Nasal Polyps, Sleep, and Modern Sinus Care

What do island-hopping physicians, aviation safety, sleep medicine, and nasal polyps have in common? Dr. Adam Shapiro.

In this episode of the MedEvidence Podcast, Dr. Michael Koren sits down with ENT specialist and sleep medicine expert Dr. Adam Shapiro to discuss his remarkable career practicing medicine in the U.S. Virgin Islands, commuting between islands as a pilot, and helping aviation professionals manage fatigue-related health issues.

The conversation then shifts to a practical masterclass on nasal polyps and sinus health. Dr. Shapiro explains what nasal polyps are, why they develop, how they affect breathing and sleep, and the latest minimally invasive treatment options available today. He also discusses the connection between nasal health, sleep apnea, chronic sinus problems, ear pressure issues, and overall quality of life.

Whether you're struggling with chronic congestion, sleep problems, recurrent sinus infections, or simply curious about the latest advances in ENT care, this episode offers expert insights and evidence-based guidance.

If you found this helpful, subscribe to MedEvidence and share the episode with someone who’s always congested.

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Have a question for Dr. Koren? Email him at askDrKoren@MedEvidence.com

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Transcript

Welcome To MedEvidence

Announcer 0:00

Welcome to MedEvidence, where we help you navigate the truth behind medical research with unbiased, evidence-proven facts, hosted by cardiologist and top medical researcher, Dr. Michael Corin.

Dr. Michael Koren 0:11

Hello, I'm Dr. Michael Koren, the executive editor for Med-Evidence. We have a special guest today, Dr. Adam Shapiro, who has had a really interesting career, and he's going to tell us about it. I want to learn more about it because I've heard stories about it. They're legendary stories, quite frankly, and I can't wait to hear more details. He's an ENT specialist, ear, nose, and throat, and he's going to educate us both on his interesting travel career, sleep medicine career, and ENT career, and give us a master class on nasal polyps. So, Adam, welcome to MedEvidence.

A Nontraditional ENT Career Path

Dr. Adam Shapiro 0:45

Thank you, Michael. Great to be here. So really, really interesting career. And I want you to tell our audience about your practice over the last two to three decades where you did a lot of traveling and really took a very nontraditional course after your training from medical school. Yeah, I guess you could call it non-traditional. I finished my residency in odolaryngology and then did a fellowship in rhinology and facial plastic and reconstructive surgery. And then I was in a traditional practice in the uh Washington, D.C. area for a while. Enjoyed that, but my wife and I said we wanted to explore something a little more off-the-beaten path. And a unique opportunity came up, and uh we moved to the U.S. Virgin Islands and uh practiced there for a little over 20 years and built up a great medical and surgical practice in odolaryngology, ear, nose, and throat, and realized at that time that there was no sleep medicine being practiced there. And I had a deep interest in sleep medicine, and we started two sleep centers there and got everybody you know in the queue for being taken care of for for sleep issues. So that became more of a passion for me as I realized that there was such a need for it there.

Dr. Michael Koren 2:11

So which of the U.S. Virgin Islands were you practicing in?

Dr. Adam Shapiro 2:14

So we were practicing in St. Thomas and St. Croix. And uh started in St. Thomas, and then my friend who was an oraryngologist in St. Croix moved to Hawaii, and I said the natural thing would be for me to take over as practice. I'm also a pilot, and that was an excuse for me to fly between the islands. So I I did have the prettiest commute in the world going back and forth from one office to the other.

Dr. Michael Koren 2:41

And were you also commuting to South Florida as well, or were you just going back and forth ?

Dr. Adam Shapiro 2:46

So my my family had moved up to uh South Florida to Miami, and and I was commuting back and forth to see them. So I I did fly over and uh around a number of big name storms over the years going going back and forth.

Dr. Michael Koren 3:03

Wow.

Dr. Adam Shapiro 3:03

But uh that was a treat for them.

