Looking at Airway Space from the Eyes of an ENT Specialist

JW: This is Dr. Jill Wade and I want to welcome you today to Simplifi Health, an exciting episode where we're going to look at the airway space but from the eyes of an ENT specialist. Dr. Mehendale, thank you for being with us here today. NM: Thank you, Dr. Wade. I look forward to talking about this exciting subject that’s near and dear to my heart. JW: It is near and dear to our heart as well because I truly believe that people don’t realize like air is essential like you don’t get a choice to breathe or not. Your body must have only a few things in life and air is one of them. NM: Absolutely. It’s actually one of the things that I went into ENT because I had an issue with my nose and I had it corrected when I was younger, eighteen, twenty, and it made a world of difference. I didn't know any better until I had it corrected. Once I did, I realized that, “Wow, this is how people can live. Who knew?” JW: I know. I will have to give you kudos here because you've actually worked on me personally and I would have to say the same concept. I had had large tonsils forever, I mean I can remember having tonsillitis time after time again. Nobody wanted to take my tonsils out. As an adult, as a professional who is learned, trained all about sleep apnea, I finally told my physicians I was like, “Listen, guys, the CPAP machine is not working. The mandibular device is not working.” I want to get down to the root cause of the problem. I got into your office, you were like, “Jill, your tonsils are huge and so are your adenoids.” You were able to take those out for me as an adult, which I have to say was not bad at all, so don't believe the horror stories. But let me tell you the funniest story, I remember waking up from the anesthesia, had not even opened up my eyes yet, my sister was standing next to me and I took my conscious first deep breath in and I go, “Oh, my God. Where did that lump in my throat go? It had been there forever.” And all the sudden I could breathe with so much ease. That was immediately after surgery. It’s crazy. NM: Yeah, you were just so used to it that you didn't know any better until it wasn't there and then you did. You’re a lot tougher than the average bear so I’m not sure. You did a great job and it was a tough recovery I think you definitely toughed through. JW: Well, there's nothing like going back to work on Monday when you shouldn’t have been. NM: Exactly. JW: But I just want to tell people who have become listeners of Simplifi Health that you realize that part of my passion, part of my voice that I keep trying to share to everybody is that hey, guys, it is about symptoms and symptoms point you towards the direction of root causes and I'm not a huge believer on just band-aiding the symptoms, I want to find real solutions to those root causes. That's why I wanted to have you here today because this airway obstruction is, in my opinion, becoming more and more of a debilitating, if I could say, issue for the public. I don't think many people realize just that their health issues are actually stemming from an initial problem of an airway obstruction that is keeping them from sleeping deep enough and then that disruption of their sleep pattern is really keeping them from healing, making them gain weight, and it is just basically compounding the problem. NM: Absolutely. You and I have talked about this in the past just on our casual conversations that the efficiency of our sleep, we don't always get as much sleep as we need, obviously, we'd like to correct that. But there are some things in life that get in the way. So what we want to do is when we do sleep, we want to sleep as efficiently as possible. That means getting as much oxygen as we can during the time we're sleeping so that our body can recover so that our body can rest. Again, I tell my patients that, “We can give you medicine for this, we can give you antibiotics for this. But ultimately your body has to heal itself. Anything we're doing is helping your body heal it and one of the number one ways your body's going to heal itself is sleep. Nutrition certainly is a very close second, but sleep is number one.” JW: Agreed, 100%. So let's say that I, as a dentist or as a mom, was thinking that the person in front of me, child, patient, friend, family, anybody was having an airway obstruction creating some sleep disturbance and I say, “Hey, I want you to go have a consultation at the ENT specialist and have them look and evaluate basically from tip of the nose down towards the lungs your airway space and let's see if there happens to be any physical obstruction.” Can we start there and you just kind of take people through the process of looking in and how you evaluate to see if there's an obstruction? NM: Absolutely. I'll tell you initially, one of the signs and symptoms people may come in for is snoring. Their spouse, their child, their significant other may snore and we’re finding that snoring can certainly be a social issue and can disrupt other people’s sleep. But it also can be a sign of disrupted sleep in the person that's actually snoring. Oftentimes people say, “I don't stop it or my partner doesn't tell me that I stopped breathing.” It’s not always stopping breathing, just the snoring itself can indicate that you're not having