Episode 142: UARS: The Hidden Sleep Condition with Dr. Steven Y. Park, MD

Hi and welcome to episode 142 of the Untethered podcast. Today we have Dr. Steven park joining us. Dr. Park is a board certified ENT surgeon and sleep doctor, blogger, podcaster and author of the Amazon bestseller Sleep Interrupted. A physician reveals the number one reason why so many of us are sick and tired. His passion is to empower people with chronic health conditions to breathe better, sleep better, think better and thrive in life with much more Energy. After 23 years in private practice in academia, he recently left practicing medicine to focus full time on his mission through his online holistic wellness model to reach and serve as many people as possible. Quick Disclaimer all information, content and material of this podcast are the opinions of the speakers and is for the informational purpose only and not intended to serve as a substitute for the consultation, diagnosis and or medical treatment of a qualified healthcare provider. Welcome to the Untethered Podcast. I am your host, Hallie Balkan.

I'm.

I'm a certified orofacial myologist, feeding specialist and mentor. This podcast is all about getting your questions answered and collaborating with colleagues to bring you the most up to date information in the orofacial myofunctional therapy, tethered oral tissue and airway space. I challenge you to keep an open mind and join my mission to get this information out to the masses. Let's get started. Steve, thank you so much for joining me on the podcast today. I know we're going to talk all about UARS and some other fun topics, but I'm really excited, excited to have you here.

Thanks for inviting me Hallie. Really looking forward to it.

Yeah, let's jump right on in. I know everybody's got a story and I would love to hear about your personal journey as it relates to uars. Upper Airway Resistance Syndrome.

So growing up as a child and as a young adult, I was always falling asleep in classes, lectures. Everyone made fun of me and I just kind of just. Luckily in medical school it was much easier because I was running around all the time and not sleeping at all. And then surgical residency was the same thing. Just didn't sleep and just always constantly on the go. But even in the lectures during medical school and residency, I just could not stay awake. I just thought, well that's the way it is. And when I went to practice I came across this article by Dr. Christian Gimonot. You may have heard of him, very sleep medicine pioneer at Stanford. He passed away a couple of years ago, but he wrote a paper called Upper Airway Resistance Syndrome or a variation of that Title which described me exactly. He studied a bunch of young, thin, healthy looking men and women who are tired and fatigue all the time, but did not have sleep apnea. On the sleep test, what he did was he put an esophageal pressure catheter through the nose into the esophagus to measure pressure in the chest cavity. What he found was that even though they're not having apneas, these inspiratory efforts are leading to lower and lower pressures, at which point the brain waves kept waking up, fragmented sleep, causing deep sleep fragmentation, which is what was leading to these symptoms.

I mean, that's me too. So I've been there, I've had mostly home sleep tests and it all comes back fine. And I'm over here going, well, why am I waking up so exhausted? And it was so interesting too because I made it through school with great grades until I got to college. And I really struggled my first semester in college. And so my parents took me to get tested for adhd and sure enough they're like, well, you have a really high iq, but you're highly distractible. And you know, on the test you, you're a candidate for ritalin. So at 19 they put me on Ritalin and my grades, they were great. And I was like, what gives? Why are other people able to take my notes from class and not attend class and get straight A on the test? But I got a C. They were my notes and I know the answers two weeks later, but I didn't know them on the test. I haven't looked at this material in two weeks. Like I was very confused. And you know, I go along my personal journey to later find out that I was that traditional UARS case and orthodontic relapse. I had upper and lower permanent lingual bars placed on the back of my teeth following braces and invisalign and all the things expansion and. But I wasn't expanded enough. I was, my palate needed to be grown forward and you know, I needed further expansion and so I've done that since. But it's, you know, I'm still in my airway journey too. I still have to deal with the nose. But it's interesting because when I say uars, most people have never heard of it. So do you get like a lot? I know that when you're working with patients, like did you get a lot of patients who had never heard of that and how would you explain it to them?