Dr. Michael Koren 3:05

Isn't that crazy? So literally you are island hopping and practicing ENT medicine at the same time. That's that's true. That's correct. In a nutshell. ENT and sleep medicine. Oh my God. That so

Aviation Fatigue Meets Sleep Medicine

Dr. Michael Koren 3:20

that is pretty nontraditional.

Dr. Adam Shapiro 3:22

Yes. And and I I left there last year, and I've recently opened a new practice in Miami specializing in minimally invasive nasal and sinus surgery as well as sleep medicine. And I've sort of combined my love for aerospace and and and aviation, and I deal with a lot of pilots and scuba divers, people who have barrow trauma and air traffic controllers, and take care of a lot of them, not just for their regular medical exam, but also help the aerospace industry try to make sure that there's uh fewer fatigue-related incidents, which will hopefully avert errors and accidents and decrease the cascade of events that can occur in an untoward event. And as I I did my uh master's degree in aerospace studies at Embry Riddle, not not far from you down the down the road, and did my dissertation on fatigue in aviation and reviewed 20 years of uh NTSB National Transportation Safety Board information for accidents and found that over 70 percent of the accidents were attributed to some fatigue result in in somebody involved with the uh with the incident. And my guess is that that is a is an underestimate, and probably nearly 90 percent have a fatigue component involved. So that's where the sleep medical world and the aerospace medical world dovetail so well, and and and that's that's really where my my passion is that way.

Dr. Michael Koren 5:06

Interesting. Wow. You cover a lot of ground, uh both physically and professionally.

Dr. Adam Shapiro 5:11

' Yes, yes, and and and at high speeds,

Island Patients Cruise Ships And Care

Dr. Adam Shapiro 5:15

too.

Dr. Michael Koren 5:15

So just a few questions about the practice. I'm fascinated by it. So in the U.S. Virgin Islands, you probably had a pretty interesting mix of patients. Um I'm curious, sort of the breakdown, native population versus tourists versus, I guess, companies and individuals that take advantage of some of the tax differences in the U.S. Virgin Islands compared to the mainland. So break that down a little bit for us in terms of your patient population. Well, everybody in the Virgin Islands are U.S. citizens. There's a misconception by a lot of people, including many people who are continental statesiders, that people who live in the U.S. Virgin Islands are not part of the United States. We're not contiguously part of the United States, but people in the U.S. Virgin Islands are American citizens. And you know, the it's it's interesting. It's a it's an interesting mix of people from all over the world. There are people from different Caribbean islands, a lot of people from Puerto Rico and uh Dominican Republic, a lot of people from what we call Down Island, down the chain, going to St. Lucia and uh Martinique, Guadeloupe. And there are a lot of people from Europe, a lot of people who uh moved from many European nations just because it's a it's a beautiful, lovely place to live. The sailing is, you know, without compare in in the world. The winds are always nice, the weather's, you know, except for one or two days a year, it's always very nice there. So so it's sort of, you know, a mix of people from all over. And the nice thing about our field is that everybody has ears and noses and throats, and everybody sleeps. So we see people with problems from young to old. So and that's one of the nice things about our field is that we capture men and and women and kids and adults to make sure that they're all breathing well through their nose and and throat and and making sure that they're sleeping okay. So just curiosity, you had you have all this cruise ship traffic through there. Somebody gets off a cruise ship with an intractable nosebleed, for example. Were those the kind of people you're seeing? Or

Dr. Adam Shapiro 7:19

yeah, we did see a fair amount of those. Those people would want to get right back on the ship. And uh, you know, it was unfortunately my opportunity to tell them that they were not getting back on the ship. They were they were sticking around for a little while until they recuperated and and uh you know uh visit the the lovely Virgin Islands, and then they could, you know, get a plane back at some point. But you know, the the problem with a lot of cruise ship passengers is you know they're not screened medically before they get on the boat. And many of them waited their entire lives, they're in their 90s, they're on multiple medications and anticoagulants, and they fall down at the at the breakfast buffet and they they hit their nose. And and so it was always a bad sign when I saw the cruise ship turning around coming back into port in the evening. Uh I said, Oh, you know, maybe they have something that for us. But the Virgin Islands is the the medical port of call for the for the cruise ship industry. It's the uh only primary English-speaking American-trained place with accredited hospitals and physicians there. So we we did see a fair amount of folks from you know, tourists and and cruise passengers.

