Sleep Apnea Beyond CPAP: Airway Surgery, Root Causes, and Team-Based Care

Welcome back to Breathing for Better Sleep, the podcast where we dive into the root causes of sleep apnea, snoring, and airway issues that impact your sleep and well-being. In today’s episode, Dr. Fred Eck is joined by Dr. David McIntosh, an ENT surgeon from Australia renowned for his deep expertise in upper airway obstruction and innovative approach to breathing and long-term health.

Together, they explore why understanding and addressing the root causes of airway problems especially early in childhood is essential for healthy growth, development, and lifelong cognitive function. The conversation challenges the idea of one-size-fits-all solutions, examines the evolving role of surgery in airway treatment, and highlights the importance of individualized, collaborative care. With insights from both dental and surgical perspectives, this episode provides valuable guidance on how to move beyond simple numbers and truly uncover what’s driving sleep-disordered breathing in each patient.

Whether you’re a healthcare professional, a parent concerned about your child’s sleep, or someone struggling with sleep issues yourself, this episode is full of practical wisdom about finding the right solutions and the right specialists to help you breathe and sleep better.

00:00 Training in ENT specialty

05:53 Collaboration with dental community

13:43 Need both for success

16:40 Reflecting on cultural and historical context

24:33 Issues with early sleep apnea treatments

30:30 Discussing ENT consultations and communication

33:34 Finding an airway-focused ENT

41:20 Discussing healthcare network challenges

44:45 Cost comparison with private healthcare

49:00 Combining CPAP with oral appliances

57:51 Link between weight and dental health

01:03:44 Diagnosing allergies in kids

01:06:21 Future hopes for tonsil treatments

01:09:58 Acknowledging medical uncertainty and care

Podcast Website - https://breathingforbettersleep.com/

Dr. Fred Eck - Website - https://sleeptreatmentdirect.com/dr-fred-eck/

Podcast Media Partner: TopHealth - https://www.tophealth.care/

“Disclaimer: Informational only. Not medical advice. Consult your doctor for guidance.”

Transcript

SPEAKER_00 0:00

When I look at uh people on dose appetite, injections, I even see patients that are not necessarily losing a lot of weight, but they're still benefiting and they're still getting better as far as their sleep goes. I think these medications are gonna be helpful over time.

SPEAKER_01 0:13

I have to agree with you. The fact that they're breathing better, sleeping better, losing weight, metabolically improving, these are all such big benefits. Everything comes at a price.

SPEAKER_00 0:22

So far, the price of these medications seem to be worth paying forcome back to Breathing for Better Sleep, where we explore the root causes of sleep apnea, snoring, and airway-related sleep issues. Today we're excited to welcome a special guest, Dr. David McIntosh, an ENT surgeon from Australia who has dedicated much of his career to advancing the understanding of upper airway obstruction and challenging the way we think about breathing, sleep, and long-term health. As an airway-focused dentist, I spend much of my time helping patients understand how the mouth, jaw, and airway influence sleep. Dr. McIntosh approaches many of these same challenges from a different perspective as an ear, nose, and throat surgeon. One thing we both believe in strongly is addressing root causes, and there is often more than one. We also believe in treating kids as early as possible because the more time that passes with abnormal breathing, the more potential there is for cognitive deficits. We can also adversely affect growth and development when we do not breathe properly. Today's conversation isn't about whether surgery is good or bad. It's about understanding when surgery is the right tool and when it isn't, and why every patient's airway story is different. Dr. McIntosh, welcome to Breathing for Better Sleep. It's great to have you on with us.

SPEAKER_01 1:57

It's really a pleasure. Um, I'm I'm really looking forward to what we're going to be talking about today. This is this is great. So thank you for the opportunity. Thank you for joining us.

SPEAKER_00 2:06

Before we dive into the airway surgery, I love for our listeners to get to know you. What led you to focus so much of your career on sleep-disordered breathing and upper airway obstruction?

SPEAKER_01 2:18

Yeah, so the evolution of this um is is everything has a context. So um you you start off on a normal journey uh that I had, which was going to university, doing getting my medical degree, uh, finding that uh I was attracted to the specialty of ENT, uh, working towards that and being accepted into the program, uh, and going through what was a standardized training program here in Australia, exposing you to you know all the elements of ears, nose, and throat. But there was one little anomaly with the training program that I was in, and that was that one of the ENT surgeons who'd finished their training went over to the US to Stanford and spent some time with two people whose names are considered pioneers when it comes to upper airway surgery in adults, uh, and that uh were they the names Riley and Powell. Um they were surgical pioneers, and he went and spent some time with them learning about their perspectives, their approaches uh to adult-based obstructive sleep apnea. And then he brought that back to Australia to our training program, and so we were the only training program in Australia at the time being exposed to these concepts. Uh, so the ideas, the approaches, the understandings, uh, and the complexities. And what uh started to evolve uh from our observations, learning, and understanding uh from what he had to share, was that you had to treat each person on their merit. Every person has their own story. What had happened over time was people had been distilled down to a number. And that number is what we call the AHI, which is a measurement of breathing patterns when you're asleep and obstructions associated with the same. And if I was to say you have an AHI of 30, um, that gives us an indication of what you've got, but there's no background as to the why. Um so for example, if I said, look, person number one has an AHI of 30 uh and they have a deviated nasal septum to the left, they have nasal polyps, uh, they have grade three tonsils, they have a grade uh four tongue, uh, and they are overweight, uh, is very different to someone who has a AHI of 30 uh with normal ENT and skeletal deficiencies. Uh it the AHI was the same, but the reasons were different. And so that was the sort of part of the starting point. And uh I can still remember to this day the the there was a uh conference uh they were at as as trainees uh where they bring all the trainees from Australia together, and one of the ENT surgeons did a presentation uh but about children. And that uh presentation uh was in, I can timestamp it, uh 2005, uh where they there was research starting to come out talking about upper airway obstruction in children, uh particularly highlighting that these kids were not breathing properly, not sleeping properly, um, and the remarkable improvements that were coming about by looking at tonsil and adenoid surgery, which um through the passages of time had initially, if you go back in the books, mostly been done for airway obstruction, if you go way, way back and then evolved into being done for infection, um, and then uh you know the wheel was turned where obstruction came back on the radar again. And it was probably more the the pediatric side of it that I gravitated towards. Um, and the background to that's just to sort of make a long story even longer, is the way I paid my bills through my university education was I was a swimming instructor. So I got very good at uh, you know, dealing with children um that were apprehensive and anxious and worried about you know getting in the water, getting their heads wet. Um and I just found out a way to just make it fun. Um I came up with all these stories that we would have as a means of getting these kids to do it, and I managed to actually blend that into my clinical work. And as a result of that, um, you know, working with children just became easy. And given that upper airway obstruction is the most chronic uh health condition um of childhood, um, it sort of just evolved from there. Uh and then I started sort of having, you know, again, these these seminal moments was well after my training, well after university, well after ENT, well after my pediatric fellowship uh that I did. So, you know, collectively, after 16 years of learning about this, um, it was about a year and a half after the same that a dentist uh basically helped me understand what was going on with jaws that has never been on my radar uh at all. Uh and then I started to see things that I'd never seen before, uh, not because they weren't there to be seen, but because I didn't know to look for them. And that basically led to a a real deviation uh from the norm as to, you know, the pathways that are out there, where I started working extensively with the dental community uh and uh range of professionals, you know, general dentists, pediatric dentists, orthodontists, hygienists, therapists, um the list goes on, really coming to have a a broader understanding of what is really going on here and identifying the fact that um my treatments as an ENT um only go so far. Uh and they are absolutely uh supplemented uh and and so forth by having a team approach where we're looking at all, as you said, all of the you know underlying causes that are contributing to how this person has ended up with the problem. So, like I said, you know, long answer uh, but I just want to give people sort of that that broad brush stroke because I think that's gonna be a great foundation for where we're gonna um bu you know go on from here.

SPEAKER_00 8:27

Absolutely, and I like the point you make about you know the AHI uh one person could be a 30, the other person could be a 30, and they are just different people. And you can the person who has an AHI of nine, and they're actually at more health risk than the person with a 30, based on a lot of things. So, you know, I hate the fact that we have to use that that number all the time, but uh uh there's so much more important numbers on a sleep test. Um so over the years, what's one belief about airway medicine that you've completely changed your mind about compared to when you started?

SPEAKER_01 9:03

Yep, so like again, uh this is a symptom of my learning, my education, and and you know, this is not a criticism of anybody along the way. Um, you know, this is just pure self-reflection. Um in children, uh my grounding was that uh these children had problems with their tonsils and adenoids, and all we had to do was take them out, and not only did we fix every single child um there and then, uh, but we fixed them forever. That was that was my mindset. Um and I know now that that's totally wrong. Um and what what it the numbers are not terrible, you know. We don't throw the baby out with the bathwater, as the saying goes in some corners of the world. Um but it it's it's just you've got to you know you know add the context. So this this is this is where I am now. So not every child needs surgery. If it's surgery, not every child needs their tonsils and adenoids out. Um the treatment needs to be tailored to the problem. And if it is um, you know, you know, surgery is part of the mix, the reality is still to this day um that most children do need their tonsils and adenoids out, and in doing so you will help most children. Um but there's two-thirds of children that need dental um management as well within that group. So that's that's that's where you know again uh the the exposure to the dental parts of it um change that dynamic. So uh yeah, I definitely changed my mind about uh the role of surgery as an isolated therapy. Um it's it's not the be-all and end all, but at the same time, it's still top of the tree. It's still at the you know, uh, you know, the top of the podium, um, but there's a whole lot around it now um that I never knew that I'd uh I needed to be aware of, that I'm very much aware of now.

SPEAKER_00 11:09

So I would say in in my regard, it's identical, but the flip. So it used to be, you know, we did everything to try to avoid surgery, uh, make a mouthpiece, do expansion, do all these things so we could avoid and try to do myofunctional therapy to avoid the tonsil removals and everything else. And I think it's just for me the same thing, but the opposite. It's it's come to the point where you realize, yes, today I get a result, but long term, okay, it takes that collaboration. It takes both sides. Uh it's not an isolated thing that you can do. That in combination with the development and usage of epigenetics and using your body's genes and stem cells to help grow three-dimensionally as opposed to this just two-dimensional expansion process. Uh, I mean, those are the two biggest things that have changed in me. So it's quite interesting. It's the same, but kind of the opposite force.

SPEAKER_01 12:08

Yeah, yeah, yeah. Look, uh the the the the important thing is to evolve. Um, you know, because if you if you uh are grounded upon what you were taught 30 years ago and you stay there, that's that's you you're not gonna progress as as a professional in this field. Um and you know, I I have a very different mindset now. I I'm not looking to be proven to be right. I want to know what I'm doing wrong. I'm I'm looking for things that challenge what I think I know. Um, because at the end of the day, there's there's nothing intrinsic about my knowledge that's absolute. It's just developed over time because of what I've been exposed to. Um so I continually expose myself to things that are contrary to what I would have thought would be right, um, and then go and and test and model it and go, alright, well, this is this is new for me. Um and then I'll go and fact check it a bit and go, alright, well actually that one's just another social media bit of nonsense out there, we'll move on. At other times they'll go, huh, okay, I need to pivot. And you know, just reflecting on what you've said, um the the the I've I've seen it in the past six months. Um people are starting to publish their outcomes of trying the therapies that don't include surgery. So they're saying, look, we're going to do the expansion, we're gonna do the myofunctional therapy, we might be releasing a tongue tie on, you know, working on, you know, restoring nasal breathing. Um but then is it actually delivering results um, you know, that are as because they you know, anything that you're doing is different needs to be as good as or better than whatever you're comparing to as the standard. Um say that the standard is the the be all and end all, but if that's the one that's you know the best at the moment, then whatever you do has to be compared to that. And the outcomes are are exactly what you you're reflecting on, they're not as good. You know, when when um surgery is compared to um, you know, the dental interventions compared to both in the circumstances where the children need both, and this is really the important bit, you know, um if if they need both, which one is best? The answer is one is not best, both is best. So um, you know, we talked uh uh you know about analogies and I'm renowned for my analogies. So my analogy in this regard is a car that's got a flat tire and a flat battery, and you're arguing over which one of those things you need to fix for that car to make it functional and operational. Um, you know, I'm the tire mechanic and you're the you know, you know, elect electricity battery guy, and we're arguing over which one of those two things we need to fix for that car to work. When the reality is we're absolutely both right and neither of us is wrong, but we've got to work together if we want to get that car back on the road again. And it's the same with these children, it's the same with these adults. Um people uh you know are are looking for a you know, and I have these people, they come and go, look, I just want the operation that'll fix it. And it's like, well, that doesn't exist. You know, um I can make this better, I can make that better, but you know, when I have a look at you, you've got a problem with this, this, this, and this. You know, you've got three things uh that are going wrong. There is there is no operation that's gonna fix those three things. There's an operation that's gonna fix your nose, there's an operation that'll fix your big tonsils, but that's not gonna do anything about the fact that your jaw is no good. Um, you know, you you need to look at the whole picture. Um, you know, and and again, that's that's part of the the process, I think, in counseling these these patients that have developed these thoughts and expectations. And again, you know, a lot of it's being driven by social media these days, um, you know, which is a blessing and a curse because it's it's a blessing that it's drawing people's awareness to it, but it's a curse because it's misguiding them to thinking that there's a a you know a a silver bullet um that fixes everybody. Um and all I need to do is find out what you know works for my neighbor next door and do exactly the same thing and it's gonna work out, and that's just not reality.

