Center for Advanced Subspecialty Care and Otolaryngolgy providing otolaryngology services for Plymouth County and surrounding southeastern Massachusetts.

Snoring and sleep apnea can prevent a good night’s sleep, for the sufferer and for those trying to sleep nearby. While snoring and sleep apnea affect three times as many men as women, these conditions can affect relationships by preventing both parties from sleeping soundly. Children also can snore or have sleep apnea, affecting behavior and performance in school.

Snoring is caused by the soft palate relaxing too much during sleep; the soft palate then vibrates during breathing and that causes the noise that others can hear. Often the person will wake up several times during the night, interrupting sleep cycles.

Sleep apnea, which may include snoring, is a condition in which a person stops breathing for short periods of time while sleeping. The person will arouse enough to start breathing again, but this interrupts the sleep cycle. The person may be unaware of the sleep/wake cycles.The majority of people with sleep apnea don’t even know they have a problem.

Untreated sleep apnea also can lead to depression, high blood pressure, and higher risk for heart attack and stroke.

Sleep apnea can be properly diagnosed with the help of a sleep study. Jordan Hospital-affiliated surgeons Anit Patel, MD (shown at left), and Bernard Durante, MD, offer state-of-the-art techniques for diagnosis and management of snoring and sleep apnea.

“Once a proper diagnosis is made, the most common treatment for sleep apnea is a machine known as continuous positive air pressure, or CPAP. The patient wears a mask during the night that allows air to flow into the nose during sleep,” says Dr. Patel. “For those who can’t tolerate the mask, surgery may be warranted.”

For snoring without apnea, the doctor will inject an inflammatory material into the soft palate causing it to thicken so it doesn’t flap during breathing. A second option to stiffen the palate is implants. These are procedures conducted in the physician’s office. For more information, contact JordanCall at 800-750-5343.

Bob Barker, a financial planner from Mashpee, was diagnosed with sleep apnea in 2001. He tried a CPAP machine but was unable to tolerate it due to a deviated septum. His sleep apnea left the financial planner tired all day, but unable to sleep soundly at night. His wife, Patricia, described his snoring as “roof-shaking” and she would race to get to sleep before he did. On a family vacation, she noticed that the noise even kept the children from sleeping well, “I hadn’t really thought that it touched so many lives.” A schoolteacher, Patricia’s sleep was disrupted so often that she took a nap in the afternoon and was still exhausted at bedtime. She also was concerned about Bob’s sleep apnea leading to heart disease and heart attack.

As a last resort, Bob had two surgeries at the same time last December with Dr. Patel. One removed his uvula and tissue from his throat and soft palate; the other corrected his deviated septum. Patricia says that within a week of the swelling going down and the nasal packing being removed, she noticed a huge change. Bob puts it best, “I have more energy than I’ve had in years.”

When healthy, happy and handsome 24-year-old Ryan Anderson of Plymouth smiles at you today, his entire face beams. But in early 2000, while we were celebrating the dawn of the new millennium, Ryan was receiving very scary news from Dr. Bernard Durante, Chief of Surgery at Jordan Hospital. An MRI showed a large juvenile angiofibroma tumor – a rare type of tumor with an occurrence of 1 case in 4,000 – which was lodged down in the nasal passage behind the left side of his face, and growing dangerously and aggressively in his skull base and down toward his spinal column.

“The diagnoses was a complete shock,” says Ryan. “I had thought I would need a simple cauterization that would eliminate the frequent nosebleeds and headaches. But the confidence and expertise of Dr. Durante and his team inspired me, and kept my family and me from fearing the worst.”

“Although I was given the choice,” he explains, “there was never a question in my mind about opting to go to Boston. I found out that we have an extremely high level of training, expertise and competence in our own backyard. I knew I was in great hands right here at home.”

On Monday, March 13th, 2000, Ryan underwent 12 hours of surgery at Jordan at the hands of a team of five surgeons led by Dr. Durante. “The wonderful nursing care at Jordan got me through post op. I was able to go home after a bit and recover successfully. Today I am healthy, I have had no recurrence, I have no physical limitations of any kind, and I have no visible scarring. I am one lucky guy, and I am very grateful to Dr. Durante and all the docs and nurses who helped me through this.”