as efficient oxygen exchange as you should. One of the first things we’ll do is we come in, we take a look at just the overall patient. Are they overweight? They may not be overweight but maybe they have a larger weight distribution, a potbelly, so to speak. Do they have a larger neck? Those are some small things. I don't harp on that but I do tell patients that plays a part in it because of the analogy I use is think of as you’re breathing at night, if you have to move more tissue out of the way, so think of drinking water through a straw and then now think of drinking using that same straw to drink the milkshake, well the walls of the straw collapse when you have to suck in harder. The same thing can happen with our airway so if we have to push a little more potbelly out of the way our airway sucks in, collapses, makes a little harder to breathe. That's why I just look at the overall patient. Then specifically, I'll start with the nose so initially looking at the nose and I can look at somebody's nose and it can be very crooked on the outside, does not necessarily mean it’s crooked on the inside or the converse is true, it can be very straight from the outside, does not mean it’s straight on the inside. One of the first things I look at as something called the septum which is the middle part of the nose that divides the nose into right and left nostrils and we're looking to see is there a deviated septum, very common to have a deviated septum. The septum is made of cartilage and bone and most times it’s not related to trauma. A lot of people come and say… JW: That is a misconception. NM: Absolutely. JW: Absolutely. NM: It’s mostly genetic and it happens a lot of times as we get older. So we look at that and that's pretty obvious to see in some patients and that can definitely block off the nose. There is something else called turbinates inside the nose. Turbinates inside the nose, those are pieces of tissue that hang down on the sides of the nose and their job is to heat, humidify, and filter the air. When you lay down at night, they actually get swollen with blood and if the turbinates are swollen, to begin with, because of say allergies, because of just enlargement anyway, and then they swell even more, it causes more nasal obstruction. You add that to a deviated septum, all of a sudden it's like putting a clothespin on your nose and you're not having a lot of breathing. JW: They can’t breathe at all. NM: Exactly. Then as we slide further down the back of the nose, there's an area further in the back called the nasopharynx where the back of the nose meets the top of the throat, that's not something that I can see just by looking at a patient or even using a handheld light so sometimes I'll actually do what's called a laryngoscopy or a scope. It's a small flexible tube, fiber optic tube, it’s like about a stick of a piece of spaghetti. It lets me look in the back of the nose and I'm specifically looking for something called adenoid tissue. Adenoid tissue is similar to tonsil tissue, it’s part of our immune system but we only use a small part of our immune system so this is tissue that's in the back of the nose and it can be enlarged. It’s in the very back of the nose. It can also block off the nose whereas, the septum maybe straight, the turbinates maybe not enlarged but the adenoids can block off the back of the nose. That can be very, very common in children. Then as we get further down the back of the throat, I'm looking at two other things, one is the tonsils. Now the tonsils are the small balls in the back of the throat that are on either side of what we call the hangy-down thing, or the uvula, for those patients who are a little more medically inclined. Those can be enlarged and sometimes they’re enlarged of course when we examine patients sitting up, but when they laid down at night, they really collapse in. What I try to impress with my patients is the airway is very dynamic. It’s not a fixed, it’s not like a PVC pipe that’s just static. It can collapse, it can open up, and sometimes those tonsils and adenoids although they’re moderately enlarged when I see them sitting up, they really block off the back of the airway when they're laying down. JW: I think that maybe I'm blessed in dentistry that actually is the position in which I look or examine a lot of patients, they’re laying down, they’re laying back, and when we look in we see that collapsed airway. NM: Absolutely and you’ve touched on it. You were so astute at looking at that and being able to identify those patients who maybe have been told by their primary care doctor, their pediatrician that, “Well, the tonsils are sort of large but they're not terrible.” The pediatrician, the primary care doctor doesn't oftentimes have the luxury of examining that patient when they're completely prone. JW: Exactly. NM: And maybe even a little more relaxed because they’re fully laid back for a period of time. JW: Right, absolutely. I don’t want to get us off track yet but we actually see a ton of signs and symptoms in the mouth of the results, if you want to say, of an obstructed airway. It really kind of like with you, I just start by focusing in on the face. If I see someone who has an extremely narrow arch form in their mouth, this has usually occurred overtime because of that, exactly what you're