Sleep Disorders Patient Story: Jack Smith

Examining the “Property” Leads to Good Sleep for Agent

Jack Smith

When Jack Smith attended meetings at work, he often struggled to stay awake. It’s not that the meetings were boring; Jack suffered from a sleep disorder that prevented him from having quality sleep — but he didn’t know it.

Jack, the top agent in the north shore area for a leading real estate company, has worked in the real estate business for 20 years. For years, Jack felt tired in the morning and fatigued throughout the day, but he didn’t pay much attention to his symptoms. “I just wrote it off as not being a morning person,” he said. “I always felt like a train had just hit me but didn’t realize that I didn’t have to feel that way.”

Jack said he often would hear himself start to snore as he dropped off to sleep. He also noted that his voice sounded muffled and his tonsils felt large. In the fall of 2005, Jack made an appointment with Albert Merati, MD, an otolaryngologist (ear, nose and throat physician) at Froedtert & the Medical College of Wisconsin. Dr. Merati is director of the Center for Communication & Swallowing Disorders at Froedtert & the Medical College.

“After examining my throat, Dr. Merati told me that my tonsils were huge,” Jack said.

While the cause of Jack’s enlarged tonsils was unknown, it is known that they can cause obstructive sleep apnea (OSA), a disorder in which the airway is blocked, causing a temporary suspension of breathing (10 or more seconds) repeatedly during sleep. OSA may also be caused by other types of airway obstructions.

Because of Jack’s symptoms and large tonsils, Dr. Merati arranged for Jack to take part in a sleep study at Froedtert & the Medical College. A sleep study provides data to evaluate sleep-related problems and identifies sleep stages, body position, blood oxygen levels, respiratory events, heart rate, muscle tone, snoring levels and overall sleep behavior.

Following the sleep study, Jack learned that he had experienced 122 apneic episodes per hour. This meant that his breathing was reduced or stopped 122 times each hour during sleep. He also discovered that his blood oxygen level was 78 percent during sleep. (During normal breathing, a person’s blood oxygen level ranges from 90 percent to 100 percent. People with sleep apnea often have a blood oxygen level in the 60 percent to 80 percent range.)

The diagnosis: obstructive sleep apnea.

Initially, Jack was treated with nasal continuous positive airway pressure (CPAP) device that delivers air into the airway through a nasal mask. The flow of air creates enough pressure when a person inhales to keep the airway open. Jack did not tolerate the CPAP well, however.

Dr. Merati referred Jack for a surgical evaluation with B. Tucker Woodson, MD, a Froedtert & the Medical College of Wisconsin otolaryngologist who is a board-certified sleep specialist specializing in upper airway reconstruction for sleep apnea. Dr. Woodson is also chief of the Division of Sleep Medicine and director of the Sleep Disorders Program at Froedtert & the Medical College.

Dr. Woodson conducted an in-depth structural evaluation of Jack’s upper airway, which revealed both enlarged tonsils in the back of the mouth (palatine tonsils), abnormal muscle enlargement in his throat, and enlarged tonsil tissue at the base of the tongue (lingual tonsils). The lingual tonsils also were affecting Jack’s voice box.

“It’s relatively uncommon to see adults who have lived with big tonsils most of their lives,” Dr. Woodson said. Plus, enlarged lingual tonsils (those behind the tongue) may be missed in adults during a routine medical exam and often are only seen during an upper airway endoscopy.”

Dr. Woodson recommended a two-stage surgical procedure, which would allow Jack to have a faster overall recovery than doing all the procedures at once.

The first procedure, performed in November 2005, involved surgery on the palate (tissue on the back and roof of the mouth) and removal of the tonsils in the upper throat. Because years of chronic airway blockage had resulted in profound changes in Jack’s throat muscles, a routine “traditional” tonsillectomy would not reduce this blockage and required more sophisticated treatment. Dr. Woodson performed a reconstructive procedure developed at Froedtert & the Medical College to open the breathing passage. This preserved much of the normal tissue and anatomy, in contrast to earlier procedures that sacrificed the uvula and parts of the soft palate.

Jack’s lingual tonsils posed a different problem according to Dr Woodson. “These tissues are located at the base of the tongue and can be very difficult to remove, especially in the sleep apnea patient who already has a very small airway.” Traditionally, a laser is used, but this method carries an increased a risk of bleeding, airway obstruction and incomplete removal of the tonsil. Using a new technique first described and developed in collaboration with physicians in Australia and at Froedtert & the Medical College, the procedure was simplified.

The technique involved using a “plasma knife,” a special, bendable surgical tool that breaks up tissue using much less energy than the laser, resulting in less trauma to tissue, less bleeding, and less pain for the patient. When combined with the operating microscope, tissue could be precisely removed.

After the surgery, Jack was found to have an uncommon disorder that increased his risks of blood clots. This was treated by the medical and hematology specialists at Froedtert & the Medical College. “In light of the clotting problem, I’m glad we were able to minimize the surgical time and trauma of the procedure,” Dr. Woodson said.

Following the surgeries, an overnight sleep study showed Jack’s apneic episodes had declined to only 1.4 events per hour, and his blood oxygen level had returned to normal.

“I could sleep well right away after the first surgery,” Jack said. “I used to be able to move walls with my snoring, but I don’t snore now, and I sleep as much as I want. It’s been tremendous!”


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