Ryan as gone on to complete his studies in organizational communications at Northeastern University. He graduated in June 2002, and is now the manager of the Boston Bruins Pro Shop at the Fleet Center, a very fast-paced retail environment that has an average attendance of 16,000 to 20,000 fans on most game nights. During his limited free time, he enjoys roller blading, weightlifting, and jogging. Ryan has done very well indeed.

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By SUE REINERT, The Patriot Ledger

Jade Steffy yearned for the simple pleasure of taking a deep breath. But it was an impossible dream with her severe sinus infections. The 22-year-old Kingston resident had scored high on college aptitude tests but she couldn’t finish even two years of higher education. She regularly lost jobs because of fatigue and absences.

Her lifelong sinus and tonsil infections had worsened in the past year. ‘‘It affects everything,’’ Steffy said.

She couldn’t breathe, therefore she couldn’t sleep, therefore she often was too tired to study or work. ‘‘A lot of things got thrown on the back burner,’’ she said.

That helps explain why Steffy lay on an operating table at Jordan Hospital in Plymouth last month, ready to undergo a new kind of procedure for opening clogged sinuses.

Dr. Bernard Durante, an ear, nose and throat specialist and chief surgeon at Jordan Hospital, had suggested the operation, called sinuplasty.

In the procedure, the surgeon passes a balloon-tipped tube through the patient’s nose to the narrowed area that’s causing problems, then inflates the balloon.

‘‘It gets rocky hard,’’ firm enough to cause tiny fractures in the underlying bone and widen the opening to the sinus, Durante said.

Sinuplasty uses the same technique as the artery-clearing procedure called angioplasty for heart patients. Government regulators approved sinuplasty equipment for marketing in 2005. Since then, some surgeons have embraced the procedure, although its long-term effectiveness has not been proven.

Less invasive

Fifty years ago, patients like Steffy faced the prospect of scarring and even disfigurement from sinus surgery that required incisions into the face. Then surgeons developed less invasive options that used a small tube called an endoscope to access sinuses.

Endoscopic surgery that cuts away tissue and bone, called Functional Endoscopic Sinus Surgery, or FESS, is still the leading option for patients with sinus disease that doesn’t respond to medication.

Durante said it was two years ago that doctors began to experiment with the gentler balloon technology, and he was trained in the procedure.

Durante has performed sinuplasties since July and is suggesting them to more and more patients, he said. South Shore Hospital in Weymouth is the only other local hospital that offers the surgery.

The balloon ‘‘helps us access places that are very difficult to access’’ and it works ‘‘as good or better than FESS,’’ Durante said.

It’s easier on patients because the balloon doesn’t destroy the lining of the sinuses, Durante said. Microscopic fractures of the bone heal quickly, he said. Patients suffer less pain and recover faster.

‘‘There’s no downside other than the potential that what we did won’t last; that doesn’t seem to be the case so far,’’ Durante said.

Still, the most recent study to examine sinuplasty followed patients long enough to establish that sinuses stayed open for six months, scarcely long-term. Some patients, such as those with polyps and patients with problems in ethmoid sinuses next to the nose, can’t be treated with sinuplasty.

And not all surgeons recommend the procedure. ‘‘There was a lot of controversy at academic meetings,’’ Durante said. ‘‘The older school was very much opposed to this. I brought this up at an eye and ear meeting a year ago and it was pooh-poohed as experimental.’’

But for Durante, ‘‘particularly with frontal sinus disease I would make this my first choice.’’

‘‘I feel pretty good’’

Steffy, under general anesthesia, was covered from head to foot in white sheets; only her face was uncovered. A fluoroscope towered behind her head.

Screens on both sides of the operating table showed pictures of glistening pink and red membranes inside Steffy’s nose. Another screen displayed cross-sections of her skull in four quadrants, derived from CT-scans taken earlier. Durante would use the diagrams to help place the balloon in the right spot.

Durante inserted a right-angled tube into Steffy’s nose and threaded a thin wire through the tube into the target sinus. The wire would guide the balloon-tipped tube to the narrowed opening.

Now the screens showed the deflated balloon no thicker than a pencil line moving along the wire to the target. At Durante’s command, a surgical technician began inflating the balloon, calling out the numbers as the pressure increased.

Durante enlarged four sinus openings in 35 minutes, looking carefully at each balloon placement. At one point, he withdrew the guide tube and reinserted it.

‘‘I feel better about that,’’ Durante said. ‘‘That was a false passage.’’

Durante also took out Steffy’s tonsils, repositioned her septum, the membrane dividing her nose, and cleared her ethmoid sinuses using FESS.

Steffy had to return to the hospital on Easter Sunday, two days after the procedure. ‘‘I woke up in excruciating pain. My nose was still bleeding and my throat felt awful. I was admitted for three days,’’ she said.

But a week later, Durante removed splints from Steffy’s nose ‘‘and it was instant relief,’’ she said.

‘‘She just had a lot of post-operative discomfort, more than normal from the tonsil standpoint,’’ Durante said this week.

‘‘The sinus issue went fine,’’ he said. ‘‘She’s doing very well.’’

These days, Steffy feels rested after sleeping for eight or nine hours, although she still senses some pressure in her sinuses and her throat has not healed.

‘‘I feel like when I breathe in, I breathe in a full breath,’’ Steffy said. ‘‘I feel pretty good.’’

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A few years ago, during his internship and residency at Montefiore Medical Center in New York, Anit Patel, M.D., M.B.A., welcomed the opportunity to rotate through hectic, metropolitan hospitals in the Bronx, Manhattan and Long Island. Now, though, with a flourishing ear, nose and throat practice at Jordan Hospital, Dr. Patel - a Methuen native and Tufts Medical School graduate - says it feels great to be back home again.

"Coming to Plymouth from the Bronx was a big change, but a nice change," Dr. Patel says. "I always wanted to come back to Massachusetts."

But it was not just the comfortable setting that drew Dr. Patel to Jordan Hospital. He was also attracted by the hospital's commitment to becoming a regional leader in ear, nose and throat care. From operating room equipment that is state-of-the-art to revolutionary diagnostic tools for disorders like sleep apnea, Dr. Patel reports that Jordan Hospital has it all.

"We offer comprehensive otolaryngology care," he says. "So, pretty much everything that can go wrong in the head and neck, we can deal with here. Patients don't necessarily need to be referred to Boston."
For example, Dr. Patel is one of the few surgeons in the region who offers image-guided sinus surgery, an advanced, safer way to perform procedures that are typically within millimeters of critical structures like the eyes, the brain and the carotid artery.

"When I do sinus surgery, 1 have a probe in the nose," he explains. "The tip of the probe lights up on a computer screen, and I know exactly where. I am on the CAT scan. This makes the procedure much safer, and it's something we're proud to offer patients at Jordan."

Dr. Patel also uses another innovative tool - a microdebrider - for surgery to remove polyps, tumors or other diseased tissue. The microdebrider simply makes sinus surgery much more precise, and that improves patient outcomes.

"Recovery time with the microdebrider is definitely improved, because I'm not performing as big a surgery," he says. "I'm not removing as much of the. normal tissues, so there's less swelling, less congestion and less bleeding. All of that improves recovery times."

In addition to the image-guided sinus surgery and microdebrider procedures, even more innovative technology is on its way to the operating rooms at Jordan Hospital. Soon, a C-arm will be available to take real-time images during otolaryngology surgeries.

"After I've done a portion of the surgery, I'll be able to see what the scan looks like in real time, and then determine how the surgery should progress," Dr. Patel explains. "Maybe I'll see an area on the scan that still needs to be debrided, for example, or that there's more. disease I need to explore."

In addition to sinus surgery, Dr. Patel also specializes in the treatment of sleep apnea, a condition that disrupts the quality of sleep, leading to bothersome - or even debilitating - daytime fatigue. Sleep apnea is a common disorder that affects both adults and children.

"Many people, even some primary care docs, don't know that otolaryngologists do so much sleep apnea work," Dr. Patel says. And he notes that there have. been several exciting advances in the field.

For instance, until recently, accurate diagnosis of sleep apnea required an extensive nighttime sleep study, usually conducted at a specialized sleep lab. Patients often waited months before they could participate in a study, and, typically, these tests were expensive. Because patients need to spend a night at an unfamiliar facility, diagnosing children with sleep apnea has been especially difficult.

Remarkably, however, sleep apnea diagnosis is now as simple as having the patient put on a glove.
"We actually have a glove-like device at the office," Dr. Patel explains. "It measures the. change in blood flow while the patient is sleeping and, through proprietary technology, is able to detect whether the patient has obstructive sleep apnea. It's better for the patient because they're in their own home, in their own setting. And, certainly, it's easier for a child to undergo this kind of sleep study."