talking about with the straw, this forcing of the air and you're calling it a collapsing, I call it a collapse of the arch form itself, and then that in return squeezes out the space for the tongue and then all of a sudden this tongue, which is this amazing muscle, extremely strong, begins to have a whole mind of its own. It loves to curl up, get bigger, get more in the way, create even more of a loudness, if you want to say, to the snoring effects. But really especially in children can start to create a formation of their facial structure that isn’t what you and I would consider the more perfect facial structure, more broad smile. NM: Absolutely. And I think that comes into play a lot with what you're dealing with and also what orthodontists are dealing with. That’s one of the things I tell parents of maybe children who are getting orthodontic work is, “Look, it's fine to do the braces and do the orthodontic work but if we're not getting them to breathe correctly, it's almost like taking two steps forward, one step back. The tongue is working against us and yeah, you may get to the finish line but you're going to be a long time before you get there and frankly a lot of money before you get there.” JW: Absolutely. Great point that you're making on that, when you haven't ever dealt with the underlying cause of why that arch collapsed in the first place, they get out of their braces, God forbid that they forget to wear their retainer like one week and boom, all of a sudden it won't fit anymore. Well, guess what? There's a reason, I mean that this doesn't happen on everybody. When you are stable, when your airway space is stable, your arch form will stay stable. If not, it’s going to collapse and then gravity starts and you’re going right back to ortho again at some point. NM: That’s a great point. JW: Let’s talk about that because you've also had the pleasure of working with my daughters. I'm lucky and blessed that I know what I know and I was made able to notice that they were making a, I don’t even know if I would call it a snore but a noise at night and I knew better than that, I knew that children are not supposed to make any type of sound at night and they shouldn't be thrashing around in bed. I couldn't even sleep with Isabella, my God, it would be black and blue. She's thrashing around in the bed, throwing her arms everywhere. I realized that as I begin to see her facial structure start to narrow again that we had an airway obstruction and I brought her in to see you prior to her orthodontics starting although we kind of combined and started her orthodontics but also then had adenoids and tonsils removed. This just seems like when I was a kid, nobody wanted to take out our tonsils, nobody wants to take out our adenoids, but before that like my mom’s generation, they did it all the time. Where are we now? What's today's normal? Right or wrong? NM: Great, no, you’re right. The pendulum has swung both ways. Back in the early seventies, late sixties, everybody, when you’re four years old, you lined up and you got your tonsils and adenoids taken out. We didn't know exactly why but it happened. Then we went back and said, “Why are we doing it all of this kids? So the pendulum swung far the other way where there was no indication to it, it was part of the immune system, why would we take out tonsils and adenoids?” Now we really have fallen more in the middle where we realized there are very good indications to it, we don't do it automatically, but actually, now the number one indicator used to be, “Oh, for recurring strep throat, let's take out tonsils and adenoids.” That's not now the main reason we take it. There are some cases we do that but the number one reason is airway obstruction now. That typically happens anywhere from three to four years onwards to adulthood. So that's really what we're looking at. One of the things you brought up a good point is I use the word snoring and that’s probably not always correct, it’s really more of an airway noise. So in children, we call it sleep disordered breathing. What that is as children breathe, they’re breathing and oxygen and their brain say that we’ve got enough oxygen so they keep them asleep. Now imagine if we’ve got some blockage in the airway, do the tonsils, adenoids, allergies, things of that nature, you walk by your child's room and you hear a little bit of audible breathing, you see the thrashing around, the reason they're doing that is as they breathe or snore, their oxygen level dips down. Their oxygen level dips to a low enough point, the brain says, “We need more oxygen,” so they kind of move around, it tightens up and they get a deep breath, their oxygen level goes up, they get into a deep sleep, their oxygen level goes back down. They kind of wake up, their oxygen level goes up, they get into the deep sleep, so you can imagine the cycle, the way I describe it to parents is, “Imagine now you were to sleep at night, but your snooze alarm every hour, overnight after night, after night.” I can tell you and my kids can tell you and my wife can tell you, I am not a pleasant person when I don't sleep, I'm cranky. I don't focus well. I don't pay attention well. I'm not behaving my best when I don't sleep well. Because of that, there's definitely a correlation between sleeping and attention and behavior