So patients and most doctors have never heard of it and even most sleep doctors Dismiss it, because gold standard is a sleep study, and if you don't meet that cutoff of five, you don't have sleep apnea. Despite the evidence showing that even young, thin women that don't snore can still have severe sleep apnea, but they still have this mental image of the older, heavy, stats wearing man with a big neck that snores. And even then they miss. They don't question whether or not they have sleep apnea. They just put them on medications or whatever. So it's really frustrating. And I thought I could just make some headway with my colleagues in medicine. And that's why I went in from private practice to academia about 10 years ago. And there's no budgeting whatsoever. Most of my research studies and publications were against the grain, and fortunately I got some published. But most of the time the argument was, well, this can't happen, so it's not worth publishing.

That's so frustrating to not even be able to have an open conversation with your own colleagues and people in related spaces that, you know, we see this all the time in our patients, but we can't diagnose it as speech pathologists and myofunctional therapists and, you know, like, we can obviously identify the need to refer onward, but it's very hard to find sleep doctors or ENTs who can appreciate that even if you don't fall on the typical sleep apnea, you know, within those numbers that diagnose you with sleep apnea, then there could also be uars at play along with mild sleep apnea. I mean, we. I get so many adult patients back to my practice and they go, oh, it's just mild sleep apnea. You're fine. And we're like, what? I know that Christian Guilleman never intended. I've heard, you know him say he never intended for mild to be dismissed. Mild was still a problem. And unfortunately, it's not always treated as such. So, yeah, it's. It's an interesting topic for sure.

Yeah. And now, fortunately, the group of practitioners that have the most knowledge of this is actually dentists, because they're in the mouth all the time. And there's a lot more dentists that are much more aware of these concepts. Not everyone, but there's a growing trend now in the last five, 10 years, and they're much more aware of the more subtle differences. So they're like the first line doctors along with you guys to kind of see what's going on before it turns into something much bigger. And then you have to see A doctor for that reason. And so that's why this is such an important topic to talk about and create more awareness among the general public. That's why I jumped ship and started to promote this to the general public as both to try to convince my colleagues.

Yeah, and I love that. I know we were talking for a brief moment before we recorded and I was talking about how stepping away from personally treating at the moment to go on and educate on a larger scale so that we can reach more patients at exponential levels. It's, you know, it's not easy work, but it's really rewarding work. And it's really, I think, an exciting time to be in this space because it's so needed and to see so many clinicians and even dentists. I've seen a ton of dentists come forward. Like you were mentioning, we work with a lot of airway centric dentists, as we like to call them. And it's, you know, if we can't, unfortunately, in the dmv, we have a really hard time getting ents on board to further the discussion and further help our patients. But we found that a lot of our airway centric dental colleagues are really at the forefront this. And sometimes we can work around, you know, having to pull ENT in and just go to the airway centric dentist, which I hate to say because I really wish that our ENTs would take a better look at this, but that's a whole other conversation for another day.

It's really frustrating for me because I, ever since I quit, I get probably five or ten questions a day asking, who can I go to see? Yeah, honestly, I, I mean, I'm sure they're out there. I just don't know of any personally. Especially in the tri state area in New York.

Right, right. It's a huge problem. It's a huge issue. I know there's like a couple token ents in the United States of America that I know that we can definitely refer to and trust, but none of them happen to be within the DMV either. There's some that are, I think, more airway focused in the way that we're airway focused. And I was talking to another ENT on the podcast recently who is more in this space, and he said, I really don't like that whole airway centric term for like, from an ENT standpoint. Like, I'm like, yeah, because ENTs should be airway centric by definition of what you all do. So it was, yeah, it was a very interesting enlightening conversation around that.

I can see why he would be against that term because by definition we ents are airway centric.

Right. That's what you do.

You're missing an important aspect of the airway when you're sleeping.

Right, right. Yeah, yeah. So let's talk a little bit more about uars, because I think it's a really. I think we're going to have a lot of listeners, whether they're parents of young children and they're the children, possibly they need to be checked for this, or the parents themselves, which always happens, and. Or the providers, the professionals listen to the podcast. You know, I know everyone's going to ask me, like, well, what causes uars? Like, how do we know someone might have UARS versus sleep apnea, aside from a sleep study? Cause I know like, as myofunctional therapists, we can look in the throat, we can see if the tonsils are enlarged, and maybe that's a red flag to refer them onward. Obviously we can't visualize the adenoids without sending them onward for a scan or a scope. But what causes UARs and what are some of the things that you recommend people look for?