Dr. Michael Koren 8:34

Now, I know that the the U.S. Virgin Islands has different tax structure than the rest of the U.S. Did that affect the practice of medicine at all?

Dr. Adam Shapiro 8:41

Not really. No, I mean it's it's similar to living in Florida there. So you don't pay, like Florida, you don't pay a state income tax. In the Virgin Islands, you don't pay a federal income tax, but you pay a mirror tax code, which goes to the Virgin Islands. So it's really a wash there. There are some economic benefits for people who open qualified businesses down there. But you know, percentage-wise, there's not that many people who are there for that reason. There, I mean, there are some people there, but it's not not that uh popular in the you know, in the in the grand scheme of the percentage of people living there. I'm just kind of curious about the breakdown between people that live there full-time versus the deterse that come in on the cruise ships in other ways, people come in versus um you know people that have moved down there to retire, that had businesses that kind of it worked out better for them to be residents of the islands. I'm not sure exactly numbers, but I think that there were approximately two million visitors a year that visit the Virgin Islands. Most of them are cruise passengers, so they're only there for a day. And some, you know, all of the crew for the cruise ships would come and see us as well. You know, I remember telling my daughter that I saw the Cinderella today or the you know Snow White from the Disney cruise, you know, would come in for some vocal problems. And the, you know, I'm not sure exactly what the breakdown is, but the majority of people there are, you know, grew up there and are from there. And you know, maybe 10% of people moved down uh or moved from you know some someplace else, maybe 20%. I I really don't know the exact number, but majority of people, you know, grew up there, went to school there, you know, call that call that their home.

Dr. Michael Koren 10:37

Wow. Super cool. Super cool. And

Office Based Minimally Invasive Sinus Work

Dr. Michael Koren 10:40

now you're back in Miami and and this is now more traditional ENT practice. Is am I correct about that?

Dr. Adam Shapiro 10:45

Yeah. Well, I I joined a practice, and it's called Miami Breathe Free, and we're really specializing in minimally invasive care for people with nasal and sinus disorders, and also sleep disorders. And the sleep and the nasal and sinus, they they sort of dovetail and go hand in hand. So, you know, most traditionally, when when I trained, you know, back when you did, we brought everybody to the operating room, everybody had to go to sleep. There was all kinds of risks associated with not just the anesthesia, but the emergence from anesthesia after doing our procedures. There's airway issues, there's bleeding problems. And I transitioned for the most part, doing, you know, the majority of uh the procedures that I do now in and operate operating rooms in the office under local anesthesia with perhaps a little you know oral medication just to uh take the edge off for people. And it's incredible how well people tolerate it for the most part, and how immediate and impressive the results are. And it's an interesting story. When I first started practicing, uh I had some senior partners who told me, you know, in 20 years, what you're gonna be doing is gonna be completely different from what you're doing now. And I said, What do you know? I am on the cutting edge. I've I've been doing all the latest, greatest procedures. And they were absolutely right. So 20, 30 years after that, doing completely different procedures to achieve the same ends with much less morbidity, much less problems, much fewer problems. You know, many people will be able to go out to you know, to grab a bite that night after they have it, or to go out the next day and go back to work, you know, a day or two later. You know, uh years ago we used to keep people in the hospital for three or four days after these things. So that kind of stuff is is gone. So it's it's it's a it's a completely new type of um paradigm for treating people in a you know as limited and minimally invasive way possible and still taking care of the problem for the most part. There are still people who have problems that require more involved procedures. But I would say that's probably 5 percent and 95 percent of people we can take care of uh in a minimally invasive manner.

Dr. Michael Koren 13:11

Fascinating.