issues. Again, not all ADHD is that but a lot of it is related to sleeping and I tell parents, “Just imagine you not sleeping well and imagine again you have your newborn but you have your newborn for three years where you're waking up every couple of hours, how well are you going to perform at your job, parenting, whatever else you need to do, it may not be as good as you can do.” JW: Absolutely. What I love about what you're saying is I know that just intrigued many parents that are listeners. They're going to go do something about that for their children because that's what we do, we take care of our kids, we make those decisions and by golly, if they need braces or if they need their tonsils out, they’re going to make it happen. So why not do the same thing for you as an adult or your loved one who's keeping you up at night because they’re snoring? So just realize that even as an adult, there are huge benefits for being sure that your airway is open and functioning properly so that you can get to sleep, the rest, the extra energy that you want to live your life to the fullest because if you're not, you don't want to get up and workout, you don't want to do those extra little things that you used to do. It slowly happens over time, you don't even realize that you stopped really being active. NM: Absolutely. And you touched on a great point when I talked about weight a little bit earlier and it’s self-fulfilling cycle when you're not sleeping well, your metabolism goes down, you don't have the energy so you're not going to exercise, if you're not going to exercise, you’re going to gain weight, if you gain weight, you’re going to have more airway obstruction, all of that comes into play. One of the other things, we had talked about this earlier, it just went in a casual conversation, one of the things that you can do as an adult just to kind of gauge of, “Hey, do I have a blockage?” You can close one side of your nostril and say, “Am I breathing okay?” Close the other side, “Am I breathing okay?” JW: So when you say close just by laying finger on the side. NM: Just gently, gentle, very gentle pressure, very good point, yes, very gentle pressure. The other thing you can do is you can go to a mirror and look in your mouth and you don't need to tongue depressor, just look in the bathroom mirror and say, “Alright, what can I see?” You should be able to see the little uvula which is the thing that hangs down, you should be able to see if you have tonsils which are two balls on the side. Now there are some patients, especially in adults, this doesn't happen so much in children but as you talked about the tongue, their tongue can be quite large and if you open your mouth and you can't even see your uvula, there's a very good chance that tongue is falling back when you lay down at night, when you lay down at night, the tongue is in visional blockage piece in the back of the throat area. JW: Absolutely. I want to dive into, I had the pleasure working with a lot of different patients over the years and so I've pretty much experienced anything and everything that somebody has done to “try to make them stop snoring.” I wanted you to comment on a couple of things. Having surgery to correct the deviated septum, having surgery made to take out your adenoids and tonsils, I've seen surgery with the lasering of the actual kind of configuration of the back of the throat to gain more space and then recently seems like we're working with the tongue itself to kind of pull it down. Can you maybe just touch on some of those options for actually correcting some of the root causes? NM: Absolutely, again, the airway obstruction thing can be multiple levels. You mentioned the nose, often times that's the deviated septum or the turbinates that are enlarged, and maybe some allergies play a part in that. So that is a procedure that can correct that. Removal of the tonsils and adenoids will correct sort of the back of the nose, also the throat area, there's a procedure called the Uvulopalatopharyngoplasty or UP3 which is a very long word but it’s the laser kind of remodeling of the back of throat area. What I tell patients is, “Imagine taking a door frame and just making the door frame larger so you can move bigger things in and out of that room. That's the idea behind that.” Then as you talked about there are some options for treating that large tongue and one of the things we’re doing is now doing a relatively minimally invasive procedure where we're putting a small stitch in the back of the tongue just to prevent it from falling all the way back, this is all on the inside of the mouth. It’s really just preventing that tongue from collapsing on the airway. Those are some surgical things that can… JW: And/or combination of [inaudible 00:21:49] NM: Exactly, right. Absolutely. It’s not always one. Now, there are some other treatment options, there’s CPAP which can work great but not all patients can tolerate. There’s something called mandibular advancement device which you deal a lot within your specialty but it’s basically where you’re putting a device and it’s moving your lower jaw forward. The whole purpose of that is, again, trying to prevent the tongue from falling back. The negative we see about the mandibular advancement device is it can lead to TMJ which is jaw joint issues over a long