So let's step back a little bit and talk about the big picture. And this is what I talk about in my book, that modern human faces have been shrinking over the past couple of decades, accelerating in last even 10, 15 years. And we go back thousands of years ago, but because of a change in our diets and what kind of foods we eat, our bites have changed with our teeth. So agriculture going from hunter gathering societies to farming communities eating more processed foods, grains, those kind of things. So softer diets in general. So that shifted our jaws. And then there was a really interesting book I just came across called Consider the Fork by B. Wilson. And she talked about culinary tools over the centuries of how people use tools to eat. And there's one really fascinating chapter about knives. And she pointed out this anthropologist named, I think, Loring Brace. Yeah, Bracelet. And he looked at thousands of skulls in England and China. And what he discovered was that up until recently, humans had edge to edge bites. So the front teeth met together like this. But modern humans have an overbite that started when these people started to eat with utensils and cut with knives. So it's interesting that in England, the rich people, the aristocracy had access to the knives, so they had to overbite first. And then the peasants came last. Same thing in China.

I mean, that's so interesting. I love hearing about this because I Really, I mean, you can, you really come to appreciate evolution and how we got from where we were to where we are today. And I've heard this conversation around shrinking skulls. I know that there's some research being done on this too, looking at prehistoric skulls versus, you know, where we are today. And you can, you can see it, I mean, it's very obvious when you look at the actual prehistoric skulls to see, see the bite change and just the skulls in general shrinking. Do you feel like that is one of the primary reasons for UARs?

Right. That was the main point of my book. But it's scary that it's happened. It's even accelerating even more in the last 50 years. So we just did a study, waiting for answer from publication. We looked at 13,000 college yearbook faces from 1930s to now, and we analyzed width to height ratios. And not too surprisingly, modern faces are much more narrow and taller. That's why people have these more triangular, longer faces and the jaws are more narrow, the smiles are not as good looking. If you look at These people from 1930s, these movie stars, they look like aliens because they have these wide jaws and just perfect smiles. It's really shocking how quickly it's happened in the past 50 years. But a lot of these concepts, I didn't invent this, I didn't discover this. A lot of my ideas came from dentists before me, like Dr. Wesson Price, I'm sure you're familiar with him, who traveled the world in 1930s, looked at these indigenous cultures throughout all five continents. And as long as they ate off the land, ocean and mountains, they had perfect teeth and no cavities and they're healthy. And then as they adopt western diets, they got much sicker health, more prone to infectious diseases, more cavities. And so there's a lot of points along the line that contributed to my understanding. But the biggest paper that kind of had this eureka moment for me was paper by Dr. Terence Davidson, his ENT. He wrote this paper on the forgotten the title. Basically it's the evolutionary reasons for developing sleep apnea because we can talk. Speech and language development, unprotected upper airway. I don't have the diagrams here, but basically during development, the hip voice box. If this is a tongue right here and the voice box is here, in chimpanzees it's behind the tongue, whereas in humans it's below the tongue. It's called laryngeal descent. You need learned this descent to create a true oral pharynx, the gap between the soft palate and the epiglottis. So that allows for complex speech language development, but also unprotected the airway. So that's why only humans have these choking and swallowing problems that animals don't have.

Interesting. I never knew that. That's really fascinating.

So then, and we accommodated, right, Language, culture, civilizations. But then as it jaws get even smaller and smaller, now it's starting to cause problems.