What Nasal Polyps Look Like

Dr. Michael Koren 13:12

So let's use this as a transition. And we get a lot of questions in MedEvidence about nasal congestion, nasal inflammation, and nasal polyps. And particularly nasal polyps is an area that people get get concerned about. So given your experience, I was hoping you can give us a little bit of a masterclass on what is a nasal polyp and how do you deal with it? Is it something that's serious? Is it something that patients should get immediate attention? So just run through that a little bit for us. Obviously, this is what you do day-to-day. So give us a definition of nasal polyps uh versus nasal inflammation and sort of the spectrum of disease that you see.

Dr. Adam Shapiro 13:52

h So there's a few different types of nasal polyps. Nasal polyps are they look like translucent grapes or pearl onions that hang in the nose, and they can block the airway and they can block the sinus drainage pathways. Most times they originate with either within the sinuses or within the sinus drainage pathways. And the most common types of polyps that we see are inflammatory polyps. They're caused by some type of inflammatory process. And that could be allergies, it could be a sensitivity to something, it could be a genetic predisposition that people have to develop the polyps. And the polyps themselves, a lot of people will have polyps and not know that they have them, and they're asymptomatic, they don't have any issues, and they go through life, and nobody told them, nobody saw them, and that's fine. There's nothing to do about it in that case. So just because you have polyps doesn't mean that you have to do something about it. However, a lot of people are troubled because the polyps will block their airway through their nose, and it will block the drainage pathways. We normally make one to two quarts of fluid every day in our nose and sinuses. And if that stuck can't get out, it's a dark, warm, moist uh space. It's a setup for infections, it's a setup for getting facial pain, pressure, stuffiness, runny nose, post-nasal drainage. And it will exacerbate and make allergies worse. It will make migraines worse, it can trigger migraines. Migraines also can make nasal issues worse. So they those sort of work hand in hand. So we see a lot of people with both kinds of problems.

Dr. Michael Koren 15:38

They work hand in hand or nostril to nostril.

Dr. Adam Shapiro 15:41

Yes.

Dr. Michael Koren 15:42

There's always gonna be at least one dad joke in our podcast. So there it is. I apologize.

Dr. Adam Shapiro 15:48

That's okay. And it also affects sleep. If your nose, if you're not breathing well through your nose, it's going to adversely affect your sleep. Not just, you know, for people who have severe sleep problems, but anybody. You know, you're not going to sleep as well if if you have polyps and they're blocking your nose. My fellowship preceptor, the famous Dr. Mark May, made the comment that the nose is the barometer of the body. If your nose is not happy, you're not going to be happy. So, you know, we're our job is to try to make the nose happy. So a lot of times these polyps or what we can be mistaken for what we call retention cysts, which are areas of swelling where the mucous membranes from the sinuses get pulled off the bony wall. And a lot of the time that's caused by narrowing and blockage of the drainage pathways. And what happens is every time we swallow, every time you sniff in, there's a little bit, a tiny bit of negative pressure that goes by the drainage pathways, exerting a little bit of negative pressure, pulling on the lining of the sinuses. And when that happens, that can actually distort and impair the sinus from working as well as they should. It also is involved in eustacean tube problems. The eustacean tube is the tube that connects the ear to the back of the nose, and that can contribute to people who have clogged ears, hearing loss, fluid in the ears, ear infections, trouble clearing their ears if they're going up in an elevator or in an airplane or underwater diving or scuba diving. So all of these things are intimately related.

How Polyps Affect Ears And Sleep

Dr. Adam Shapiro 17:28

A lot of people also who have noted sleep problems, they have sleep apnea, for instance, they're being treated with a CPAP machine, and they're not tolerating the CPAP machine well. Well, there are alternatives to the CPAP machine, but one way we can get them to tolerate the CPAP machine is to make them be able to breathe through their nose well. And that oftentimes is addressing the polyps, addressing what's going on in their sinuses, uh the turbinates. Turbinates are things that heat and humidify the air that we breathe, so like a headers or manifolds on a car, and fixing their septum, if the which is the wall that separates the right side from the left, to make sure that that's even so they're getting an equal amount of air through both sides.

Dr. Michael Koren 18:10

Interesting. Interesting. So what percentage of the population suffers from nasal polyps or the difference between men and women, age when people typically present with this problem? Give us a little bit of those details.

Dr. Adam Shapiro 18:22

It's a little bit of a bell-shaped curve. You'll have some kids present with it. You know, if they have some other type of syndromic problem, cystic fibrosis, they'll have polyps. And then we'll see a dip, and then it'll pop up again. And you know, I don't know the exact age and and age and gender distribution, but it we we see it in in both men and women, we see it in kids, we see it in adults. And it is common. You know, I I think, you know, a lot not everybody who has a stuffy nose has nasal polyps, certainly. Most people don't who have stuffiness. But uh we do see polyps frequently. You know, sometimes polyps can be mistaken for something more serious. There can be tumors and cancers that may be considered to be a polyp, but are actually not. That's that's not common. We see that more with people in certain industries uh that uh have exposure to toxins that are more likely to cause that kind of stuff. But we don't see that that frequently in uh in our regular practice.

Dr. Michael Koren 19:25

Interesting. So uh when you diagnose a nasal pulp, typically with some endoscopic method, I would imagine a fiber optic method. That's the common way of diagnosing it, I imagine.

Dr. Adam Shapiro 19:37

Yes. So normally we'll take a look with a nasal endoscope, and usually we'll we'll start with a rigid nasal endoscope, which may sound daunting, but it's a teeny little, usually a four millimeter, three or four millimeter scope. And we're we're looking uh on the TV, we're able to see it through a video monitor. The the patient is able to see it on the video monitor at the same time, so we can describe what we're seeing. And we can get an idea of the extent and how much it's involving the nasal cavity. If we need to, sometimes we'll need a flexible scope so we can go further down through some of the passages if it's extending south into the into what we call the hypopharax or oropharynx. Sometimes the polyps are that big, sometimes they're so big they're hanging out the front of the nose. And you wonder how people have walked around with them, you know, without somebody tapping them on the shoulder to come in. And we we oftentimes will get a uh some other imaging, usually a CT scan, so we can see the extent of how far these polyps go and whether the drainage pathways to the sinuses are compromised. Because you what you may be looking at might just be the tip of the iceberg and it may be going interesting further.

Dr. Michael Koren 20:47

Interesting.

Scopes CT Scans And Diagnosis

Dr. Michael Koren 20:48

So tell us about the treatment. You you you uh diagnose the problem, then how do you proceed with treatment for most folks?