period of time if it’s not monitored and closely assessed, given at multiple times. That's a little bit of a concern with the mandibular and just the fact that a lot of patients say, “I spit it out. It’s in my mouth then I spit out.” But those are our options to consider as well. JW: I agree with you. There are things that patients find online that kind of do the “same thing” then come in later like you said with TMJ problems and/or then by issues, their teeth actually don't fit together correctly anymore. There are some just because you can get it out there doesn't necessarily mean that you should without the advice of a professional. I want to go back to the CPAP concept that you were talking about a few minutes ago because over the years, that's been kind of the gold standard to help people with sleep apnea or just any sleep obstruction. But so many of them started off with it, it changes their lives, they are finally getting good sleep, it really does change their world. Then it seems like over time, they just can't tolerate it anymore, they just don't want to use it anymore. Why is it that we don't go first towards finding if there's truly in airway obstruction rather than just slapping everybody on with the CPAP machine? NM: I think a lot of that is just the concern of going into surgery or doing something invasive and there is some rationale to that. But you're right, the CPAP is very effective if patients can tolerate it. What happens is it’s not a natural device, it’s something you have to physically think about, put on, and if you're traveling, if you're with a partner, it's cumbersome. So a lot of times what happens is the feeling of sleeping well takes a back seat to the annoyance of having to use the CPAP. I do think it does have a good place but as you talked about, if there are severe anatomic obstructions at things that can be fixed, sometimes that may be a better route to go as opposed to putting a band-aid on it. JW: Absolutely, I guess I'm just going to recap with that and just say, “Hey, you don’t like your CPAP machine, you don't like the way you’re sleeping, you want more energy, then consider a consultation with an ENT specialist like Dr. Mehendale who knows what they're doing and who believes that is part of it. I will have to say and maybe you can comment on this, not all ENT specialists are made the same like I know a lot whom the patients will go and I know they have an obstruction, I know it without a shadow of a doubt in my mind and they’ll go and it's just kind of like I don't know, I guess everybody, just like anything, doesn't have quite the same… NM: I think you’re right and you’re very kind in your words. I think that is correct. There are just some ENTs that may be focused on different areas and aren't as attuned to this although I do feel like, for ENT, most of this is ENT 101, this is what deal with and most ENT should feel comfortable at least assessing the airway and really giving a definitive, “Yes, you have this,” or “No, you don’t.” JW: Right, I don't even care if their recommendations are different, I just want the assessment correct, just let us know what really is going on in there and then let the patient know all their options and then let the patient decide what they want to do. NM: Correct, and that's a great point because there may be other life reasons where they can't or don't want to do something now but at least if you give them that option, it plants the seed. Sleep is not a just-today problem, it's going to keep being an issue so maybe they can't deal with it now but maybe six months from now or a year from now… JW: Or three years from now… NM: They have the ability to deal with it and it’s still going to be very important to do. That’s, as we talked about earlier, from childhood all the way till our end of life. JW: I completely agree. I am a big proponent that we, as individuals, need to be our own health care advocate and that's the exact concept I'm talking about like don't assume for them that you know the right answers for the patient. It's our job and expertise to share that with them, give them our recommendations as well, and then let them make their choices. NM: Absolutely. I couldn’t agree more. JW: I love talking to you. I could be here all day, I'm a goober. I love airways, I love head and neck specialty conversations because you know what? It’s connected to the rest of the body. Everything has kind of a yin and yang effect and I just want to thank you again so much for sharing your expertise with us here today on Simplifi Health. I wanted to allow you to tell people how to get in touch with you. NM: Again, thank you for having me on the program. I love it, I love speaking with you, and it’s always enjoyable to have this discourse. You can get a hold of myself or my partners on the internet, we’re at www.enttex.net. Our phone number is 972-731-7654. We are also on social media on Facebook and you can also reach us via email at info@enttex.net. JW: Thank you once again. I wanted to share with the listeners that if you would like to download any of the information that we provided to you here today, you can go to youniversityhealth.com and for dental professionals interested in learning more with us, then they can go to relevancehealth.com. This is Dr. Jill Wade, keep smiling from the inside out.