AN OVERVIEW OF THE SPECIALTY

We are the newest member at the otolaryngology fellowship table. Most people, including otolaryngologists, are unaware of this emerging career path. I will spend the rest of this space detailing my unexpected foray into the field and the promising future that lies ahead, biased as it may be.

As I was beginning to explore skull base fellowship options during my PGY-3 year, I happened to be on the Sleep/Swallow rotation at the University of Pittsburgh with Dr. Ryan Soose. In addition to his infectious charisma, I was taken aback by the patient narratives in the clinic. For example: "Dr. Soose, my sleep study shows that I have severe sleep apnea. For years, I have felt that I can't breathe when I sleep. I tried the CPAP machine but it makes me feel claustrophobic. Do I have other options?" We would perform sleep surgery and some would return for follow up thanking him for allowing them to have the first night of refreshing sleep in years. As a junior resident, I likened their sleep troubles to being on call EVERY night. And there was something I could do as a surgeon to actually liberate them from incessant mommy calls (i.e. apneas)? That was my calling.

So that is the first reason to become a sleep surgeon --- patient gratitude. There are several others of importance: 2) intellectual challenge 3) interdisciplinary practice 4) surgical variety 5) research opportunities 6) limitless patient base and 7) lifestyle.  Allow me to expand on each of these points.

• Intellectual challenge. Every patient's airway and resulting treatment selection is unique. Operating on the sleep airway entails a comprehensive understanding of the relevant anatomy - skeletal structure, soft tissue components – and the physiology of the neuromuscular-driven patterns of collapse during sleep. We operate on a state-dependent phenomenon which remains elusive in many ways. We attempt to simulate sleep using an anesthetic in the operating room (drug-induced sedated endoscopy) but it’s a rough approximation, at best. This is part of the field's mystique.

• Interdisciplinary practice. As a medical student, I was torn with between GI and ENT. As a sleep otolaryngologist, I get to marry my interest in sleep physiology and head and neck surgery. In the clinic setting, I work closely with pulmonologists, neurologists, cardiologists and pediatricians. In the surgical setting, I have unique interactions with anesthesiologists and perform team surgery with oral/maxillofacial surgeons.

• Surgical variety. Sleep apnea commonly affect adults and kids. The sleep airway starts at the nasal valve and ends at the larynx. A complete surgical sleep apnea practice includes functional septorhinoplasty, modified expansion pharyngoplasty, midline glossectomy (robotic or coblation), supraglottoplasty, hyoid suspension, genioglossus advancement, maxillo-mandibular advancement, tracheostomy, and most recently, hypoglossal nerve stimulator implantation.

• Research opportunities. I firmly believe there are more questions than answers in our field today. This field is in its infancy with the leaders just beginning to organize multi-institutional studies. Our short-term success rates are suboptimal and there are almost no long-term prospective data. Funding sources are ecletic, as sleep apnea continues to gain traction across medicine given the increased understanding of its functional and cardiovascular morbidity.

• Limitless patient base. The obesity epidemic has increased the number of sleep apnea patients, and simple math demonstrates the magnitude of need. Of roughly 240 million adult Americans, 5% are affected by moderate-severe sleep apnea, 50% of whom do not use CPAP long-term. That amounts to about 2% of the U.S. population or 6 million people! That doesn't include the pediatric population in which OSA is the leading indication for tonsillectomy. If we continue to make great strides in our field, we will have, without question, the biggest impact of any ENT subspecialty.

• Lifestyle. There are no emergency sleep surgery consults. All surgeries are elective. Post-operative hemorrhage, however, can be challenging and requires adept difficult airway management.

Fellowship options. As an immature subspecialty, fellowship opportunities are both scarce and heterogeneous. Fellowships come in 3 flavors: sleep surgery, sleep medicine and hybrid sleep medicine & surgery. Sleep surgery only fellowships provide excellent exposure to advanced sleep surgery but do not offer sleep medicine training and thus, preclude eligibility for the sleep medicine boards. There are more than 50 ACGME sleep medicine fellowship programs which are strictly sleep medicine without surgical training. There are few ACGME sleep medicine fellowships that incorporate surgical training (20-30%) with an ENT sleep specialist. For example, I completed a 1-year ACGME fellowship in sleep medicine and surgery in which I spent 30% of my time in clinic or the operating room with a sleep apnea surgeon (Dr. Edward Weaver at the University of Washington). On other side of the coin, I recently trained an otolaryngologist in Emory’s sleep medicine fellowship who spent roughly 30% of his time with me, roughly split between operating room and clinic. I feel strongly that sleep otolaryngologists need to master sleep medicine to optimize patient selection --- the current Achilles heel of our field.

Whatever course you select, our field needs you as it expands and matures. Best of luck in your exploits.

Fellowship Program List
Below is list of hybrid sleep medicine & surgery fellowships as of August 2019. More fellowship details can be found on Otomatch and on the ENT Connect website, Sections for Residents and Fellows-in-Training, Discussion Board.

University of Cincinnati | Contact: Stacey L. Ishman, MD

Henry Ford/Wayne State University | Contact: Kathy Yaremchuk, MD

Medical College of Wisconsin | Contact: Tucker Woodson, MD

University of Pennsylvania | Contact: Raj C. Dedhia, MD MSCR

University of Colorado | Contact: Katherine Green, MD

University of Southern California - Keck School of Medicine | Contact: Eric Kezirian MD, MPH [HYBRID SLEEP SURGERY & SLEEP MEDICINE; SEPARATE SLEEP SURGERY]

Stanford University | Contact: Robson Capasso, MD and Stanley Liu, MD, DDS

University of Washington | Contact: Ed Weaver MD, MPH

Texas Facial Plastic Surgery and ENT | Contact: Jose Barrera: San Antonio [SLEEP SURGERY ONLY]

Thomas Jefferson University | Contact: Colin Huntley, MD

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