SPEAKER_00 16:19

You know, I once uh once had somebody uh say, I heard him say on stage, you know, do your best until you know better and then do better. So as the new stuff comes, you know, don't jump on every bandwagon, but when new stuff comes that makes it better, and sleep is such a rapidly progressing medicine. I mean, you think about it, the CPAP was only invented in what, 1981. So the as far as in modern medicine, it is very young and it's changing drastically. So what what we learned two years ago, now and for the next two years, it's drastically different. And people just want to keep holding on to that old stuff, and it's nuts. You gotta you gotta move on. You gotta you gotta learn. And may and you know what? It makes us uncomfortable to admit sometimes, you know what? It wasn't the best thing, but it was the best we had at the time. 100%.

SPEAKER_01 17:16

Yeah, yeah, yeah. And you look, we have the plenty of moments where you know we can reflect on how we judge people based on today's standards. Um, you know, there's a whole lot of cultural issues that we could bring into that mix as examples. Um, and you know, we can say that, you know, quite rightly. Look, you know, we don't identify with that thought process in this era. Um, and we are not um condoning um anything about, you know, might have been said or done back in the past, but you know, there's a context to it. Um and we we just need to, you know, bring our awareness to that rather than being overly judgmental and just making sure that we're not, you know, doing what they did um again and again because we recognize that it's wrong. And you you brought up CPAP, and I think that's a you know a perfect you know reflection point because um, as you introduced, you know, and the the accent gives it away, I'm I'm waving the flag from this place called Australia, which lives on the other side of the world in a different time zone. Uh, but you know, CPAP is an Australian invention. It was invented by a guy called Colin Sullivan, um, uh who is is on the record uh more than once saying that he invented uh this as a temporary measure to basically buy time uh for people with obstructive sleep apnea so that the underlying causes could be identified and addressed. Um so you know, it's evolved from being a temporary solution to um here it is for life. And it's given to people without um certainly in in Australia, um, the majority of people that have a CPAP, um, when you know, when they come in and see me and they go, you know, well, you know, why have you got a CPAP? You know, why have you got sleep apnea? And they go, Oh, because the sleep study told me that I've got sleep apnea. And I think they totally misunderstand the purpose of the question. It's like, no, no, no. But why have you got sleep apnea? You know, and again they go, oh, because the sleep study, you know, measured it. No, no, it's like, what's causing it? And they go, oh, I don't know.

SPEAKER_00 19:19

And they go, there's your problem. I always use an analogy with the sleep app when I'm talking to patients. And like you're you're like your tires on the car, right? I always use the garden hose analogy that if I have a garden hose and it has a kink in it, I have two options. One is to go unkink the hose, right? Which is ultimately what we're trying to do is get the airways opened up and cure the problem, right? Yeah. The other option is to leave the kink in the hose, go over to the faucet, turn it up all the way, and force as much water through the kink as possible. You're not fixing anything. So the problem with this, and and this is why I talk to patients all the time about the CPAP was intended to be a temporary use. Yeah. And the reason is because it doesn't fix any of the kinks, right? So therefore, your sleep problem progresses. If I redo your sleep test in 12 months, your numbers are worse and another 12 months and so forth and so on. And if we're not doing something to stop that, which the CPAP does not, it's continuing to progress, which is why every few years you got to turn the pressure on your machine up for it to keep working. Well, it's gonna come a point where that pressure is gonna be intolerable by most. Secondly, once that pressure gets above a certain number, right? Above an eight, we kind of start losing our medical benefit from it. And once the pressures get, especially in the double digits, well, now you can increase your risk of heart attack and stroke from wearing the thing. So it's it was designed to be temporary, and that has completely seemed to be lost in medicine.

SPEAKER_01 20:53

Yeah. So my my analogy is that you you you you go into the kitchen and the kitchen sink is blocked. So you call in the plumber, the plumber looks at it and then sets up a pump next to your kitchen sink and says, every time that you use the sink, just push this button and it will force things through, and then walks out the door and takes $2,000. And you sit there and go, You didn't even look at the pipes. He didn't even look inside to see what's blocked. You know, if if if a plumber genuinely turned up to a blocked kitchen sink and sold you a $2,000 pump just to force stuff through a blockage, you'd look at it and go, No, no, no, you haven't done your job. You're supposed to look inside. But we have exactly the same thing in medicine when it comes to obstructive sleep apnea, which is is a disease of the upper airway. It is an upper airway disease, and and you have these people being given a pump, and and nobody who's the plumber, and that's me, I'm the glorified plumber, has looked inside the the plumbing to see where the blockages are. You know, it it it's it's just me. Madness that we would basically prescribe a lifelong therapy without a clinical examination of the anatomical region where the disease occurs. But that's what we've that's what we've got. So yeah, I'm I'm very much of of your perspective, you know, regardless of which analogy we want to come to, the end point is exactly the same. We have a problem not only with regards to finding all these people that need treatment, but also clarifying which treatments are best for them. Because we have evolved into an industry where we can get a a sleep study, we can get a number, and that then becomes, you know, a treat by number where here's your CPAP and good luck. And what happens? Two-thirds of people 12 months down the track from that moment are not using their machine. Um they don't, as you said, they don't tolerate it. Um, you know, and again, it's just madness. You go, you know, here's your nasal CPAP. Oh, but you know, I broke my nose playing, you know, soccer or whatever, you know, like 10 years ago and I can't breathe through it properly. Um, you know, shouldn't we get that fixed first? And go, nah, no, no, we'll just swap you over to a mouthpiece in that case instead. And it's just like, you know, it it it it it just it just seems so so straightforward. It's like there's you know, anybody on the street, you know, can understand this concept that a blockage is best served by unblocking it. Um but when they're given a CPAP, they don't think twice. They they just go, oh, well the doctors know best.

unknown 23:41

Yeah.

SPEAKER_00 23:43

You know, airway surgery can be a controversial topic uh in all areas, but why do you think it's developed such a mixed reputation over the years, especially not just with the public, but it's amongst professionals.

SPEAKER_01 23:58

Yeah. Well, this is where history is a good educator. So if we go back far enough, and we're basically touching into round about the 1990s, okay? Um, so what happened is we had no real idea about obstructive sleep apnea, but we but we had snoring. People turn up, um, I'm snoring, my partner's complaining about it, um, it's embarrassing. I can't go to conferences with my work colleagues because of when I share a room, you know, I can't go camping because the whole campsite is, you know, you know, got pitchforks ready to tar and feather me, you know, or whatever. Um, you know, I I I need my snoring fixed, Doc. Um, and there was a surgeon uh in um Japan who worked out a way of using a carbon dioxide laser to ablate the soft palate uh to reduce the snoring. So that's what we started doing. We started uh getting uh you know laser ablative therapies to the soft palate to fix people's snoring. Now, the problem was um that a cohort of people felt terrible afterwards, and the reason they felt terrible afterwards is they had underlying obstructive sleep apnea, which with all the scarring and so forth that comes from this type of surgery basically made their breathing worse. Their snoring might have gone, but their breathing was worse and their sleep was worse. Um and the problem is as part of this is this treatment was basically doled out um without any discretion whatsoever. It literally was a hammer-nail approach. Snoring, I've got the hammer, let's go. Um and what happened then over time is we started to see the research started to come out with the you know, the sleep study technology that we had then, you know, pretty rudimentary to what's out there now. But it was enough to show that we were making people's airways worse. It might have made the snoring stop, but their breathing was getting worse. And as a result of that, the sleep medicine doctors basically said, that's it, we're done with you ENT guys. You're not touching these people anymore. Um, you are harming people at a rate of knots that is well beyond what's acceptable. Um, and so they basically had a divorce where, you know, they they they kept ENTs out of it all uh because of that moment in time. Um and that lingered for a good 10 to 15 years, um, and it wasn't sort of till about the mid-2000s and tens um where we started to get a creep back in. And a lot of it had to do with the what what the Stanford protocols, where they said, all right, let's take a systematic, stepwise approach. So step one, let's get people's noses unblocked. Step two, let's address anything that's going on at the back of their throat, like big tonsils, um, big tongue. And step three, let's jaw deal with the jaw stuff. And as part of all this, let's deal with the fact that a lot of these people are overweight as well. Because at the end of the day, um, you know, it doesn't matter how good your operation is, if someone is morbidly obese, you're not going to make progress um, you know, with surgery. So the the short answer is that indiscriminate use of surgery initially and a technique that was woeful in its overall outcomes basically gave us all a bad name in the adult sphere. Now, in the pediatric sphere, it's entirely different because adenotonsilectomy delivers remarkable results, extraordinary results. Um, as I said, not in every child, and not necessarily forever, but if we look at the numbers, if we take a hundred children um that meet the criteria for having adenoid and tonsil surgery, initially, 80% of those children, we will genuinely fix. Okay. But of those 80%, down the track, 20% of those will relapse because of other things. So overall, out of a hundred children, two-thirds, you know, 80% of 80% is 64%, just to you know, do some math there. You know, so 64 out of 100 children will benefit from surgery there and then and forever. That's why surgery for children, if it's due to large tonsils and adenoids, is top of the tree. But it's not the only modality. That's where the whole dental part comes into it. Because the main reason that these children relapse or fail is because there is dental issues in the mix in terms of jaw development, or there's other things going on that we've started to become aware of. So nasal allergies, for example, um is is up there as well. Um so you know, look again, you can't generalize, but just to sort of paint big picture, um surgery for children never really fell out of favor. Um, it's not, you know, top of the list of what parents want to hear. You know, they're always desperate to find alternatives. Um, and because we found alternatives in adults, the mindset was, well, if we can find alternatives in adults, we can find alternatives in kids. But again, even the problem is that we're conflating the diseases as being the same because we're using the same words. We're saying, you know, adult obstructive sleep apnea and pediatric obstructive sleep apnea. Um and four at you know, of those four words, three are the same, obstructive sleep apnea. But pediatric and adult actually defines the fact that we're dealing with totally different underlying pathologies. So, you know, the the mistakes again and again as we keep thinking that we if we treat kids like adults or adults like kids, we're gonna get the same results, and that's just not true. So surgery in adults absolutely fell out of favor because of of how uh what I alluded to, but it never um fell out of favor in children. Um it's just that you know people have hoped that there's something else that we can use that you know we can work around. And so far, um, as biased as you might want to think I am, um the reality is there is still nothing that beats surgery for kids with big tonsils and adents. Nothing, nothing even comes close.

SPEAKER_00 30:34

You know, I've always I've always said, you know, treating a child is not the same as treating a small adult. You know, it's uh you know, we used to do a lot of sedation stuff in my offices, and sedating a child is nothing like sedating a small adult. Not a completely different all completely different. Yep, 100%. What do you think people, the public, misunderstand most about what airway surgery is actually trying to accomplish?

SPEAKER_01 31:06

Okay, yeah, that's a really good question. Um it it it's hard to give a general answer because I think this all comes down to preconceived ideas, which you know can be uh, you know, all over the place, especially with what's out there in social media today. Um and also come down to uh and I see this and it it troubles me. I'm really not sure what level of discussion and communication is taking place when people are seeing an ENT. Because I see a lot of I saw the ENT and they want to do this, and what do people think? And it's kind of like, well, that you really should have asked your ENT that question. You know, like you know, you're asking a really good question. That's that's something that you should have asked your ENT. They, you know, they should have been able to, you know, explain this to you. You shouldn't have to resort to some form of social media um platform, you know, or support group to answer this. And I you know, and I I sort of lurk into these groups just to see what people are asking. And I'm like that you should what that that should have been discussed at the consultation, not with a group of random strangers hoping that there's a collective wisdom, you know, that that's going to give you a specific answer for your situation. So, you know, so you know, sort of have that in the background. Um I think the the the main problem, again, it probably circles back to what I said before, is is expectations. You know, the hope that this is going to fix everything. Um whereas surgery is just, you know, it it's geared towards optimizing the anatomical elements. Um it doesn't deal with, you know, the the functional part of it. Um it can make it functional, but then you've got to make it work. So, you know, I can give you a book um, you know, where you can learn to speak um you know Japanese, um, but it doesn't you you can read that book a million times unless you actually put it into action, you're not really learning. And it's the same with surgery. You know, we we we can unblock nose a million times, but unless you then rehabilitate the breathing, it's not working. So, you know, it it it's surgery is just a a facilitation process of sorts uh uh to optimize the anatomy. So if the nose is no good, we can make the nose better. Um if the tongue is too big, we can make it smaller. If the tonsils are too big, we can get them out the way. Um if the jaws are underdeveloped, um, you know, there are surgical options for that as well. Uh, you know, there's there's a multitude of dynamics in play. Um, and I think people's expectations need to be moderated around the fact that there is no one size fits all. There is no treatment that has a universal outcome that is applicable across the board. Um, and the reality is a lot of these people turning up, especially adults, you know, children too, but especially adults, um, there's there's a couple of moving pieces. Um, and you can't expect surgery to fix all of them.

SPEAKER_00 34:10

You know, one of the things that I mean I struggle with, so it's got to be a struggle for patients as well, is you know, when I try to find an ENT that actually pays attention to airway the way you do. It's not easy. And if it's a doctor who's not paying attention to airway the way we do, it's a completely different consult than that person who actually does pay attention to airway uh and understands the importance of the timing of this stuff, and the sooner the better on a child. Uh, but if I can't hardly find an ENT that will pay attention to this, how does a patient find the right one? It's I mean, I don't know what percentage of ENTs in general are paying attention to airway the way you do, but um it ain't many around me, I can tell you that.

SPEAKER_01 35:03

All right, so let me give you some insights into that because this this is where people trip over, and hopefully this will help clarify that. Um and I'll I'll talk in generalities first. Um so ENT is a huge specialty, it's enormous. Okay? If we actually sort of tease ENT out, give or take, there's 12 to 14 subspecialty subspecialty elements of ENT. 12 to 14, okay. So the reason I bring that up um is let me compare this to something else. So let's think about a gener you know, a general surgeon, alright? So we might have sort of some terminology issues here in terms of what we call things across you know the continents, but you know, in in Australia, a general surgeon is someone that has a basic uh starting point of covering general surgery. Um, and that includes things like um the bowel, um, things like uh the thyroid, things like the liver, uh things like the kidneys. You know, they have a basic sort of general you know element of everything. Um but then they can and they can just sit at that point, you know, they can do that, do gallbladders and hernia's and appendices, for example. Um, or they can sort of branch out and they can do, you know what, I'm gonna focus on breast cancer. I'm gonna focus on colorectal cancer. Now they're both general surgeons, but they've differentiated themselves into specific things, um, and that makes it easy for the public to go find them because they go, Oh, okay, um, I've got breast cancer, I'll go see the breast cancer person because it says breast cancer on their wall. Easy. Um, same with colon cancer. Um so people don't have a tr you know struggle with that, but they've seen general surgeons. There's still general surgeons, okay? Where people make the mistake is they think that the starting point is they need to see an ENT. And they just go looking for an ENT. Now, pretty much all of us put the fact that we're ENT on our wall, because that's what we are. Right. Um, what doesn't happen, as you're alluding to, um, necessarily, is then, you know, putting airway, you know, on the wall. And part of the reason is that is because not a lot of them do air. You know, if there's someone, you know, has on their wall rhinology clinic, well, you go and see them because you've got a nose problem. You don't go and see them because you've got, you know, an airway problem, even though the nose is part of the airway, um, obviously, you know, if their focus is on nose and allergy and sinus type problems, um, they're not the right ENT for you. If on the wall they they have, you know, you know, facial cosmetics, well, that's not the right person for you. You know, so so in some sometimes they can make it easy for you because they'll tell you what they specialize in, um, and it doesn't match with what you're looking for, even though they're an ENT. You know, you you know, and this is what you you know need to do is you need to find the airway ones. You ask me what percentage. The reality is I would put it at less than five percent, okay? In terms of those that focus on it. You go, my God, that is terrible. And and and and it yes and no at the same time, because you've got to realize that ENT is an enormous specialty. Okay? So we need the ENTs that do focus on rhinology, we need the ENTs that focus on ear disease, we need the ENTs that focus on um, you know, cleft, lip, and palate. We need the ENTs that focus on throat cancer. We need those ENTs. Because if we don't have those ENTs, then those elements of ENT don't get booked at. And this is where we've got to take our blinders off because you know, we you and I are sitting there going, look, we're trying to find all the solutions to airway problems and with a team approach and we're looking for the ENT. And then we want, for example, do we really want the ENT that helps people with throat cancer to stop doing that? Of course not. And if they're really, really good at it and really you know developed and sophisticated at it, um, that's a huge benefit to society to have that person with that skill and knowledge. And if the trade-off is that that person is out of, you know, the pool of opportunity as an ENT, um, we can't be upset about that. You know, it's frustrating. You go, all right, well, I'm still looking for that airway ENT. So what's what happens then? Well, again, it's the same as, you know, if you've got throat cancer, you don't necessarily have a throat cancer specialty team in your back back door. You know, some people have to travel to specialized, advanced clinics to have their throat cancer managed by the team of people that manage throat cancer. Um, and airway, we need to redefine and reconfigure that as being the same um concept. Um, you can't have everything, you know, outside and around the corner or next door to you. Sometimes you might need to do some travel. And again, this this might be cultural, but here in Australia, it is not unusual that because of the way uh uh geography is set up and population distribution, you know, someone will literally drive four to eight hours one way to see someone like me, spend fifteen minutes with me, and then drive home again. Okay? Um, you know, and again, that that might just be an Australian mindset because you you really don't have a choice because that's that's all you can do. Um you gotta do what you gotta do. Um, you know, so so my comparison is you can't have Disneyland in every city, you know. So what do you do? Well, you go on a holiday, you go to LA, you go to Florida, um, and you go to Disneyland. Why? Because that's where Disneyland is. And it's the same with airway, it's the same with anything. If that's where it is, well, that's that's where you get to it. Because at the end of the day, um find you know, going to the right person the first time is better than going to the wrong person three times.

SPEAKER_00 41:09

100%. I I've I mean I when I refer to ET right now, my number one and number two referrals are one's two hours away, one's two and a half hours away.

SPEAKER_01 41:20

Yeah.

SPEAKER_00 41:21

But I just like you said, I just don't have that person close by. I just don't have it.

SPEAKER_01 41:27

No, and you've just got to educate the family. You just go, you know what, I've been doing this for a long time. Um, all I'm gonna share with you is what I think is in your best interest. And what I think is in your best interest is to get the best information from the people that I have found for you that I think can give you the information that is more sophisticated than someone that's in town. And that's not to disparage who's in town, um, but this is just not the part of what they look at. Um whereas these ones do, um, and I I know from experience, you know, that that parents and patients and and and the like end up with much better outcomes by going down this road, albeit two and a half hours away, rather than you know, up and around the corner for this particular problem. If it was something else and this person is good at it, I'd be I'd be you know happy for you to see them. But you know, I just want to encourage you to to consider you know going down that road. And I think one of the other problems you have, especially in the US, is the whole health insurance industry and the whole thing of you know, network. Um, because people get captured, you know, within their network. And it's like, well, I have to see someone in my network if I want to get it paid. And you know, the the extraordinary costs that come with healthcare access in your country, you know, that that that is a you know a genuine and serious consideration. It's like, well, you know, that person's out of my network. This is gonna cost me time, you know, more than than and and but the money involved, I'm not gonna get any reimbursement. I've got no coverage because this person's not in my network. Um, we don't have that problem in Australia. You know, we we have genuine freedom. Um, you can see any specialist that you like anywhere in the country. No, no, nobody is captured by a network in in our system. Um so you know, again, you know, just highlighting differences of um you know what can blend into decision-making processes that are, you know, they are they are real.

SPEAKER_00 43:20

Yeah, and we and it's not just the access because of people being in network, it's the insurance companies strictly dictate and control what procedures will and will not be covered. So oftentimes the procedures that people need, especially on the adult side, yeah, they're not covered. Uh, I mean, I had a I had a nasal sinus procedure done, and it's not a covered procedure unless you've got this two year long history of repeated sinus infections, repeated sinus treatments, et cetera, et cetera. It's not a covered procedure. So even when you find somebody in your network, the the procedures that are beneficial oftentimes are not covered anyway. Yeah, you know, and when we look at we have people who come to see us from all over the place. I literally have patients. By the way, I got a phone call for a telemedicine from Australia last week. I have patients from Thailand, Italy, all over, all over Canada, the Bahamas. We have people that come to see us from everywhere. Um there's just not a lot of people. You mentioned less than 5% of ENTs. Uh when it comes to dentists, it's even less than that. I mean, I I'm I would estimate doing what I do, there might be 70 of us in the entire US. That's not even two per state. Yeah, exactly. Yeah. Yeah, exactly.

SPEAKER_01 44:39

Um and and you know, you know, you know, as I say, just as a as a side point, you know, I I've done the economic modeling of this. You know, if you were to share how much you spent on your surgery because it was all out of pocket, it was all out of network, um and so forth. Um and you know, and I and I've just seen these numbers come out of the UK too. Um, you know, I shall use the UK example because that's contemporary. Um so they've costed out what it costs in their public health system uh in the United Kingdom uh to have a nasals, you know, nasal procedure, just a septoplasty and a turbinate reduction, not even sinus. Um and it's literally cheaper. It would be cheaper for the United Kingdom to fly that patient business class to Australia to pay a private service, so a private surgeon, private hospital, private anaesthetist, and then pay a top-notch hotel bill for two weeks, and then fly them back again business class is cheaper than what it's costing them in their national health service to deliver the same care. You know, the the the the the the the the the money you know is it's just abhorrent um as to how inefficient these health systems are becoming um and how expensive those inefficiencies are, when you know, I can genuinely say that it is, you know, it is cheaper by about 20% of their cost um to literally fly someone business class. If you fly them economy, it's less than half the cost. You know, I just use business class just to emphasize just how ridiculous it is. Um and it's not dissimilar in the US, you know, when you look at the the costs involved, um uh you know, you know, Australia's missing the boat. Australia needs to set up a whole medical tourism thing to service first world countries because um the health costs are just spiraling out of control.

SPEAKER_00 46:43

Yes, they are. How do you I know I I speak to patients oftentimes about dual therapy, which means, you know, you're gonna need more than one thing. Okay, I can put you on a CPAP, I can put you in an oral appliance, but you're gonna need a nasal procedure, you're going to need a high weight airlift surgery, um, you know, these combination treatments. Uh when you're seeing a patient for a consultation, obviously for a surgical consultation, is this something that you bring up? I mean, dual therapy needing to do.

SPEAKER_01 47:18

Yep. So so with when somebody comes in, um, and I've been doing this for over 20 years, okay. Um, is I I do what's called work out their phenotype. Okay. Now that's a medical term. Um, it's got lots of other, you know, places that it turns up as well. But basically, it's the this is what you've got, but this is why you've got it. And to make it comprehensible to patients, you know, I I basically say, look, we've got to look at this, you know, in terms of the breathing, we're dealing with four levels. All right. Level one is through your nose. Level two is through your throat, and in terms of your mouth level, level three is down here, and level four is your weight. And you've got a problem at level one and three. You've got a problem at level one, two, and four. Your problem is just level four. You know, whatever, whatever it is, so then they've got an understanding in very simple terms as to what it is that needs to be sorted. And that'll clarify. Say, look, level one, that's a surgery thing, okay? Or level one, it's allergies. This is going to be allergy treatments. Level two, uh, you've got uh tonsils that are too big. Um, your tonsils are fine. You've got a tongue that's too big, your tongue is fine. Level three, your lower airway collapses when you breathe in. But when you bring your jaw forwards, it's a lot better. So a mandibular advancement splint is gonna be good for you. Level three, your lower airway collapses, but when you bring your jaw forwards, it makes no difference. A mandibular advancement splint is not gonna work for you. Level four, weight. You know, we can do level one, two, and three, but if nothing happens to your weight, we're not gonna make progress. But you know what? We've got to do something for level one, two, and three, because if we don't, um, you're gonna have ongoing sleep problems related to breathing problems, which uh result in metabolic problems, and those metabolic problems facilitate ongoing weight gain. So you're going to struggle to lose weight until we get on top of these things. You know, and I will, you know, like you, I say, look, you know, this is where I think we're gonna be. You know, you know, I'll see someone and go, look, if we get your nose fixed and we get a mandibular advancement splint um and you lose weight, then I think we can get you in a position where um you won't need the CPAP. But until you do lose the weight, um having the nasal surgery and the mandibular advancement splint are gonna facilitate what the CPAP needs to do, um, which is to keep your airway functional. You know, and I think this is a, you know, just as a side note, I think this is a huge mistake that dentistry made as a profession uh trying to basically get a seat at the table, where the initial paradigm was um how good is a splint versus CPAP? And the reason I think that's a mistake is that there's a good number of people that actually derive benefit from using both because they have lower airway compromise that the CPAP pressures need to be turned up real high just to hold the airway open. Forget about moving air through it. We're doing that basically as a pneumatic splint to hold the airway open. Um, and but we're needing really high pressures to do that, whereas if we gave them a mandibular advancement splint and that reduced their lower level three collapse even by half, um, and that then meant that the CPAP pressures could be reduced and we were then tolerable, which meant that they were actually then able to use their CPAP without feeling miserable. Um, you know, so that's what we call combined oral appliance therapy. You know, it's it's like, you know, it it this this one or the other concept um is is actually a disservice to a lot of patients because they don't like their CPAP, they get the mandibular advancement splint, but it doesn't fully control their disease, they still feel miserable, so then they throw the splint away and go, this all these treatments are just a whole lot of you know hogwash uh and nonsense. I've spent all this money and I feel terrible still, um, and they just give up on it all. Um whereas if they'd seen someone, you know, in a team approach, you know, the ENT has gone, look, you know, if you want to, you know, deal with your your airway and you want to wear a mandibular advancement splint, the reality is you need to be able to breathe through your nose. And until you can breathe through your nose, if we put a mandibular advancement splint in, you're gonna feel like you're choking. Because at the end of the day, that oral mouth breathing thing that you're doing, that's your survival pipe. And we're about to, you know, put stuff into that pipe, um, you know, to keep the lower pipe open, but you haven't got the upper pipe clear yet, we're gonna fail. It's the same with the CPAP. So, you know, I everything, you know, that I look at is all about phenotyping and then giving patients a sense of understanding of who's involved in this. You know, it's ENT, it's dentistry, it's myofunctional therapy, plus or minus CPAP, and and and weight loss by whatever means too.

SPEAKER_00 52:37

I I often see people coming in because they're trying to get rid of their CPAP because they can't tolerate it. Now their pressure got turned up, and it's just it's it agitates me a little bit because uh for some of these patients, it's as simple as putting a simple mandibular advancement appliance in, and now they can actually turn the pressure on the CPAP down to where it's tolerable and healthy. But I just don't ever get pulmonologists sending patients over for dull therapy, it just doesn't happen.

SPEAKER_01 53:05

Well, again, you you can have that chat when they can you know come in. You can put it in the screening questionnaire, you know, you know, again, it's just education. You know, like you know, like I said, you know, we we've we've all got our analogies here, you know. You know, there's you know, your your your um garden hose is kinked. Has anyone bothered to look to see where the kink is? Like if if you're at one end of the of you know the force that is on and you're at the the end of that hose and there's no water coming out, what do you do? You trace it back and you find where the kink is. You know, you go, you so you go, the purchase goes, so you've got a kink, you've got the effectively at least one, if not more, kinks in your airway. Um, which ENT have you seen to have a look and see you know where those kinks are? And they'll look at you and you go, Well, I've never seen an ENT. You go, Well, here's the problem.

SPEAKER_00 53:52

We take a 3D cone beam on every patient to just evaluate, you know, that midface uh and where it's underdeveloped, uh, where those kinks are. We look for the position of the hyoid bone. You know, I tell I tell patients all the time, I can take a 3D image, and based on where I draw a line from C3 to the bottom of your lower jaw, based on where that hyoid bone is, I can usually predict the severity of your breathing disorder. Right? Yep. So that's one of the kinks, you know? Yeah. So if we know where the kinks are and we know what options are needed and which options will and will not work.

SPEAKER_01 54:31

Yeah. Because again, they've been phenotyped. You know, the the you know, the the the actual underlying causes are being explored, investigated for, and addressed. Um, you know, you know, and again, you know, the sleep study tells you what you got, it doesn't tell you why.

SPEAKER_00 54:49

Now you mentioned something before we got started, we were talking before we went live. You mentioned something called CPAP induced obstruction. Can you can you explain that?

SPEAKER_01 54:58

Yeah, 100%. So there's a cohort of people where we put the CPAP on um and they they actually obstruct um rather than open up. Um and it's got everything to do with this part of anatomy called the epiglottis. So just to keep it you know on the low down here, the epiglottis is in the lower part of our throat. It's a little flip-top valve. So when we swallow, um, you know, food, whatever, that that valve goes down and covers over our larynx and then facilitates the flow of everything down into our esophagus. Okay? So it protects the airway when we eat or drink. Now, when we put CPAP onto people, if that epiglottis um is you know it's sitting um back a little bit, um the the the pressure of the CPAP then blows onto the epiglottis, which blows the epiglottis down as if you were swallowing. What does it do? It obstructs the airway. So so that is CPAP-induced airway obstruction. It's got everything to do with epiglottic collapse. Uh, and again, it's something as a as a you know, as an airway ENT, we can physically see when we do our nasal uh uh, you know, and upper airway anatomy assessments with our scopes. We look in there and go, oh, your epiglottis is already sitting half over your airway, just in an upright resting position. Of course, you know, if we blow on it, of course it's gonna fall down. You know, if you're if I had a piece of paper and I just was to blow on it, you would see it fall down. Epiglottis does the same thing. So that is CPAP induced airway obstruction. They are the people where CPAP actually makes things worse. Um, and again, unless somebody has physically looked at it, uh, you know, these people go back to their, you know, sleep clinic and go, I tried the CPAP, but I just feel worse for it. And they go, Oh, okay, well, you know, just keep trying, just keep we'll try, put we'll put the pressure up some more. Oh man, that's even worse. You know, and so you you know, what could be a really useful and effective therapy in the majority of people is provided as a cookie-cutter approach. Um, and there's a cohort of people that abandon what is actually perfect treatment for them because they were set up to fail. Because nobody looked at what what is going on that needs to be addressed before this, you know, is you know, then looked at as a as a you know part of the solution.

SPEAKER_00 57:32

You know, somebody that treats airway like yourself. I first time I speak to somebody, I always like to ask this question because I know this person in my life. Um looking back over your career, is there a a person, a patient, whose outcome fundamentally changed the way you think about airway?

SPEAKER_01 57:53

Okay, that's a really good question. The the honest answer in general is no. Um I I do have one. I'll I'll I'll I'll I'll bounce back to that. But in general, the answer is no. The thing that changed it for me was uh dental professionals. If I was to look at the journey in terms of the road that I was on versus the road I'm now on, um, we're not talking about slight deviations, we're talking about right-hand turns and U-turn type material where I've gone back and revisited and revised substantially um the way that I look at this as a concept. Um, and that has come from dental professionals rather than patients. Um Having said that, I I will reflect on I do have my one patient, and I and I share this with with the people that I see because it has everything to do with weight loss. Um and and, you know, because weight loss is a crucial part of this overarching element. Doesn't matter how good a surgery you get, doesn't matter how good dental care you get, doesn't matter how perfect anything might be for you. If you're overweight, that's gonna be an anchor that's gonna hold back your your your progress, not just from an airway point of view, but from a health point of view. But people struggle to lose weight. They struggle to lose weight because they're tired, they struggle to lose weight because they're not getting good quality sleep, they struggle to lose weight because metabolically they're all a mess because of their airway problems. You know, it's really the perfect storm. You know, I say, look, let's get your breathing and sleep optimized, and but then you've got to lose the weight, um, you know, and so forth. And I had this chat with a guy, and you know, I said, Look, you know, I've got to get your nose fixed, you're a perfect candidate for a mouth guard, but you're gonna have to lose weight, um, or else we we're just not gonna make it. And he goes, Okay, all right. Um, and I saw him six months later, and I did not physically recognize it because he had lost so much weight. And I was just like, What how did you do that? And he says, I just listened to what you said. You know, I took what you said seriously, um, and you know, I didn't do it stupidly. I, you know, I got a team of people, I got, you know, a trainer, I got uh I got nutrition people to help me, I looked at what I was doing, um, and he he looked remarkable. The thing I haven't told you is that he was an amputee. There's no excuses. Right. All right. There's no excuses. Um you've just got to have the knowledge, but you've got to apply the knowledge with a great sense of urgency and a great sense of motivation. Um and you've got to do it with support. Um you know, we we we we've got to give up on this, you know, social media being the resource of solutions. Um, because it it it's it's it's not real world.

SPEAKER_00 1:00:38

Um, at an individual level. With these patients, you know, you know, when somebody comes in and I'm talking to them about weight, you know, I'm not the first person in their life to talk to them about their weight, you know. Uh and they've tried and almost everybody's tried, right? So the one thing I always do to encourage them, and it oftentimes does work well, is that when you treat your sleep disorder, the sleep disorder itself could be part of your weight problem. You know, with the increase in cortisol and and inflammation and prediabetes and diabetes that can come along with it, uh lack of ability to control hormones because of lack of deep sleep. So I encourage them and say, you know, you treat your sleep disorder, and your weight journey is going to get easier. 100%. You know, yeah that a lot of times can encourage them. Oh, yeah, absolutely. Yeah. When we talk about the future of airway care. Um, I mean, in the last 10 years it's drastically changed for me, but where do you think airway medicine is headed over the next 10 years? Are there any changes in particular you're excited about?

SPEAKER_01 1:01:44

All right. Well, I'll I'll flip that round a bit. I'll I'll share one thing which is an emerging problem, um, which is actually uh bad news for everybody, um, and wave the flag for Australia, possibly leading the world here, um, and that's the evolution of nasal allergies coming into this conversation. Um and I've seen this happen over 20 odd years, and I literally saw a paper last week um which basically confirms what I'm seeing. So we have historically and sensibly talked about tonsils and adenoids in this pediatric population as being the main thing that's driving the bus. Um, allergies are starting to take over. Um, allergies may actually be even more prevalent than tonsil and adenoid problems now. Certainly in my clinic they are. Now, Australia has one of, if not the highest rates of nasal allergies in the world. Um, it used to be one in seven here, it's now one in four, um, and that's just over the passage of about 20 years. Um, so so part of um you know what I'm seeing um that the literature is starting to evolve and and demonstrate is that we are going to have to really revise our approach to pediatrics in terms of upping our activity in managing nasal allergies in children. Because I'm seeing more of it as a overall. I'm seeing it at a much younger age, and I'm seeing it at a far greater severity. Twenty years ago, it was really unusual that I had to do uh nasal you know procedures um to help a child breathe through their nose. Um and if I was, it was extremely unusual that they would be under the age of eight. I'm now doing two-year-olds. So so that is a change for the worse that I think we are going to see escalate more and more over time because that's just the trajectory and the trend. So that's that's the bad news. Is that escalation in adults and children both? Yeah, it is. Yeah, but but it's showing up on my radar, it's showing up predominantly in children. Um most of the most adults have had allergies for a while and they kind of just accept it and they're good and they put up with it because they didn't they don't know otherwise. Um whereas when kids are getting it and it's smashing their airway, um, and you know, the parents don't know it's allergies, you know, the parents are just bringing them in because they're snoring and mouth breathing. You know, that's that's the parents' observation. It's just my findings that go, all right, well, this is being driven by allergies, guys. Um, because you know, some of them they'll come in and go, Oh, look, we think they've got you know tonsil and adenoid problems because they're snoring and mouth breathing, and we've done our research and you know, Dr. You know, insert online agent um says it's tonsils and adenoids, and have a look. Well, actually, those tonsils and adenoids are alright, but we've got a nasal allergy problem. They look at me and go, oh, so we're gonna try to fix this with medicine instead of surgery, and they go, Oh, okay, this is good. Um, so you sort of they they take the good with the bad there. Um, so it's definitely showing up more so in the pediatric population, but that's just because kids are far more sensible to airway obstruction. You know, that that that you know it only takes a bit of a problem to be a big problem in kids. Um, so there's that. Um, I think one thing that we're definitely seeing on the upside um is this evolution of medications for weight loss. You know, we we we disparage the I want the pill, but look, the reality is we we we might have tripped over something here. The problem is we don't have the long-term results to know what are the what are what are we trading off. You know, weight loss, great, but what what's what price are we paying in other domains of wellness down the track that comes with this? Um so that might be a blessing and a curse. Um, you know, it everything comes at a price. Um, but we're definitely seeing weight loss translating into adults having less airway problems, which just goes back to what we were saying before. You've got to you've got to manage all the moving pieces. Um, so so from that point of view, we're probably going to see hopefully adults with less severe disease because we see the losing weight um with with with these therapies that have evolved and gosh knows where they'll be. And and and look I wish I I had that crystal ball. You know the the the thing that I think we're all aspiring for at the end of the day is some sort of therapy that can address these big tonsils and adenoids in a timely manner that means that surgery you know disappears. Just like you know back in the day when I was doing my medical school um if you had a a stomach ulcer um that was a surgical disease. Now we know that it's due to Helicobacter helobacter pylori which by the way was an Australian thing again um you know um and we can treat it with you know three medications um so the need you know for having your stomach ulcer surgically operated on has become a thing of you know negligible intervention now because we found underlying cause and we found medications. The problem is as much as we want to you know hope for it we just don't have anything yet that can do that with tonsils and adenoids. As much as people want to sort of wish and hope and and and so forth the reality is if we're going to be honest we don't have that magic pill yet. And I think you know that that's that that'd be great. You know you know this is coming from someone that you know you know obviously makes you know a living and a profession out of doing these surgeries. If there's anything that we can find that means that it's as good as um or better than surgery that you know that needs to be embraced um you know for anything that we come across and you know you know my my hope is that some night stage over the next 10 years we'll have a better grasp and understanding of all the papophysiology that drives this bus and we'll have some form of therapy um that is you know suited for you know maybe not everyone but uh you know enough kids and that we give them this and you know it helps even if it helps half of us um and that that's half that we can say look you know we dodged surgery because this worked um that'd be great but it's yeah that that's there's nothing there that I've seen yet.

SPEAKER_00 1:08:14

Yeah I think um over time we're gonna start to find the role of nutrition, uh balanced hormones, gut health uh all playing a role in this and uh and it comes back to that same old thing if we can combine and do this and that and that it you know it takes the combination uh to do it. When I look at the people on twice epitites uh and you know these injections I even see patients that are not necessarily losing a lot of weight but they're still benefiting and they're still getting better uh as far as their sleep goes on these medications. I was at a lecture once uh with the gentleman who actually got it FAA approved for sleep. And he mentioned several reasons for it but you know it does help. Keep in mind these medications were not invented for weight loss. It turns out to be a great side effect but they were invented for a lot of other reasons and there's a lot of other health benefits to these medications. And one of those side benefits is it actually helps with visceral fat. So we can lose visceral fat which can help with our breathing but not necessarily going to lose a lot of weight from that. So I think these medications are going to be helpful over time become more mainstream for sleep over time in addition to the weight.

SPEAKER_01 1:09:40

Yep I I I I have to agree with you. Like everything, you know, we we can get ahead of ourselves in terms of you know where things are at versus what we know you know the the the the moment for pause is we don't have long-term data. You know that's that's just the the the moment for pause um in terms of just making sure that we do keep an eye on you know what are we trading out here. But um the the fact that people are breathing better, sleeping better losing weight metabolically you know improving too you know the these are all such big benefits. You know if there are risks um well look you know we've got to like everything like surgery has risks and benefits. You know there's there's a price that you everything comes at a price um and so far that price for these medications seems to be worth paying um but it's too early to know whether we're right about that yet but you know that we gotta be again like we talked about early on we just have to accept where we are right now you know and if in ten years from now you know we we learn that oh this medication causes this absolute disaster of a problem in 90% of people well we can't be criticized for right now because we didn't know right now. But if that is happening and we keep doing it well then yeah that is where we can be criticized because that's that's you know when we're definitely not doing the right thing. But we just got to live in the moment you know and we're doing the best we can and we just got to realize that you know there are there is a cohort of people like you and me out there that focus on this um in far greater depth and detail than others and that's not a criticism because if you come to me with throat cancer I can't help you you know but you come to me with this problem I'll I'll run rings around um you in terms of finding out you know why we've got to get you better um and you'll you know as people often say is you know they've said look I've learned more about my problem in the past 10 minutes than I have in the past ten years.

SPEAKER_00 1:11:45

It's the same thing with me. If somebody wants to come to me for any dental you know traditional dental work I can't help them. I don't even have a drill in my office. Yeah exactly all we do all we do is airway. Yeah exactly really good at it I I don't do anything else haven't for a long time. Yeah exactly well Dr. McIntosh want to be respectful of your time you're in a way different time zone here you've got to get your day going. Thank you so much for joining us and sharing your perspective today's conversation is a great reminder that there isn't a single solution for every patient. Understanding why someone has sleep disordered breathing is just as important as deciding how to treat it. To our listeners thank you for joining us for another episode of Breathing for Better Sleep. If today's conversation helped you better understand the role of airway surgery in sleep health be sure to share this episode with someone who may benefit from hearing it. To learn more about airway focused sleep care and treatment options visit sleeptreatmentdirect dot com better breathing, better sleep better life have a good day