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When Jose Salas walked into the USC Sleep Apnea and Snoring Surgery Center in 2017, he was beyond exhausted. At that point, he had been dealing with sleep apnea for 15 years. Instead of joining colleagues for lunch at work, he often spent the hour napping in his car in a vain attempt to catch up on sleep.

His memory took a hit, too, and he soon found himself struggling to remember where he put things or what time he needed to be somewhere. The absolute worst part of chronic sleep deprivation, he says, was knowing that he was sometimes short-tempered with family, friends and work colleagues even though they were never the source of his sour moods. Sleep deprivation had robbed him of his cheerful nature and innate positivity. “I was just so tired all the time, and I didn’t feel like myself,” says Salas, 45, who first experienced excessive sleepiness around the time he turned 30. He was young and trim, had no other medical problems and was not a smoker or heavy drinker. In other words, he wasn’t an obvious candidate for sleep apnea. But, after checking in to a sleep clinic, he learned that was the cause of his problem. It is estimated that 22 million Americans have sleep apnea, mostly obstructive sleep apnea (OSA), in which blockage of the airway in the throat interrupts breathing throughout the night. Normally, people go through various stages of sleep, the deepest of which is known as rapid eye movement, or REM, sleep. OSA disrupts these cycles and can prevent a person from entering the deepest stages of sleep. This inability to experience sustained rest results in excessive tiredness and other symptoms during the day. Research into OSA in recent decades has shown that it may be far more detrimental than just causing problems with alertness during the day. Increasingly, sleep apnea has been associated with high blood pressure, diabetes, cardiovascular problems, depression, anxiety and numerous other serious medical conditions.

Knowing that she was supposed to walk as part of her recovery, she took a walk with her boyfriend Richard Gutierrez a few days after going home. As the young couple sat down to eat lunch, she went pale and he caught her just as she was about to pass out.

The Right Expertise to Help

In other words, sleep apnea is no longer swept aside as a condition that only affects a person’s quality of life. It is understood now that improving sleep can help people live healthier lives. And yet, for some patients, including Salas, finding an effective treatment can be a struggle. By the time he met Keck Medicine of USC’s Eric Kezirian, MD, MPH, one of the few surgeons in the country who specializes in sleep apnea and snoring, he had tried numerous methods including three separate surgical procedures. “He was getting poor sleep every night,” says Kezirian, professor of sleep medicine and surgery in the USC Caruso Department of Otolaryngology – Head and Neck Surgery at the Keck School of Medicine of USC. “We all are tired, have changes in our mood or experience fatigue and difficulty concentrating when we do not get a good night of sleep. The problem with Mr. Salas was that he never was able to have a good night of sleep, so he was feeling this all the time.” A family member had read that Kezirian was using a new device that encourages upper airway stimulation. Salas was hoping he would be a candidate for the device because he tried just about everything else and nothing helped.

Kremer Johnson Photography

Working in Concert

While most surgeons are trained with a single surgical procedure for all patients, research has shown that this one-size-fits-all approach is not successful for most patients. One of Kezirian’s areas of expertise is using state-of-the-art approaches to evaluate each patient to determine what surgery will work best for them. Kezirian is an expert in the use of drug induced sleep endoscopy, which is an evaluation that involves threading a camera through the nostril while the patient is sedated in the operating room. This allows Kezirian to see exactly which structures in the throat are causing blockage of breathing, allowing him to create a personalized surgical plan for each patient. “There are different procedures available for sleep apnea, but you want to tailor it to each person,” says Kezirian, “and that is what the evaluation procedure does.” Kezirian evaluated Salas using this method and learned that he wasn’t a candidate for upper airway stimulation due to the type of blockage he had. Instead, Kezirian said he could help him using a newer surgical technique called expansion sphincter pharyngoplasty that involves removing the tonsils and repositioning the tissues of the soft palate and sides of the throat. “I was a little hesitant to have another surgery until he explained the evaluation and what he found,” says Salas, who had never been evaluated using drug-induced sleep endoscopy by other doctors. “He was able to show me where I was getting the obstruction. That was the first time I had seen anything like that.” After the evaluation, Salas decided to embrace the old adage about the third — well, fourth — time being the charm and agreed to Kezirian’s surgical plan. Several months later, Salas is doing things at home and work that he could not have imagined a few years ago. He has taken on new responsibilities at work and is enjoying new challenges for the first time in years. And instead of going home and collapsing on the sofa, he often takes his kids to the park to kick around a ball. His most recent sleep study showed that his sleep apnea is no longer interfering with breathing at night. He says that he didn’t need that study to know that Kezirian’s surgery worked. “I wake up in the morning and instead of being tired, I am good to go,” he says.

Looking for another option?

What if a patient isn’t a candidate for tumor resection? The USC Comprehensive Epilepsy Center calls on a variety of leading-edge techniques such as responsive stimulation devices and other neuromodulators — essentially pacemakers for the brain — that work to prevent seizures at their source. The center was involved in early clinical trials that led to approval of the devices.

KeckMedicine.org/sleep-surgery (800) USC-CARE

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USC Health is a publication of Keck Medicine of USC. Permission to reprint articles is available on request.

