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An ENT with ESP?

Three times this week, people have asked me if I have ESP. If they are in front of me, their eyes open wide and with a scary look and they asked me, “Do you have ESP?” I assured them that I do not. In all three situations, I had just asked these people questions from a list of common symptoms that people with airway resistance syndrome have. Some of these symptoms include: sleeping on their side or stomachs, never waking up refreshed, cold hands or feet, occasional dizziness or lightheadedness, frequent headaches, and a parent that snores heavily. More often than not, the parent that snores also has a complication of untreated obstructive sleep apnea such as hypertension or heart disease.

These list of symptoms are so consistent that I stopped asking if either of their parents snore, or which position they sleep in—their back, side or stomach. Instead, I now ask, which parent snores, or do you sleep on your side or stomach? Sure enough, about 99 % of the time, they’ll answer one or the other. 

Do you have any of the symptoms that I described above?

The Real Reason Why Some People Are Lazy

More than a few times per month, I have patients comment that they think others perceive them as being lazy. Whether they like to "sleep in" or have trouble getting up in the mornings, or if they’re prone to taking naps in the afternoon, their sleepiness often elicits other’s perception of them as being lazy or unproductive. Add to this a saying from Proverbs: "Laziness brings on deep sleep, and the shiftless man goes hungry." Given that this type of work ethic runs deep in our modern day culture, it’s difficult to avoid being called lazy if you’re not the first one in the office and the last one to leave.  

 

However, laziness may have less to do with sleep than it does with how well one is breathing while they’re sleeping. Without assessing the latter, it would be wrong to assume the former. 

 

Sleepy or Sleep Deprived? 

 

Typically, most self professed "lazy" people don’t look forward to waking up in the morning. On more than one occasion, patients have complained that they "curse the mornings" when they have to get up. Often it takes multiple cups of coffee, or vigorous exercise, before they feel even somewhat functional. Naps are also a requisite for most of these people and almost all of them crash at night, completely exhausted by the time they get to bed. In the morning, they never feel refreshed—always feeling like they’ve slept only for a few hours.  

 

The other common misperception people have about other sleepy people is that they must have trouble sleeping or that they have insomnia. However, what many supposed "lazy" people suffer from is not usually due to insomnia—they can fall asleep just fine. In fact, many of these people fall asleep too easily. The difference is, these people just can’t wake up once they do fall asleep.  

 

So, if these people are not sleep deprived, sleeping more than their peers, why do these people seem so tired and "lazy" all the time? The true answer lies in how well they’re breathing while they’re sleeping. 

 

 

To Breathe Or Not To Breathe 

 

Many supposed "lazy" people that I see in my practice often have a sleep breathing problem called Upper Airway Resistance Syndrome (or UARS for short). This often occurs to those who have a smaller than average airway opening, or a bigger than average tongue to jaw size ratio. And for those who suffer from UARS, this is the primary reason why they’re not getting the deep and restful sleep that they truly need and desperately desire.  

 

It’s taken for granted that all humans have rigid, open windpipes that allow air to pass easily from the nose through the lungs. What’s unique about the human upper airway, however, is that due to our unique ability to talk, our voice boxes are much lower down, underneath the tongue, which forces the tongue to rotate backwards. This is fine when you’re awake, but when you’re on your back, the tongue and voice box falls back partially due to gravity. Furthermore, when you go into deep sleep, your throat and tongue muscles relax, then with a bit of deep inspiration, the tongue falls back completely to occlude the 1-2 mm airway space behind the tongue. 

 

If you have UARS, a number of different scenarios can occur: the tongue falls back, and you can wake up after a few seconds, with you panting, in a sweat, your heart racing, and in a state of panic. Or you wake up from deep to light sleep only, never realizing that your sleep was disturbed.  

 

Also, if you stop breathing for 10 seconds or longer, and then wake up, then you just had an apnea or a "loss of breath" due to an obstructed airway. Five or more apneas per hour is in the range of having obstructive sleep apnea. But even if you stop breathing 20-30 times every hour, each lasting anywhere from 1-9 seconds, you’ll be told you don’t have any apneas, so therefore there’s nothing clinically wrong with you.  

 

This is the major conundrum many UARS patients find themselves in. Although they’re not found to have a clinically diagnosable problem, they still suffer from the same level of fatigue and exhaustion that many OSA patients experience. This may be why so many UARS patients are often mistaken for being lazy and not properly treated as someone who suffers from a sleep breathing problem. 

 

Fighting While Sleeping 

 

Another physiologic phenomenon that many UARS patients experience is that they’re constantly under a low grade state of stress or anxiety.Whether or not they feel this way while they’re awake, while they’re sleeping, their bodies are in a constant mode of "fight or flight." Both hormonally and neurologically, having UARS can put your body under enormous stress. Since you’re never able to reach a deep level of sleep, and stay in a sustained state of light sleep, your entire nervous system goes en guarde, and becomes hypersensitive. Even your emotions and senses are heightened, including your hearing, vision, taste, and smell. Simultaneously, you are exhausted all the time. 

 

Also, in this constant state of readiness, blood is taken away from your gastrointestinal system, your reproductive organs, your skin or your hands and feet. This may be why so many people with UARS have cold hands or feet or suffer from a rash of gastrointestinal problems. 

 

Laziness May Be a Virtue 

 

But there is one positive side to all of this. Contrary to popular belief, I see many people with UARS who self proclaim themselves as being lazy, compensate for their chronic fatigue and lack of energy by becoming overachievers, being highly productive and creative in everything they do, going non-stop during the day, but crashing at night. They’re also much more attuned to their bodies, being proactive about their health, and taking care of whatever illnesses they have before they become huge problems. 

 

However, there are those who can’t sustain this high energy lifestyle especially as they get older and they start gaining weight. What happens for many of these patients is that they now progress into a more severe form of sleep breathing problem like OSA. 

 

So the next time you think you’re lazy or think that others perceive you this way, the way you feel and act may actually be due to chronic deep sleep deprivation and not a personality defect. Something else to sleep on.  

Sleep Apnea, Michael Phelps & Swimming Records

This may just be coincidence, but on an online forum for sleep apnea sufferers, a member commented that he could hold his breath the longest while swimming when he was in the military. Shortly thereafter, two others replied with similar experiences when they were children. As we know, sleep apnea is not something that develops all of a sudden at a certain age when you reach a certain age. If you have sleep apnea, you’ve had some degree of it since you were an infant. So if you have episodic breath holding spells while sleeping when young, it makes sense that your capacity to utilize oxygen is enhanced, similar to what occurs when elite athletes train in higher altitudes to acclimate to lower oxygen levels.

This brings us to Michael Phelps. He seems to always surge ahead when he’s swimming underwater just after the turns. Next time, look at his narrow jaws and malocclusion. Could he have a sleep-breathing problem? Look at his mother.

Is there anyone reading this post who has sleep apnea with a similar story?

When Men Cry

Once in a while, I see male patients that reveal that they sometimes cry in the mornings upon awakening from sleep. There are two major reasons: The first group includes men who can’t stay asleep or keep waking up, feeling exhausted when the alarm goes off, and they feel as if they only slept for 2-3 hours. The other group includes men who undergo definitive treatment for obstructive sleep apnea (whether via a positive air pressure machine, a dental device or via surgery), who are able to achieve deep sleep for the first time in years. These men have tears of joy.

The most memorable experience is one man who had severe sleep apnea who couldn’t tolerate a positive pressure mask, and after a long discussion, decided to undergo major throat surgery involving the soft palate and tongue. He noted that one morning, a few weeks after the surgery, he awoke and for the first time in years, felt light he achieved deep sleep and felt clear headed. This is when he noticed his eyes welling up with tears.

Unfortunately, I see more people in the former group, in women as well as in men. One woman even told me that she curses the mornings when she has to wake up. 

 

Do you ever cry because you can’t sleep?

 

 

Need To Carve The Turkey? Call A Surgeon

 

It’s Thanksgiving time again, and once again, around our family’s dinner table as the turkey’s being served, everyone will ask: Who’s going to carve the turkey? Should the job go to Uncle Jason, since he’s good with his hands, or should it go to my father, since he’s the eldest, or should my wife do it, since she cooks more?
    
Naturally, since no one volunteers for this job, the task comes to me, the only surgeon there. I’ve never understood the logic of this decision, since I’m not trained in cutting poultry. Even so, I always get the honor of carving the Thanksgiving turkey.

When the family centerpiece is on the line, one can never be too choosy. But what if your life and not just your meal were at stake? If you had to find a good surgeon to operate on you or your family member, what criteria would you use and why? Would you verify the surgeon’s credentials and qualify his or her expertise? Or perhaps you’d contact the Office of Professional Misconduct to see what sort of complaints if any have been filed? Or perhaps you’d do all this and still feel unsure, what then? Many patients tell me that in these circumstances they’d go on their gut instincts. But before you do that, I’d like to offer up a few of my suggestions. They may not be the best advice nor will they be comparable with what you may have heard before. But just as there are many ways to carve a turkey, there are many ways to find a good surgeon. Use these to help bolster your due diligence, if needed.

A Good Surgeon Has Steady Hands

Just like any other technical skill, there is great variation from surgeon to surgeon. I’ve seen average appearing surgeons perform amazing dissections with rapid speed, almost like magic, and other technically skilled showman-like surgeons that take forever in the operating room. There are some surgeons that are not too good with their hands, but with patience and perseverance, they get the job done.

But you may say that surgery is different than plumbing or painting, and I’d agree. It’s truly a privilege for us surgeons to legally and ethically be allowed cut into another human being. But just as with any other profession, it takes a passion for what we do and a desire to constantly improve that ultimately matters most. Whether it’s surgery, or painting, technique is a learned skill, which can be obtained by just about any one. Many are master technicians, whereas some go beyond the technique, becoming talented artists. But first and foremost, the surgeon’s clinical judgment is paramount, more important than any surgical skill they may possess. The best surgeons are ultimately the ones that know when and when not to operate.

One word of wisdom that I learned from one of my mentors is that how quickly and safely a surgeon moves through a surgical procedure is not determined by how fast the surgeon operates. In fact, it’s how good the first assistant is that determines the final outcome. Imagine if you are the captain of a battleship. Could you win a battle if you simultaneously steered the ship, loaded the cannons, looked for the enemy, aimed the guns and called out the orders? A good captain delegates, letting others push the buttons, pull the levers, and turn the steering wheel, while he or she makes critical decisions, thinking ahead and preventing any adverse outcomes.

Whenever I have a good resident as a first assistant, the procedure goes much more smoothly. During delicate or dangerous parts of the operation, I do the procedure myself, but for routine parts, I sometimes first assist, and the operation proceeds faster. Sometimes I just call out, "cut here…tie there, retract here…" Other surgeons are so in tune with co-surgeons that such verbal instruction becomes unnecessary. One just anticipates what the other surgeon is going to do. Having a good scrub nurse participate in this sort of intricate dance is truly a pleasure.

The Best Surgeons Operate The Most

It is true that practice makes perfect. On the other hand, practice without improvement will have the same results. As Albert Einstein once said: “The definition of insanity is doing the same thing over and over again and expecting different results”. Without learning from your mistakes and making positive changes, doing thousands of procedures will not make one a better surgeon with better outcomes. Similarly, there is a wide range of surgeons who have performed high volumes of procedures that have vastly different outcomes and complication rates.

Conversely, there are some surgeons that have performed very few numbers and are very good at what they do. This may sound overly simplistic, but I see surgery like being an elevator operator. Suppose an elevator operator worked 15 years pushing the buttons to various floors, but for some reason, was never asked to go to the 23rd floor. One day you get on this elevator and ask to go to the 23rd floor. Would you wonder whether he or not he was able to get you to the designated floor? Would you question his ability to push the right button since he’s never had the chance to push the button to the 23rd floor in the past? What would concern you most? Her ability and experience in pressing a button for the first time, or getting you to the 23rd floor?

In selecting the right surgeon, the other major variable is the patient. Humans are not like computers where one hard drive is just like any other. Every patient is different. One can perform the same exact procedure from a technical standpoint on ten different patients and get two to three different results.

So if a patient were to ask me how many of a particular surgery I’ve done, I really should be answering, "zero.” Since every patient is different and every surgery is vastly different, I never operate the same way twice. In this way, surgeons’ skills can’t be defined by the number of procedures they’ve done.

A Good Surgeon Is Complicated

Complications are a fact of life as a surgeon. But there’s so much variation in terms of the complexity of cases amongst surgeons that it’s hard to make any sort of generalization. A world-renown expert who performs a rare or risky procedure will have a higher complication rate, whereas a technically weak or insecure surgeon will only choose low-risk cases and therefore exhibit a seemingly “low complication rate”. The dilemma here is that if the surgeon has never had a complication similar to the one that you may have, then will she be able to handle it if it occurs? You want someone who has done a moderate number of procedures but has had enough complications to be able to manage yours, if in the case it should arise.

A Good Surgeon Is The Captain of The Team

I’ve been taught during training that as the surgeon, I should be "in charge" and take control of whatever crisis situation arises. In many situations, particularly with airway emergencies, other doctors yield to ENT doctors for management, but in a routine procedure, the best way to work is as part of a team. In my hospital (a teaching hospital) there is usually a scrub nurse, a circulating nurse, an anesthesiologist, and one or two resident or medical student assistants. The surgeon, although responsible for the patient’s welfare, should also get along well with others to set a good "tone" and working environment in the operating room for better teamwork and ultimately, better outcomes.

Good Surgeons Have Big Egos

It’s only natural that someone that saves lives day after day might feel a little special or privileged. I’m reminded of a scene from a movie (which I can’t remember) where a cardiothoracic surgeon proclaims, "I am God", in reference to his lifesaving skills. In real life, there are some colorful surgeons. Some just huff and puff and are harmless, and others can be abrasive and abusive, especially when in the operating room. I’ve overheard many surgeons cursing out their residents, sometimes in front of patients. When I was a surgical intern, I even overheard my chief resident tell another senior resident, "There are two ways to lead: by gaining respect, and by instilling fear. I lead by fear".                                                                                                                                                            

The worst situation is when a surgeon loses his or her cool when things start to go wrong during a procedure. Like in the TV show ER, the monitors start blinking and beeping, and anesthesia is nervously telling you some bad news. Usually in our field it’s some sort of airway problem, where the breathing tube can’t be placed inside the windpipe, or it becomes dislodged. The best surgeons that I remember during my training had "grace under pressure". Those that don’t have this will begin to panic, yelling out multiple orders and creating havoc in the operating room, ultimately to the detriment of the patient and the team.

The vast majority of surgeons that I know are kind, humble, respectful and keep their tempers under control when things go wrong. But as with any profession, there are bound to be some insecure people who take their frustrations out on others. Ask yourself, "Do I want to have a surgeon like this operate on me, no matter how technically skilled he is? You may need to do a little asking around, but try talking to people who work in the operating room along with the surgeon (nurses, OR technicians, nursing assistant, etc.). You may get some interesting answers.

A Good Surgeon Is Rich

It depends. Successful cosmetic surgeons do very well. Most surgeons make a decent amount of money, but there is such a wide variation that it’s hard to say what a decent amount is. One thing for sure is that if the surgeon takes insurances, he or she’s probably struggling to get paid from the insurance companies just like all doctors. From my personal experience and from what I hear from other colleagues, many insurance companies routinely delay or deny payment automatically, asking for more paperwork or not paying altogether. So unless the doctor’s office has top-notch billing and claims staff that can stay on top of these denials, most surgeons likely lose money in most cases. Add to this the fact with the volume of paper work that’s needed to get a claim paid, it’s less cost effective to take a patient to the operating room.

In other words, a typical surgeon can “lose” money by taking patients to the operating room. This is happening in otolaryngology and some other fields as well. With some insurance companies paying less than $200 for a tonsillectomy, which takes about one hour in the operating room along with all the risks and postoperative care involved, some surgeons have opted to cut back on recommending procedures in the operating room. As a result, I have seen situations where a child that obviously needed a tonsillectomy was told he would outgrow it with time. As you can see, there are some pros and cons to choosing a surgeon simply based on his or her financial status.

Surgeons Can Carve Turkeys

I’ll let my family decide this Thanksgiving. On an interesting historical note, the first surgeons were barbers (read Those Good Old Days of Surgery on page 6). Using this logic, that would make me a good haircutter as well. I tried this a few times on my children many years ago. Needless to say, it didn’t work out too well. But with a little training and practice…

Being a surgeon myself, I admit that the 7 traits mentioned above are somewhat biased. But these are the considerations that I use when I choose a surgeon for my own family members.

For most people, the decision on how to choose the right surgeon is a difficult one. Chances are, if you were referred by your doctor, the surgeon you were referred to probably passes all the criteria on the list that you got from WebMD or your newspaper article on how to choose the right surgeon. Realistically, you’ll go to the surgeon that your doctor recommends, as long as he or she takes your insurance. How many of you will shop around and interview 3-4 doctors for your sinus surgery? Very few people have the time or the energy to even get a second opinion. Even when a second opinion is obtained, for most routine procedures, the second surgeon will usually concur. Ultimately it comes down to trust. You trust that your medical doctor sent you to someone that she trusts, and that once you develop a trusting relationship with your surgeon, you’ll most likely go ahead with the surgical recommendation, assuming it’s necessary. You trust that even if something goes wrong, he will do the right thing. At this point, the number of procedures, number of years in practice, or board certification, all become secondary.

When I had a major hand infection many years ago, and faced the possibility of surgery on my hand, the last thing on my mind was how many he’s done, or if he’s qualified to do the procedure. In my mind, I was thinking, "Can I trust him to do a good job?" Instead of asking him how many times he performed this procedure, I placed my hand (and my career) in his hands, and decided to trust him entirely.

I’m reminded of the old Smith-Barney commercial, "where the relationship is everything." This applies to medicine and surgery as well. Most doctor-patient relationships last longer than many marriages. If you don’t feel comfortable with your surgeon on the initial visit, either because of his demeanor, choice of words, or office staff, find someone that you’ll be comfortable with. If there’s a flashing red light going off in your head, take notice. Malcolm Gladwell, in his book, Blink talks about thin-slicing, which he describes as an immediate, innate gut feeling or intuitive sense that can’t be easily verbalized. It goes without saying that surgeons can be thin-sliced as well.

 

Ear Mystery, Solved

In many cases, taking a good history and asking some pointed questions can solve a medical problem without resorting to medications. For example, I saw a man in his late 30’s who came to see me with 3 days of left ear sound distortion and reverberation with mild fullness. He had no other problems, including hearing loss. His exam was completely normal. Most doctors at this point will give a diagnosis of Eustachian tube dysfunction, where due to mild nasal inflammation, the tube that connects to the ear is partially blocked, leading to pressure changes that can cause ear problems. Many patients will walk out the door with prescription allergy mediations or over-the-counter decongestants.

After going through my standard list of questions addressing what changes or lifestyle issues that he’s been going through, it turns out that his wife delivered their first child 2 weeks ago. Obviously, this can be detrimental to sleep. Upon further probing, he admitted to working later the last few days, coming home late, and eating just before going to bed. He also had some alcohol late at night as well. To top it off, he normally likes to sleep on his left side.

 

The history alone solved the puzzle: He normally likes to sleep on his side to partially compensate for his tongue falling back during deep sleep (due to muscle relaxation). When he ate late the last few days, every time he stops breathing even temporarily he sucks up small amounts of stomach juices into his throat, and since he’s lying on his left side, it can easily travel to his left Eustachian tube, causing mild swelling and partial blockage. He also noted afterwards that he has post-nasal drip and mild throat clearing, which is consistent with reflux in the throat.

 

He was advised to eat dinner much earlier and avoid alcohol close to bedtime. This should be a life-long habit. Another great example of using my sleep-breathing paradigm to solve a medical problem without the need to give to medications.

 

 

Surgery For Insomnia?

I’ve been holding off saying this until now, but, "I told you so." In my recently published, book, Sleep, Interrupted, I proposed that many people with insomnia may actually have a mild sleep-breathing disorder due to very narrow breathing passageways which worsen in deep sleep. Inefficient sleep sets off a low-grade stress response which stimulates the nervous system, preventing the insomniac’s mind from calming down before going to bed. In this month’s issue of Sleep, Dr. Guilleminault and colleagues reported on a study where they took patients who have both insomnia and mild sleep breathing problems, and randomized them into either a surgical arm (to treat the sleep-breathing problem) or to cognitive behavioral therapy (CBT). Based on subjective questionnaires, people who underwent surgical management rated much better in their insomnia scores than people who underwent CBT, although the CBP scores did improve to what was considered "normal.". The researchers went further and crossed over each group into the other, and the effects were additive.

I realize that they didn’t choose purely insomniacs, but their premise in designing the study was to determine how to approach someone with both insomnia and a mild sleep-breathing disorder. They also noted that most patients who have mild sleep-breathing problems also have insomnia, are women, and are thin and don’t fit the typical sleep apnea profile. 

This study is one more in the daily to weekly studies that are published that only serves to strengthen the sleep-breathing paradigm that I describe in my book. I realize it’s controversial to say that most of insomnia is actually a breathing issue, but take a look at all the studies that show that having insomnia places you at a higher risk for developing depression, diabetes, and heart disease later in life—all complications of obstructive sleep apnea. Of course CBT is still very useful and should be recommended much more often than offered currently. In addition, good sleep hygiene is still the gold standard and must be tried first. Unfortunately, our medical establishment’s obsession to search for the magic bullet to insomniacs to sleep better without all the side effects will dominate treatment recommendations for years to come.

Copyright © 2008 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent