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

(Reprinted from the Patriot Ledger)  
Anit T. Patel, MD,MBA

Sleep is a window to our health.  Good sleep contributes to our health, safety, and overall well-being.  Getting a good night's sleep impacts every aspect of our lives - at home, at work, in community life, and even behind the wheel of a car.

According to the National Institutes of Health, at least 70 million people in the U.S. have sleep problems for a few weeks every year, while 40 million suffer for longer periods of time.  Because of sleep problems, millions of people do not get enough sleep to function at their best during their waking hours.  Even more have poor quality sleep that may be disrupted or associated with other medical or health problems that keep them from getting sufficient deep or restorative sleep.

As many as one-half of U.S. males and one-quarter of U.S. females may snore to varying degrees.  Snoring is the sound of partially obstructed breathing during sleep.  It occurs when the structures in the throat are large and when the muscles relax enough to cause the airway to narrow and partially obstruct the flow of air.  As air tries to pass through these obstructions, the throat structures vibrate causing the sound we know as snoring.  Large tonsils, a long soft palate and uvula, deviated nasal septum, and excess fat deposits (especially in obese patients) contribute to soft tissue narrowing causing the loud snoring.  While snoring can be harmless, it can also be the sign of a more serious medical condition known as obstructive sleep apnea (OSA).

People with obstructive sleep apnea experience a complete obstruction of airflow through the airway.  This generally occurs because of muscles and excess tissue in the airway that are flabby and toneless and therefore cave in during inspiration.  It's like sucking air through a soggy straw:  when you breathe in, the airway narrows and causes complete obstruction.  During the pauses in breathing, the oxygen level in your blood drops.  Your brain reacts to the drop in oxygen by waking you enough to resume breathing (and snoring), but not necessarily enough to fully awaken you.  The cycle of snoring, not breathing, waking, and resuming breathing means that you do not get good quality sleep.  Most times, people with apnea don't even realize they're waking up and falling asleep all through the night.  But the process leaves them exhausted and they often feel very sleepy during the day, wake up with headaches, find it hard to concentrate, and their daytime performance may suffer.

The effects of sleep apnea range from annoying to life threatening.  They include depression, high blood pressure, irritability, sexual dysfunction, learning and memory problems, and falling asleep while at work, on the phone, or driving.  People with severe sleep apnea are two to three times more likely to have automobile crashes.  Risks for heart attacks, high blood pressure, heart failure, and stroke are also increased with sleep apnea.

People who have symptoms of sleep apnea should have a sleep study (polysomnogram).  The study consists of different measures of sleep that may include snoring; breathing; oxygen levels; heart rates; body, muscle and eye movements, and a recording of brain waves to determine stages of sleep and other brain activity.  Among other things, the study will allow your sleep medicine specialist to differentiate between simple snoring and obstructive sleep apnea.

In mild cases of sleep apnea, behavioral changes may be enough to stop the sleep apnea.  These include weight loss, learning to sleep on one's side instead of the back, and avoiding alcohol, sleeping pills, and smoking.

For more significant sleep apnea, the standard treatment is a Continuous Positive Airway Pressure (CPAP) machine.  The CPAP mask is worn by the patient at night to direct air flow through the nose to open the airway and allow unobstructed breathing to occur.

For those patients who can not tolerate the CPAP mask, surgery may be indicated.  This may involve removal of obstructing tissues such as the tonsils, adenoids, uvula, soft palate, base of tongue, and/or correction of a deviated septum.  In severe cases, the entire jaw bone must be advanced to open up the airway.

The future is very bright for treatment of obstructive sleep apnea as continued improvements are made in CPAP therapy as well as surgical advances to improve outcomes.  However, the main issue at this point is increasing awareness of this disorder in the community.  The vast majority of the estimated 18 million people who have obstructive sleep apnea are currently undiagnosed.

The tonsils are two masses of lymphatic tissue located on either side of the back of the throat. Adenoid tissue is located nearby; it can be found higher in the throat, behind the nose. Tonsils and adenoids play an infection-fighting role in your child’s body. Both are believed to fight infection by producing antibodies to bacteria that enter through the mouth and nose. But when tonsils and adenoids become chronically infected or obstruct normal breathing or nasal and sinus drainage, then serious health problems can occur.

Tonsillitis occurs when the tonsils become inflamed. The condition is diagnosed by examining the tonsils, which usually are enlarged and reddened. Small patches of yellowish pus also may be visible on the surface. Tonsillitis can cause fever, sore throat, painful swallowing, and swelling of the lymph nodes in the neck. Chronically infected tonsils may pose a potential threat to other parts of your child’s body. Some children who have frequent bouts with severe tonsillitis may develop other diseases, such as rheumatic fever (inflammation of the heart) and kidney infection. In some instances enlarged tonsils and adenoids can block the nose and throat, interfering with normal breathing, nasal and sinus drainage, sleeping, swallowing, and speaking. Adenoids that are chronically infected  can  disrupt the normal functioning of the tube that equalizes pressure to the ear, which can impair hearing and cause chronic middle ear infections.

