Dr. Kezirian is recognized around the world as a sleep apnea surgery expert. He works with each patient to find the surgery that is right for them.

 

The Physical Cause of OSA or Snoring

The most important part of getting good results in determining what is causing your obstructive sleep apnea or snoring. Generally, the cause is located in one or more of three locations:

• Palate Region
• Nasal Region
• Tongue Region

Many studies have shown that finding the cause is the key to success of surgery and oral appliance mouthpieces. The means that there is no one-size-fits-all solution for snoring and obstructive sleep apnea. While one patient might do well with one procedure, another patient might benefit from a different type of surgery, an oral appliance, or a combination.

Dr. Kezirian’s Approach

A thorough evaluation is the only way for a sleep apnea surgeon or snoring surgeon to choose the right surgery for you. In spite of what you may read or hear elsewhere, there is no single obstructive sleep apnea treatment or surgical procedure that works well for everyone. In all areas of medicine, cookie cutter approaches do not work because people are different. For snoring and obstructive sleep apnea, age, gender, body weight, race and ethnicity all affect treatment outcomes, as do differences in the structures of the head and neck. There are major implications for the results of obstructive sleep apnea treatment or snoring treatment, and it is important for a sleep surgeon to recognize these and choose surgical and non-surgical treatments based on them.

Dr. Kezirian was the first surgeon in the Western United States to offer Inspire Upper Airway Stimulation after FDA approval in 2014. This innovative obstructive sleep apnea treatment uses nerve stimulation and has important advantages – but also disadvantages – compared to other options. Dr. Kezirian is also considered by colleagues to be an expert in the use of Inspire therapy to treat obstructive sleep apnea because he incorporates these into the discussion with patients before rushing into offering a single surgery to everyone.

How do I know what snoring or sleep apnea procedure is right for me?

This website was developed by Dr. Kezirian to provide an overall introduction to snoring and obstructive sleep apnea treatment, with detailed information about specific procedures that Dr. Kezirian performs. There is a great deal of information (and some misinformation) available on the Internet, and this website cannot replace an individualized discussion that every patient should have with their sleep apnea surgeon or snoring surgeon. A discussion of medical history and physical examination is a critical first step, whether during an in-person evaluation in Santa Monica or Beverly Hills or a video consult.

Typically Dr. Kezirian will be able to discuss treatment options following an initial examination. In some cases, he may recommend an evaluation called drug-induced sleep endoscopy to guide the selection of procedures.  This would require coming to the Los Angeles area for an evaluation regarding obstructive sleep apnea treatment. Dr. Kezirian is an international expert in drug-induced sleep endoscopy and has conducted the landmark studies that show how best to use drug-induced sleep endoscopy in the selection of surgical procedures, including Inspire Upper Airway Stimulation. These studies have provided the foundation to help surgeons make decisions about Inspire therapy and other procedures as well. For Inspire Upper Airway Stimulation, studies led by Dr. Kezirian have shown that key findings from drug-induced sleep endoscopy are associated with associated with outcomes, as is palate shape, incorporating findings from the office examination. With other surgical procedures, the research has similarly shown that drug-induced sleep endoscopy is associated with surgical outcomes and can improve surgical outcomes and that palate shape findings are associated with results of soft palate surgery.

Types of Sleep Apnea Surgery

The procedures on this site are grouped into three categories, reflecting their treatment of narrowing or blockage of the breathing passages in three regions: nasal, palate, and tongue. The evaluation process is designed to determine what areas are responsible for blockage of breathing and, more specifically, what structures are playing an important role. This is somewhat complex, as research from Dr. Kezirian and other sleep apnea surgeon experts has shown that over 60% of people have obstructive sleep apnea related to a combination of factors. Maxillomandibular advancement is a more-involved procedure that has greater risks, but it also works well to treat obstructive sleep apnea.

 

Choosing surgeries for snoring and sleep apnea

To explain this process briefly, Dr. Kezirian’s approach to choosing procedures relies on what the procedures actually do and how that might improve snoring or sleep apnea in an individual patient. Based on substantial research, Dr. Kezirian’s lectures to surgeons around the world about procedure selection use the same principles described here. He relies on his own experience and the best published studies when choosing procedures to treat patients. You can watch his lecture about procedure selection at the 2017 International Surgical Sleep Society meeting that he organized in Los Angeles, California, when he was president of that organization.

For example, there are a number of procedures covered in the Palate Procedures section. For patients with obstructive sleep apnea, there are a number of different palate procedures that remove and/or reposition tissue. These procedures include expansion sphincter pharyngoplasty, the Australian modified palatopharyngoplasty, and lateral pharyngoplasty. A sleep apnea surgeon should choose among these other palate procedures based on what may be best for individual patients, given the structure of their throat and soft palate. Some procedures have more removal of tissue, and others have more tissue repositioning in the soft palate and sides of the throat (lateral pharyngeal walls). Other procedures (Palate Radiofrequency and Uvulopalatoplasty) are excellent options for treatment of snoring or mild obstructive sleep apnea because they stiffen the soft palate and prevent vibration. However, many surgical websites (and advertisements) suggest these palate stiffening procedures are good for most patients with obstructive sleep apnea, which is actually not true. While palate stiffening procedures are great snoring treatments, careful and well-done studies (supported by the company that developed the devices) have shown that these procedures do not work as well for most patients with sleep apnea.

As discussed on the Tongue Region Procedures section, there is another set of procedures that are used primarily for obstructive sleep apnea. They can treat the structures that contribute to blockage in this region: the tongue, epiglottis, and lateral pharyngeal walls. Dr. Kezirian’s research and that of other experts has shown that over 60% of patients with sleep apnea require a combination of two types of procedures. In addition, this research has also suggested that different patients have tongue region blockage due to different structures, further requiring selection from among the various options. Among the tongue region procedures, some are directed at the tongue (tongue radiofrequency, genioglossus advancement, lingual tonsillectomy, and midline glossectomy), and some are directed at the epiglottis (epiglottis surgery and hyoid suspension). Some of the palate procedures and hyoid suspension may also treat the lateral pharyngeal walls. Choosing among these tongue region procedures requires an evaluation to determine what structures may be playing a primary role and what are the key factors that can be used to predict results for these and other obstructive sleep apnea treatments.

The large number of available procedures can be confusing. The reason there are so many procedures is that they accomplish different things.  The choice among the procedures is based on the pattern of blockage in breathing and weighing the risks and benefits for an individual patient.

 

The following video presents a discussion of the selection of surgical procedures:

The following video presents a more-detailed discussion of drug-induced sleep endoscopy, including some example videos:

The following video discusses the role of drug-induced sleep endoscopy in the selection of surgical procedures and oral appliances: