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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.”

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

Learn more about Sleep Services at Mount Sinai

Is My Skin Care Routine Too Complicated?

Sep 2, 2021 | Skin Health, Your Health

It seems that everywhere you look, there are new skin care tips and tricks that can range from the elaborate, such as a 10-step nighttime routine, to the bizarre—like vampire facials. But not all viral trends are good, and they certainly may not be good for your skin.

Angela J. Lamb, MD, Associate Professor of Dermatology at the Icahn School of Medicine at Mount Sinai, explains some of the most popular trends and provides advice on how you can determine what works best for your skin.

What is one of the more overrated skin care trends?

I see a lot of videos on TikTok about the 10-step process that include two different cleansers and multiple serums and treatments. This method is overrated as it uses too many products, which is often not a good idea.

A good skin care routine is simple. I recommend using a cleanser, a ‘power product’—which can be a serum or an eye cream—and a moisturizer. You’re better off investing in a few of these high-quality products that are going to do what you want them to do, instead of using 10 different things.

What ingredients should I look for in products if I have facial hyperpigmentation and/or excessive redness?

For hyperpigmentation, look for products that have a retinol or a vitamin A derivative as this will help to brighten the skin. There are also a variety of other ingredients, including mandelic acid, kojic acid, and azelaic acid, which will help your hyperpigmentation.

If you have some redness, look for something that has acetamide as that will help to calm the skin and improve texture. Also, the product you use will depend on the reason for the redness. For example, if you have rosacea, a product that contains green tea would be best to decrease redness.

Are sheet masks effective?

Sheet masks are very effective. Most of the masks on the market have a high concentration of hyaluronic acid, which is great at hydrating skin. Other masks contain clay—which is great at drying out blemishes and minimizing the appearance of pores—or lactic or glycolic acid—which exfoliate skin. In general, sheet masks are great, a lot of fun, and feel good.

When should I see a dermatologist for my skin care?

You should see a dermatologist if you’ve tried a couple of over-the-counter solutions and you are still having skin issues.

Here are some examples:

If you have eczema and have tried a few over-the-counter cortisones, anti-itch creams, and moisturizers, and your skin is still keeping you up at night and making you feel self-conscious, then you need to see a dermatologist.

If you’re dealing with hair loss and have tried over-the-counter shampoos and you’re still losing more hair, that’s when you need to see a dermatologist as there may be a vitamin deficiency or scalp condition that needs prescription treatment.
If you have acne and have tried over-the-counter treatments for a few months and you’re not satisfied, see a dermatologist. Over-the-counter products are a good compliment to prescription remedies, but if you have severe acne that goes untreated, it can cause indented scars in your skin, which is hard for a dermatologist to treat. You should get treatment sooner rather than later.

This advice extends to anti-aging treatments. If the serums, potions, and masks, are not getting you to where you want to be, then that is the perfect opportunity to go to a dermatologist. We can recommend very noninvasive treatments including chemical peels and lasers. You don’t need to get Botox^®. Some people get nervous thinking that they will have to get invasive procedures, but there are all sorts of things we can do, like prescribing a retinol.

Are there any other skin care tips you would like to offer?

Prevention, prevention, prevention. Too often, people come into my office with acne scars when I really wish I had treated their acne more aggressively upfront. If I had seen them earlier, we could have gotten the acne under control and prevented facial scarring or pitting.

The same goes for wrinkles. I want to get all of my patients to their skin care goals. But when you have had damage from years of not using sunscreen, treatment is difficult. Simply wearing sunscreen will help to prevent your skin from looking more mature than you would like later on.

Use sunscreen and make sure any skin problems you have are addressed aggressively at the beginning so that you don’t have long term consequences that are very hard to treat.

Make an appointment with Dr. Lamb

Learn more about Dermatology at Mount Sinai

How Do I Keep My Kids Safe When They Return to School In Person?

Updated on Jun 30, 2022 | Children's Health, COVID-19, Your Health

As the Delta variant surges, and the timeline for vaccinating children under 12 remains uncertain, concerned parents are wondering how to keep students safe. But there are smart strategies for school children of all ages that can help protect them in the classroom.

In this Q&A, Roberto Posada, MD, a pediatric infectious disease specialist in the Jack and Lucy Clark Department of Pediatrics at Mount Sinai Kravis Children’s Hospital and Professor of Infectious Diseases and Medical Education at the Icahn School of Medicine at Mount Sinai, shares the best ways to help keep kids safe from COVID-19.

Given the current concerns about COVID-19, should parents be worried about sending their kids back to school?