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— Khashayar Pirouzmand

In one moment, engineering and neuroscience and medical school were all combining to cure the patient — me — of epilepsy. It's kind of amazing.

50 million people worldwide are diagnosed with epilepsy. One of the most common neurological disorders, it is characterized by unpredictable electrical activity in the brain and recurrent seizures. Doctors believed Pirouzmand’s tumor was too close to the language areas of his brain to operate, so he began taking two anti-seizure medications. They didn’t stop his seizures, which started escalating. Each time, he lost the ability to put words together or make sense of them. He tried finishing his university entrance exam, but couldn’t. The next year, his seizures again kept him from completing the exam. Pirouzmand’s dream of traveling to America to study engineering seemed nearly impossible.

On an ordinary February day, 18-year-old Khashayar Pirouzmand was breezing through the physics questions on an important exam at his high school in Iran, excited because doing well could help him get into a top university. Two hours in, without warning, his life changed dramatically. Very suddenly, he felt a strange pressure in his brain. He raised his hand and tried to say he wanted to go outside, but couldn’t put the words together. He took a deep breath and glanced at his paper. He could no longer solve the problems he had done only minutes before. Pirouzmand left the classroom with the test unfinished. By the time he reached home a half hour later, he could speak again. He told his family something had happened to him, but he didn’t think it was serious. He chalked up the incident to the stressful exam. The second time, about two months later, he was talking to his aunt when he heard a high tone in his ear, felt pain in his jaw and passed out. He woke up in an ambulance. After tests at a local hospital, doctors gave Pirouzmand the news: He had epilepsy, most likely caused by a small tumor on the left side of his brain.

At the USC Comprehensive Epilepsy Center, patients with the neurological disorder receive the highest level of care, backed by innovative research.

“Patients come to us because they need a higher level of care,” notes Christi Heck, MD, medical director of the center and professor of clinical neurology at the Keck School of Medicine of USC. That level of specialty is necessary because epilepsy can be extremely challenging to diagnose and treat, in part because it has a wide range of potential causes, including genetics, prenatal injury, meningitis, strokes, tumors and traumatic brain injury. More people die of epilepsy (50,000) each year than from breast cancer (40,000). This includes people who develop SUDEP or “sudden unexpected death in epilepsy,” as well as those who die from seizure-related drownings or burns. Pirouzmand initially met with George Nune, MD, assistant professor of clinical neurology at the Keck School. Nune changed Pirouzmand’s medications to see if that would halt the seizures. “Approximately one-third of patients have medically refractory epilepsy, which can’t be controlled with medication,” Nune says. Nune asked Pirouzmand if he was interested in surgery, which held the potential to remove the source of his epileptic seizures. “I was very excited,” Pirouzmand says. “It seemed like an adventure for me. I wanted to try it.”

Little did he know that in a few years, Pirouzmand would find himself at the USC Comprehensive Epilepsy Center, designated a level 4 center by the National Association of Epilepsy Centers. The highest accreditation possible, this distinction indicates the center’s capability to treat the most complex cases. When he finally arrived in Los Angeles two years ago, he saw a community physician for his epilepsy prescriptions who recommended he go to Keck Medicine of USC for help. Within the USC Comprehensive Epilepsy Center, a multidisciplinary medical team provides the most advanced care for patients with complex issues, including those who experience uncontrolled seizures, severe side effects from medication or who want to get pregnant while having epilepsy. The team includes board-certified epileptologists, neurosurgeons, neuroradiologists and psychologists, along with epilepsy nurses, occupational therapists and nutritionists. “Patients come to us because they need a higher level of care,” notes Christi Heck, MD, medical director of the center and professor of clinical neurology at the Keck School of Medicine of USC. That level of specialty is necessary because epilepsy can be extremely challenging to diagnose and treat, in part because it has a wide range of potential causes, including genetics, prenatal injury, meningitis, strokes, tumors and traumatic brain injury. More people die of epilepsy (50,000) each year than from breast cancer (40,000). This includes people who develop SUDEP or “sudden unexpected death in epilepsy,” as well as those who die from seizure-related drownings or burns. Pirouzmand initially met with George Nune, MD, assistant professor of clinical neurology at the Keck School. Nune changed Pirouzmand’s medications to see if that would halt the seizures. “Approximately one-third of patients have medically refractory epilepsy, which can’t be controlled with medication,” Nune says. Nune asked Pirouzmand if he was interested in surgery, which held the potential to remove the source of his epileptic seizures. “I was very excited,” Pirouzmand says. “It seemed like an adventure for me. I wanted to try it.”