Dr. Adam Shapiro 20:54

So we want to treat the patient for what they have. If they come in and they say my toenail hurts, and you look in their nose and it it's full of polyps, say, well, what about your nose? And they say, I don't have any problems at all with my nose, just fix my toe. Well, you're done. You just fix their toe. But most people who have nasal polyps are symptomatic and and they want to be treated. So obviously you start with conservative measures, you can try steroid nasal sprays, there are allergy treatments if they are found to be allergic, and there are uh medications, uh, some leukotriene inhibitors like Monteleucast that an acolate, which can help reduce the size of the polyps. Oftentimes those things will just be to temporize the situation. You won't get a resolution with that. You need immediate resolution, usually oral or IV or I am steroid medications uh usually do an amazing job in shrinking the polyps up. But that is a short lived thing, and that has potential complications and side. Effects that we we don't like to use unless it's in preparation for something more involved. So the traditional way to take care of polyps is usually surgically, where we will remove the polyps either with traditional techniques where we just sort of pull them out and remove them under endoscopic guidance. And we oftentimes will use a device called a microdebreeder. A microdebreeder is like a mini Pac-Man device that munches up the polyp tissue, but usually leaves the normal tissue alone. So we just address that. And while we're doing this, we uh usually will do that under navigational guidance. So we have a CT done beforehand. And while we're looking at the video monitor, we are also looking at an image of the sinuses, sort of like a GPS for the sinuses, where you see exactly where we're going. So we want to avoid areas that are important that are close by. The sinuses, most people think are these large areas, they're relatively small. We're working really in the size of a matchbox and bordered by the eye and bordered by the brain. So we, you know, we want to be careful about where we're going. So oftentimes we'll use the navigational guidance. The one of the newer techniques that we use to help open the drainage pathways to the sinuses is uh using what's called a sinus balloon. And the balloon uh is a wonderful thing. There's only one problem, and that's I wish I invented it. But the balloon is a small little wire, and at the tip of the wire is a balloon that we place into the drainage pathway, inflate it, and then deflate it and take it out. So we don't leave anything in. And the balloon is under very high pressure, it's under 12 atmospheres of pressure, and it remodels the bone of the uh drainage pathways to the sinuses. And we also use it often in the eustacean tube opening to help people who have uh chronic ear infections or problems uh clearing their ears with stuffiness and and inability to clear. So that's very helpful in the aerospace world or to get pilots back up in the air and flight crews back up in the air, and even you know, passengers who want to be able to fly and not have to take a train across the country. So so the the combination of those techniques are oftentimes very you know helpful in resolving the problems. The problem that we have with uh nasal polyposis is that there is a great tendency for it to recur. And one of the truly amazing innovations that has come out are biologic treatments. And biologic treatments are immune-mediated treatments that are used for lots of different problems and usually in inflammatory uh uh responses. And we use that to help make sure that the polyps don't come back. So it's usually used in combination with the surgical procedure because the biologics by themselves oftentimes don't give us enough UNT to open up the drainage pathways to the sinuses. Yet, doing the procedure itself without the biologics, if there's a lot of polyposis, we oftentimes will leave a small rim of micropolypoid tissue in order to avoid getting close to the eye or the brain. And that can then regrow. So using the biologics to keep that in check will give people years and years of relief without the need for recurrent procedures, which would used to be people would have to come back every few years to have their polyps, you know, readdressed.

Dr. Michael Koren 25:51

Without the biologics, is that recurrence rate? 50%, 90%, 20%? Just give us a sense for that.

Dr. Adam Shapiro 25:56

It's it's about 50%, I believe, that will require that are bad enough to require another procedure. The Samter's syndrome is associated with nasal polyposis, aspirin sensitivity, and asthma. And it's it's not an uncommon issue that we see. And we usually want to evaluate people's lung function if they have polyps and make sure that they are not aspirin sensitive. By aspirin sensitivity, it would also be a sensitivity to non-steroidal anti-inflammatory things like motrin and advil and Aleve. And those things are promoters for the asthma and for for the polyps. So we want to make sure that they're they're off of those things. But that's that's the most common type of issue that we see. We also see people who have allergy issues associated. A lot of people will have urticaria or rashes associated with this. Any type of inflammatory problem can have its origin in an association with nasal polyps.

Treatment Options And Recurrence Prevention

Dr. Michael Koren 27:06

Adam, this has been incredible. You know, thank you so much for this true masterclass on nasal inflammation and nasal polyps. Any last words of wisdom for patients who may be listening to us or viewing us that may have concerns about nasal polyps.

Dr. Adam Shapiro 27:24

Take care of your nose, treat your nose well. We see a lot of people who abuse their nose. They're using all kinds of nasal sprays, over-the-counter stuff. We see a lot of people who don't realize that they have a problem and they say, well, I'm just going to use Afrin or Dristan or VIX, which makes the problem worse, compounds it, and makes our job more difficult to take care of that. So if you have a nasal issue, go get it checked and see what's going on. And most times they're they're much more readily treatable than they used to be. And if your nose is happy, you'll be happy.

Dr. Michael Koren 28:02

Dr. Adam Shapiro, that was wonderful. Thank you for your great contribution to MedEvidence.

Dr. Adam Shapiro 28:08

Thank you very much. Thanks for having me on the show, Michael. Appreciate it.

Announcer 28:11

Thanks

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