I think it’s important for kids to go back to school not only for their education, but also for socialization and healthy development. But it’s also important to take precautions to make sure they return to the classroom in a safe way. If in-person learning is done safely, the benefits will outweigh the risk. According to the Centers for Disease Control and Prevention, children have been less affected by COVID-19 compared with adults. But kids can develop serious illness, especially those with underlying medical conditions, such as obesity, diabetes, and asthma; those with certain genetic, neurologic, or metabolic conditions; or those with congenital heart disease. In general, the best way to protect children is to make sure adults in the household are vaccinated.

What advice can you give to worried parents about keeping their kids safe at school?

It’s important to continue the things we’ve been practicing for the last year and a half: The main thing is that children over the age of two should wear a mask when they go to school. Children should also be encouraged to wash their hands, either with soap and water or with alcohol-based sanitizer frequently. Children should be encouraged to practice respiratory etiquette, which means coughing or sneezing into their elbow and washing their hands after coughing or sneezing. And they should be taught to maintain a safe distance at all times.

In addition, parents shouldn’t send their kids to school if they have a fever, cough, abdominal pain, or any symptom whatsoever of an illness, including COVID-19.

How worried should people be right now about the increasing cases of COVID-19?

The number of COVID-19 cases has been going up for the last several weeks in the United States, mostly due to the Delta variant. Vaccination is very important. Every child aged 12 and older should be vaccinated. The vaccine is safe, and in some cases it fully protects against COVID-19; in some cases people who are vaccinated may still get COVID-19, but usually it’s a much milder disease.

Is there any guidance for older vaccinated kids that you would recommend to parents?

What I want to stress is that even people who are fully vaccinated should be wearing a mask whenever they’re inside, whether they’re in school, on public transportation, in a store, or anywhere indoors. That applies to adults, as well. The reason is that even people who are fully vaccinated may have breakthrough infections, and they can still pass on the infection to other people. So by wearing a mask—in addition to getting the vaccine—you’re helping decrease cases in your area, which is what we all want.

When do you think the vaccine will be available for children 11 and under?

The original timeline was for this to be available in the fall. So let’s hope that’s going to be the case.

Is there anything else people should know about keeping their kids safe from COVID-19?

Any parent who has a particular concern about their child due to a chronic medical condition medical condition should talk with their pediatrician to come up with an individualized plan.

My Child Is Anxious About Returning to School In Person. How Can I Help Them?

Updated on Jun 30, 2022 | Children's Health, COVID-19, Mental Health, Psychiatry, Your Health

With the start of the new school year, many kids may be relieved to return to in-person learning. But others may feel more anxious.

In fact, experts at the Mount Sinai Adolescent Health Center anticipate that this transition may be especially challenging and anxiety-provoking.

Rachel Colon, LCSW, a social worker at the Center who treats young people ages 10-26, says that her case load has nearly doubled as adolescents seek help for anxiety and depression.

Rachel Colon, LCSW

“Young people are feeling a great deal of anxiety about returning to school,” she says. “They don’t know what they’re stepping into, who their friends are, and they’re nervous about the lack of predictability in an environment that has always been safe and provided routine.”

Ms. Colon offers some steps you can use to help your kids with the transition to in-person learning this school year:

Have lots of conversations with your kids; keep the lines of communication open.
Empathize with your children; let them know they are not alone if they feel anxious.
Reach out to your child’s school to ask what steps are being taken to familiarize students with their surroundings.
Look for signs of withdrawal, isolation, stomach aches, headaches, irritability. These can be signs of depression and/or anxiety.
If your child is headed to a new campus, or stepping up from middle school to high school, offer to take a walk to school before the first day of school.

Heading back to school can be stressful even in normal times. Over the years, the Mount Sinai Adolescent Heath Center has compiled a list of seven things for kids and adults to do to start the year off right. Click here to see them on the Center’s kid friendly blog.

One potential new issue this year is that kids may feel they have lost touch with their group of friends, or that they don’t belong, and masks, while a critical safety tool, may make things more difficult.

“Many kids are telling me they don’t have a friend group anymore. They don’t know how their classmates will look,” she says. “With the potential requirement of masks, this will likely compound social anxiety because it’s hard to read expressions when a person is masked. Are they happy or sad? Are they smiling at me? Though masks are a crucial safety tool right now, kids really need simple cues—like a broad smile—to maintain social relationships.”

The Mount Sinai Adolescent Health Center is a comprehensive, integrated health center that provides nonjudgmental and confidential care to young people ages 10-26 in New York City—all at no cost to patients, regardless of insurance or immigration status.

Learn more about the Mount Sinai Adolescent Health Center

Check out seven back-to-school tips from the Mount Sinai Adolescent Health Center

What You Need to Know About Cholesteatoma, a Rare Growth in the Ear

Updated on Dec 30, 2022 | Ear Nose Throat, Your Health

young woman with earache touches outside of ear

Unless you are experiencing hearing loss or an acute infection, you probably do not give much thought to your ear health. However, many conditions can affect this complex and very fragile part of the body that not only allows us to hear but also plays a major role in our sense of balance.

