleep surgeon in the Department of Otolaryngology – Head and Neck Surgery at the Icahn School of Medicine at Mount Sinai, who specializes in treating patients with obstructive sleep apnea. It is her job is to figure out what is blocking the patient’s flow of air. In some patients, for example, the base of the tongue or the soft tissue palate collapses, which then causes the airway to close.

“DISE allows us to locate the sites of obstruction in individuals with sleep apnea and figure out a plan to alleviate these blockages,” says Dr. Chou. “There are several different types of sleep surgeries, and DISE really helps determine which one will benefit the patient the most.”

According to a recent study in Sleep and Breathing, the results of DISE changed the surgeon’s original treatment plan as much as 75 percent of the time. In the past, surgeons relied only on medical history, patient evaluation, and the results of a standard sleep study to decide on the best intervention.

“In general, sleep surgeries are quite successful for patients with obstructive sleep apnea. We really try to meet each individual’s needs. When we are deciding on a surgery, it is important to think about what the patient’s main complaint is—are they snoring so much that it affects their bed partner, or is their oxygen saturation dangerously low?” she explains. “It is also important to consider how severe their sleep apnea is on their sleep study. But the key to identifying the intervention that is going to be maximally effective is understanding the patient’s anatomy. DISE is an important piece of the puzzle that helps us do that.”

In rare cases, DISE can also be used to troubleshoot nonsurgical therapies. If a patient is having some benefit with CPAP or an oral appliance, DISE may be used to evaluate if there is a tweak that could make the current treatment more effective or improve their ability to tolerate it.

What should patients expect during the procedure?

DISE is a minimally invasive, same-day procedure that is well tolerated by most patients. However, people who are pregnant, allergic to sedatives, or have severe cardiopulmonary disease that would prevent them from having surgery would not be candidates for DISE.

On the day of the surgery, after the patient checks in, they will meet with an anesthesiologist for a short evaluation. Afterward, a sedative will be administered intravenously. Once the patient is asleep, a sleep surgeon will place a thin flexible scope into one nostril that passes through to the upper airway. This scope has a small camera on the end that sends 3D real-time videos back to a monitor, allowing the surgeon to visualize exactly where and how the airway is collapsing while the patient is sleeping. The patient is then taken to a recovery room as the sedative wears off.

The procedure takes 30 minutes to an hour, is not uncomfortable, and patients do not deal with side effects besides post-surgery drowsiness, which means they will need a ride home after the procedure.

“Sleep is so critically important to our health,” says Dr. Chou. “With tools like DISE, Mount Sinai can help those who are struggling find the right plan and not suffer in silence.”