In fact, Dr. Patel believes that improved diagnostics, like the glove, may eliminate many unnecessary childhood tonsillectomics and adcnoidectomies.

"If a child has symptoms such as loud snoring or daytime fatigue, but then undergoes a sleep study that shows they don't have obstructive sleep apnea, there's no reason to take their tonsils or adenoids out," he says.
When a patient is diagnosed with obstructive sleep apnea, Dr. Patel may prescribe a Continuous Positive Airway Pressure (CPAP) mask or, in some cases, surgery to remove an obstruction in the patient's nose or throat.
Other times, the diagnostic glove reveals that the patient's sleep is disrupted only by loud snoring, and Dr. Patel can help these patients, as well.

"We do a procedure in the office called injection snoreplasty," he says. "I inject an inflammatory substance into the patient's soft palate. Over the course of a few days, there's an inflammatory reaction so that the soft palate becomes very stiff. Then when the patient is sleeping at night, it doesn't flutter around and cause loud snoring."

Even though Dr. Patel has left the fast-paced, urban medical scene, he remains at the forefront of innovative otolaryngology technology and techniques and South Shore patients can get the best in comprehensive, quality care close to home.

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Over the past several years as Jordan has continued to expand the subspecialty of Otolaryngology, head and neck surgery is quickly becoming a center of excellence. Through use of innovative techniques, new procedures, and state-of-the-art instrumentation, otolaryngologists at Jordan are bringing tertiary care excellence to a community setting.

Anit T. Patel, MD, an otolaryngologist at Jordan Hospital, says that both he and Dr. Bernard J. Durante are able to perform extensive surgeries such as radical neck dissections for head and neck cancer. These are time intensive cases that can take up to 10-12 hours of operating time. Dr. Patel explains that “these cases require a multidisciplinary team for adequate post-operative rehabilitation including speech and swallow therapists who fully understand the nature of the post-op deficit, oncology nurses trained to take care of such patients, physical therapists, and dieticians who understand the precise caloric needs of head and neck cancer patients. This comprehensive level of specialty care is in place at Jordan Hospital and allows me to ensure that my patients are getting the highest standard of care.” Dr. Patel also states that many times these surgeries will leave the patient with a large defect in the head and neck. He comments that “we are able to offer these patients single stage reconstruction so that the cancer is removed and the defect reconstructed in the same setting. These are procedures that were traditionally done in Boston, but we are now able to offer such treatment to our patients at Jordan Hospital.”

One of these patients is Linda Thayer, a 57 year-old resident of Carver who recently underwent a radical neck dissection at Jordan for throat cancer that had spread to the neck. Linda, as frightened as she was to hear of her diagnosis, was confident in Dr. Patel and the staff at Jordan Hospital.

Her successful care was coordinated amongst her surgeon and oncologists. The treatment that she needed did not require going into Boston; instead the best care that could be provided for her was right next door in Plymouth.

In addition to excellence in head and neck cancer, the very latest technology in sinus surgery is also available at Jordan Hospital. Dr. Patel uses a microdebrider for all his sinus cases. The microdebrider has rendered the laser practically obsolete in sinus surgery. “This electrically powered instrument can precisely shave away and remove diseased tissue, one thin layer at a time, leaving healthy tissue unharmed,” Dr. Patel.

Another state of the art procedure performed at the Jordan is minimally invasive radioguided parathyroidectomy (MIRP). This is for patients who suffer from hyperparathyroidism, a condition which leads to high calcium levels in the blood and can cause kidney stones, peptic ulcer disease, pathologic fractures and bone resorption. With MIRP, the patient receives an intravenous injection of technetium 99, a safe radioactive agent. The parathyroid adenoma absorbs more technetium 99 than the healthy glands, allowing the surgeon to locate it with a gamma probe inserted through a small incision in the neck. The probe picks up radioactive signals and leads the surgeon to the enlarged gland, which is then removed through the same incision. After surgery, patients rarely need pain medication, but they normally take calcium supplements for several days until the remaining glands regain normal function. Dr. Patel points out that with this new technology, removing an overactive parathyroid gland is quicker, less invasive and just as successful as the standard procedure. continues. “It encourages gentle dissection of the tissues and does not damage the healthy anatomy as is common with traditional instruments.” Greater safety for the patient is ensured as removal of tissues is more precise when compared to conventional instruments, and the total operating time is reduced. Quick healing usually follows this gentle surgical technique.

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