Cholesteatoma is a rare condition in which a benign skin growth develops in the middle ear, just behind the eardrum. Only nine out of every 100,000 adults in the United States are diagnosed with these skin growths each year. And, while cholesteatoma is not cancerous, it will continue to grow and may pose serious problems if not removed.

Enrique Perez, MD

“The middle ear is inside the body so it should never have any skin in it. When this condition occurs, skin has grown inward either due to a prior surgery, eardrum perforation, or from chronically reduced ventilation of the ear from conditions like eustachian tube dysfunction,” explains Enrique Perez, MD, MBA, Assistant Professor of Otolaryngology at Mount Sinai, who specializes in treating rare conditions like cholesteatoma. “The problem with this excess skin is that cholesteatomas behave destructively over time. If left untreated, they can cause infection, destroy the bones of hearing, and lead to serious issues like facial nerve paralysis or intracranial complications.”

Who is at risk of developing cholesteatoma? What are the signs and symptoms of the condition?

Patients who have a history of chronic ear infections or eardrum perforation are more likely to develop cholesteatoma. In the early stages of this condition, you may notice some mild pain, pressure, difficulty hearing, or drainage. As the cholesteatoma grows, your symptoms will get worse and may include dizziness, numbness, muscle weakness in one side of the face, or blood-tinged mucus draining from one ear.

Children can be born with a congenital form of cholesteatoma. “These kids often come to us with a history of progressive hearing loss without pain. The ear looks relatively normal, but upon close inspection we find a white structure, which is the trapped skin behind the eardrum,” explains Dr. Perez.

Even if your medical history does not put you at risk for a cholesteatoma diagnosis, make an appointment with your physician if you feel anything out of the ordinary, particularly in just one ear. A simple visit could save you from experiencing permanent damage at a later time.

How is this condition treated?

The only way to treat cholesteatoma is to remove the skin growth. Without surgery, the cyst will become larger and damage the surrounding bone and tissue. If it is left untreated, cholesteatoma can lead to permanent hearing loss, debilitating vertigo, and irreversible nerve damage.

“I tell my patients upfront that cholesteatoma is a surgical disease, and they will need an operation. There is no medication that can remove this growth,” says Dr. Perez.

Since the growths are difficult to remove fully—and the surrounding areas of nerve, bones, and tissues are extremely fragile—it is important to find a surgeon who has experience treating cholesteatoma. Once the skin is removed, there may be a hole in the eardrum or bones in the middle ear that requires reconstruction. There is also a risk that cholesteatoma will grow back if it is not removed properly.

What happens during the cholesteatoma removal procedure?

Most removal procedures are outpatient and, depending on the complexity of the cholesteatoma, the surgery can take anywhere between one to four hours.

At Mount Sinai, Dr. Perez and his surgical colleagues are trained in minimally invasive procedures and often use fully endoscopic approaches to treat cholesteatoma. Instead of making an incision in the back of the ear, these experts can access the growth through the natural opening in the ear canal. Operating rooms at Mount Sinai use the latest technology, including a 4K endoscopic camera system that provides more precise real-time images for surgeons during the procedure.

What is the prognosis for patients following cholesteatoma removal?

Cholesteatoma disease can be quite variable. In patients with recurrent cholesteatoma who have already undergone prior surgeries, it is possible that they will need to undergo a more extensive procedure like a tympanomastoidectomy—a procedure that repairs the middle ear in patients with chronic ear infections. In those cases, the prognosis for ending the infection is high but regaining prior hearing is not as good.

However, in a patient with an early stage of the disease that has not been operated on, the odds of achieving a good hearing outcome as well as successful removal of the cholesteatoma is quite high.

“People often underestimate a recurrent draining ear. It is not just a hassle but a problem you should take care of right away,” says Dr. Perez. “If you come in early, the procedure is more straightforward . By addressing the problem, we can improve a patient’s hearing and quality of life.”

Make an appointment with Dr. Perez

How Can I Treat My Plantar Fasciitis?

Updated on Jun 30, 2022 | Orthopedics, Your Health

man doing flatfoot correction self massage at home

Plantar fasciitis (pronounced PLAN-taar-fa-shee-AY-tus) is one of the most common causes of heel pain. According to the American Academy of Orthopedic Surgeons, about two million people are diagnosed with the condition every year. Fortunately, you can often address the pesky heel pain associated with the condition in the comfort of your own home.

In this Q & A, Meghan Kelly, MD, Assistant Professor of Orthopedics at the Icahn School of Medicine at Mount Sinai, provides at-home stretching tips that treat heel pain in more than 90 percent of plantar fasciitis patients and advises on how to prevent developing the painful condition.

How do I make my heel stop hurting?

To immediately deal with the pain associated with plantar fasciitis, you can use ibuprofen (ex. Advil) or naproxen (Aleve). In addition, rolling a frozen water bottle under the arch of your foot can also relieve the pain.

What can I do to treat plantar fasciitis?

The way to treat about 95 percent of plantar fasciitis cases is by stretching. There are two main stretches which, if done well every day, should make the condition go away in about a month. This method worked for me and every one of my patients.

On the left, Dr. Kelly shows how patients can stretch their plantar fascia and, on the right, she demonstrates an Achilles tendon stretch.

Attend to your plantar fascia.

Plantar fasciitis is an inflammation of the plantar fascia—a thick band of tissue at the bottom of the foot. You can address this inflammation by stretching that tissue. Do this by putting your leg in a “figure four” position with the ankle over the opposite knee. Then, grab your toes and pull them toward your shin and massage the plantar fascia for 5 minutes. You should do this stretch two or three times a day.

Your Achilles tendon is tight. Loosen it.

Almost everyone has a tight Achilles—it’s just the way we’re built—and a tight Achilles tendon can affect the plantar fascia. There are a couple of stretches that can help. The one I like, and that I show my patients, involves standing on a stair or curb with both heels facing out. Hold onto the railing, then move the heel that is painful off the edge of the stair or curb and let it drop. Allow your other foot to relax. Hold this position for five minutes. I know that’s a really long time, but the Achilles tendon is a very large tendon and it takes time to stretch it. Do this twice a day. It doesn’t always feel great at the time, but it really does help.

The hardest part about treating this condition is being diligent about doing these stretches twice a day, every single day. I often recommend taping a reminder on your refrigerator, or some place you can’t avoid seeing. If your heel hurts after you stretch, that’s normal. That’s when you can ice it and/or take a painkiller.

Should I try to stay off my feet? Do I need to wear special shoes in the house or outside?

You can walk as much as you want with plantar fasciitis. If it starts to hurt, you can stop—but you aren’t damaging anything if you keep walking.

In terms of footwear, the best shoes for plantar fasciitis are ones that fit correctly—both in length and width—and provide arch support. You can also use removable inserts (called orthotics) to “fix” a pair of shoes that does not have the support you need. I recommend trying over-the-counter orthotics first, to see if they help as custom-made ones can be very expensive. If you have really flat feet or very high arches, you can get over-the-counter orthotics that are designed to help with that.

I don’t routinely recommend wearing shoes inside—I’m a big fan of bare feet—but, if you’re having pain from plantar fasciitis, wearing supportive shoes in the house can sometimes help. Try it and see if it works for you.

Should I use a foot brace or splint, or a boot?

There are splints available at your local pharmacy that hold your foot at a right angle while you sleep. This will keep your plantar fascia stretched out overnight, and then, when you get up in the morning, you won’t have heel pain as you step out of bed. Some people swear by this method. The majority, however, tell me that they tried an overnight splint but woke up in the middle of the night to take it off because it was uncomfortable. If you want to try using a splint, that’s fine; it won’t do any damage. But, there are no research studies that prove its effectiveness.

Occasionally, I prescribe a walking boot for plantar fasciitis patients as it can take some pressure off the heel. But that can backfire. If you’re wearing the boot all the time and not doing the stretching exercises, your calf muscles may weaken. That won’t help with the pain. Sometimes, I give patients a walking boot for about a week, just to get them walking until the pain becomes bearable. During that time, I urge them to continue doing their stretches and, as soon as they can, I encourage them to stop using the boot altogether.

All in all, the best—and most effective—treatment for plantar fasciitis is stretching.

What if I’ve tried all this and am still having pain?

If none of this works, you might try formal physical therapy. A physical therapist may be able to help you do your stretches more effectively. Sometimes they have equipment in the physical therapy suite that you don’t have at home and can be beneficial.

If none of that works, there are also some procedures available. Extracorporeal shock wave therapy is a noninvasive method of stretching the plantar fascia that involves applying waves of electricity to the tissue. Another option is the Tenex FAST procedure. With this approach, we poke tiny holes in the plantar fascia with a needle. perform these procedures and those who do will likely only try them if everything else has failed.

How can I prevent plantar fasciitis?

The best way to prevent the condition is to avoid unsupportive shoes and to stretch before and after you exercise. But sometimes you do everything right and still end up with plantar fasciitis. That’s why it’s good to know what stretches can treat it.

Make an appointment with Dr. Kelly

Learn more about Orthopedics at Mount Sinai

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