Center of Excellence

Khashayar Pirouzmand and his golden retriever puppy, Zomi, enjoy a day at the park. | Kremer Johnson Photography

Improving Access to Advanced Care

The center serves as the academic anchor to the USC Epilepsy Care Consortium. “This unique partnership is composed of nearly a third of all the certified epilepsy centers in our state,” says Charles Liu, MD, PhD, professor of clinical neurological surgery and neurology at the Keck School and secretary of the consortium. “This maximizes patient access to the resources of an academic medical center while minimizing travel.” The patient’s local neurologist remains the main point of contact, while Keck Medicine specialists assist with care management through teleconferencing. “If a patient needs more advanced care than is available in their community,” Christi Heck, MD, says, “they can come here and we can co-manage that care with their local doctor.” The center also addresses the transition that teen and young adult patients must make from children’s services to adult care. “There’s a very big gap between being a child with epilepsy and being an adult with epilepsy,” Heck says. The transition clinic includes a navigator who reviews each case and directs the patient to the services they need.

Improving Access to Advanced Care

Jonathan Russin, MD

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If our patients have the courage to undergo these procedures, it’s our responsibility to do the job right with the least amount of risk.

George Nune, MD

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Approximately one-third of patients have medically refractory epilepsy, which can’t be controlled with medication.

For Pirouzmand, surgery gave him his life back. He occasionally hears a high tone in his ear (an “aura” or warning of a potential seizure), but the seizures no longer come. He is on two medications for now, a precaution for the first few years after surgery. Pirouzmand has started driving again and he is hard at work studying for his university degree. During his treatment at Keck Hospital, he realized the specific field he wants to pursue — electrical engineering. Being in the hospital, with electrodes implanted in his brain, he felt like a living-breathing embodiment of science at its best. “In one moment, engineering and neuroscience and medical school were all combining to cure the patient — me — of epilepsy,” Pirouzmand says. “It’s kind of amazing.”

Science at Its Best

Pinpointing the area responsible for language as accurately as possible for each individual is essential “because once patients have been having seizures for so long, their brain often has reorganized itself,” Russin notes. Armed with the results, Russin could proceed. His goal was to remove as much of Pirouzmand’s tumor as possible, while avoiding delicate tissue. “You’re talking about potentially curing somebody of their seizures and changing the trajectory of their life,” he says. “If our patients have the courage to undergo these procedures, it’s our responsibility to do the job right with the least amount of risk.” Pirouzmand was more than ready. “I said, ‘Let’s go.’ This was my chance to get better.”

The first step: capturing the electrical impulses in Pirouzmand’s brain. The center is equipped with the most advanced imaging and diagnostic technologies, including video electroencephalographic monitoring (EEG), an invaluable tool to diagnose epilepsy symptoms, using non-invasive electrodes attached to the head. Pirouzmand spent a week in Keck Hospital of USC, as his medical team gradually withdrew him from all medication to trigger and track his seizures. This would enable them to characterize what type of seizures he was having and where they originated within the brain. Jonathan Russin, MD, assistant professor of clinical neurological surgery at the Keck School, likens the on-the-scalp video EEG to “trying to listen to a conversation through a wall.” Nune and Russin escalated the testing to the next level: phase II intracranial EEG monitoring to more accurately locate the area where seizures began and those areas which are essential for speech production. This higher-level brain mapping is like “being inside the room listening to the conversation,” Russin says. Russin implanted a very thin mesh of electrodes over the surface of the brain in the relevant region. His typical seizures were then recorded over the course of several days as Pirouzmand dutifully did physics homework and watched documentaries in the intensive care unit (ICU). Nune then electrically stimulated the various brain areas under this mesh to determine which disrupted the ability to speak in his native Farsi. These would have to be preserved during surgery.

Listening to the Brain

Looking for another option?

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— Khashayar Pirouzmand

I said, ‘Let’s go.’ This was my chance to get better.

Looking for another option?

KeckMedicine.org/epilepsy (800) USC-CARE

Learn more or schedule an appointment:

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After his first sleep study 15 years ago, Salas was hopeful that getting a diagnosis would mean that relief and a good night sleep were within reach. He tried a continuous positive airway pressure device, known as a CPAP machine, which blows a stream of air into the airway through a mask, keeping the airway open during sleep. He knew the machine helped others, but it did not work for him. The machine often fell off when he turned over in bed, and it took his wife some time to acclimate to the sound of his breathing while using CPAP. The machine made a distinctive sound, to say the least. “My kids are the ones that figured out,” Salas remembers. “My youngest is three, and he said, ‘Oh daddy, you’ve got the Darth Vader mask on.’ And I said, “Yeah, I do. I have it on.” He also developed chronic sinus infections while using the device even though he cleaned his machine meticulously and used other treatments, such as a neti pot and over-the-counter drugs, to keep his sinuses clear. He tried a custom mouthguard, which he liked, but it did not help him sleep. One doctor repaired his septum, hoping that would help. Another thought scarring from the first surgery impaired his breathing and operated on him a second time to fix that. A third removed his uvula, the structure that extends down from the soft palate in the back of the throat. These helped a little, but he was back on the CPAP machine, and struggling with it, shortly afterward.

— Jose Salas

I wake up in the morning and instead of being tired, I am good to go.

Mark J. Cunningham, MD

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Ray Matthews, MD

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Jose Salas enjoys life more now that he’s getting uninterrupted sleep. Kremer Johnson Photography

USC Health is a publication of Keck Medicine of USC. Permission to reprint articles is available on request.

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Eric Kezirian, MD

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