Before the days of antibiotics, surgical removal of both tonsils and adenoids was routinely recommended for many children. Today, much stricter guidelines exist before a child is subject to such surgery.  Tonsils are removed (tonsillectomy) when children develop chronic and recurrent infection. Adenoids are removed (adenoidectomy) when children exhibit similar problems or when the adenoids are suspected of causing chronic ear infections or inflammation of the sinuses (sinusitis). The tonsils and adenoids also may be removed—either separately or together—if they obstruct normal breathing or cause significant sleep disturbance.

The procedure is performed through your child’s mouth. During the operation, the surgeon separates and removes the tonsils from the side of the throat; the adenoids are removed from behind the palate. Stitches are required infrequently.

The benefits of surgery can include the following:

Fewer sore throats: Once the tonsils are removed, patients are less likely to have bacterial infections in the back of the throat.

Decreased snoring and mouth breathing: Patients who snore or mouth breath because of enlarged tonsils and adenoids often have a decrease in these symptoms after surgery.

Fewer ear infections: Patients with frequent ear infections may benefit from removal of the adenoids if they were blocking the opening of the eustachian tubes.

Fresher breath: If halitosis (another word for bad breath) is present because of chronically infected tonsils or adenoids, this may improve after surgery. However, bad breath may persist if it is caused by bacteria in other areas of the mouth. Gum disease, failure to floss, or other medical or dental problems can also contribute to bad breath. Your doctor may be able to assist you in identifying the cause.

Improved voice quality: If the tonsils and adenoids are extremely large they may cause a stuffy sounding, or muffled voice. Removal of these tissues can help improve air flow and voice quality.

Complications from tonsillectomy and/or adenoidectomy are rare.  Although, some bleeding can occur either immediately, or several days after the procedure, usually it is readily controlled by your surgeon. If  your child should experience bleeding in either situation, contact your surgeon or return to the hospital immediately. The usual hospital stay following a tonsillectomy or adenoidectomy is eight to 10 hours, or until the patient is completely recovered from anesthesia. Most patients undergo the operation as an “outpatient” and are able to go home on the same day as the operation.  However, some patients may require an overnight hospital stay.  The first week following the operation, your child may experience some throat and ear pain. Full recovery usually occurs within 10 days to two weeks. A liquid or soft diet may be prescribed as well as restrictions on activity. You should listen to and carefully follow your surgeon’s specific instructions for a full recovery.

The evolving nature of the healthcare system in the last 25 years has had significant impact on the delivery of care.  The tools required to be successful in the 1970s are not adequate for the 21st century physician. Recent studies have shown that there are significant deficiencies in the business background of physicians as they enter practice.   They are just not getting adequate business education from their training programs and this is contributing to the increasing cost of our healthcare system.  Traditionally, medical education has focused on values of service, advocacy, and altruism. Conversely, business education promotes the values of profit and competition. As you can see, there is a perceived clash between the values required for success as a businessperson and as a physician.

As a resident of Albert Einstein College of Medicine in New York City, Dr. Anit Patel was frustrated with physicians losing control of their own field to business professionals who had no medical background. Most training programs lagged behind in teaching the business of medicine to their residents.  Dr. Patel realized that this left new physicians who were entering practice to learn business skills by trial and error. He felt there had to be a better way. 

Anit Patel,’95 MD, MBA, who is also a graduate of the first class of the Tufts University MD/MBA Health Management Program, wanted to give other physicians a chance to receive some of the business training he obtained during his time at Tufts.  Dr. Patel stated, “Having an MBA myself, I knew which topics were most important for residents to learn.” He did this by developing The Business of Medicine CD-ROM (copyright 2004). He wrote a business plan for the creation of the CD and was able to secure venture capital funding which allowed him to bring the project to completion. 

The purpose of the CD is to provide business skills to physicians that result in improved utilization of resources and ultimately higher quality of care. The curriculum consists of 9 modules and is geared towards meeting ACGME (Accreditation Council for Graduate Medical Education) competencies. The content is applicable to physicians in all specialties and addresses a broad range of both external and internal forces impacting on healthcare. The nine modules include:  maximizing reimbursements, correct coding initiatives, evaluating practice opportunities, healthcare technology, clinical practice guide, contracting, risk management issues, third party payers, and the regulatory environment. The faculty consists of doctors, lawyers, nurses, businessmen, billing managers, financial experts, professional consultants and risk managers.

To date 2500 CDs have been produced. Initially, the CD will be distributed to 750 physicians for a pilot study to test the effectiveness of the curriculum on new attending physicians.  The feedback obtained will allow Dr. Patel to modify the CD to meet the needs of these physicians. As one physician put it, “this CD could have saved me hundreds of hours of aggravation if I had access to it early in my career.”

Dr. Patel concludes that “As healthcare delivery and finance continue to evolve, effective leadership and management training will be essential for all physicians so that we can continue to focus as a field on our primary mission of diagnosis and treatment of disease.”