I mean that makes a lot of sense. It's very fascinating. As a speech language pathologist, I can really appreciate the difference in anatomy and the laryngeal descent. It's really, it makes sense. But yeah, we do also as a speech language pathologist, I work, my team works with a lot of babies and we work with a lot of these babies who are born sometimes with tethered oral tissues, who are born with narrow palates. So it's happening in utero. Right. So it's that trickle down effective epigenetics and just something that I think is not talked about enough because these babies that we're seeing, they're coughing, they're gagging, they're, you know, everyone's saying, oh, they have a sensory processing disorder. Why, why are they in fight and flight? What fight or flight? Why is their airway. Why can't they protect their airways like this other infant over here can? Why? You know, so it just, it's very fascinating when we start to like look back to where these, you know, not look back, but look at the babies that are being born right now in 2021 and even my own daughter was born. Both my kids were born with tongue and lip and we, I didn't know about my first daughters until she was 24 months. I got turned away a couple ents. She also had like 3 plus tonsils at ENT. Said he was unimpressed by them. I was like, I am very impressed by those, you know, I'm like, I'm not saying I want them taken out. I just want to know what, what can we do? Like how do we open her airway better? And there was no scan of her adenoids at the time. And anyways she ended up going into early expansion and had a tongue tie release. Tongue tie release at 24 months. Expansion around age 4, which was early at that time. And now I would like to see it even earlier now. And her tonsils just shrunk down as we opened her airway about like three months during. And when I, it was interesting because I posted this in a orofacial myofunctional group on Facebook and I was told to delete the post. I was like, they jumped down my throat. What have to say that as a mother or orofacial myologist or slp, there is no research to support this. And I'm like, I'm just anecdotally telling you what happened in my daughter's. I didn't say. I didn't make a blatant statement or claim about everybody. I'm like, but wouldn't it make sense that soft tissue would change in response to heart tissue movement? I just think this warrants a conversation.

Actually, there is evidence. There's a study many years ago showing that they looked at kids with sleep apnea with large tonsils, and they split it into two groups. One group got tonsillectomy, the other group got palatal expansion. At the end, the results were equivalent.

Interesting. Well, I not study. Yeah, I know that there's also been a head doctor Tracy Tran on the podcast who. I don't know if you're familiar with her, but she's a pediatric dentist out in the LA area. And she just told me about some research that was being done right now too, that I think it's a case study. But it was showing this. It was showing that the increase in airway in response to palatal expansion, early intervention, and decrease in some of these enlarged soft tissues. And I was like, oh, thank goodness. I feel like when you have an older study, everyone's so quick to dismiss it. When you have a case study, everybody's so quick to dismiss that. And I'm over here going like, look, guys, I mean, evidence based practice includes everything from the clinical evidence to our experience to the patient's goals and values and experience. And why are we dismissive of information that's so helpful to other patients? It's so frustrating.

It's. That's really shocking to hear about your experience with your journal. That reminds me of. There was a woman that introduced me to my official therapy. Her name is Janet Bennett. She's been on the Internet for two decades promoting tongue exercises for snoring. And she's also a speech and swallow therapist and she has an online program and her state medical board tried to ban her. Basically, she was in a fight to keep her license.

Wow. Wow. You know, it's so.

It's just.

It's sad at the end of the day. I mean, we're here helping patients and there's so much that myofunctional therapy has been proven to help reduce snoring, get the tongue in the right place. Yeah, it's sad and frustrating. I know it's an uphill battle and I'm here for it. I'm not here for the truth Journey. But, you know, that was also what prompted me to get online and I started looking for a myofunctional podcast. I was like, there's got to be a podcast on Airway orofacial myology tethered oral tissues. And there wasn't. Back in like middle of 2019, I just couldn't find something that combined those topics. And so I started the podcast then because I was like, well, someone else is not going to talk about it. Clearly, I have to. So here we are. Here we are two years later. But now it's been really interesting because it's also been a great opportunity to connect me with families who are trying to find help. And I've now been able to also go back to a lot of groups online and say, hey, I have a family here. Who can we refer them to? And whether it's an ENT or a dentist or speech pathologist, myofunctional therapist, you know, we've. We've been able to connect hundreds of families just through DMs on Instagram and Facebook and sort of my, my passion project that, you know, I invite everybody if you can't find a provider like DM me and I will put messages out to where I can. And, you know, and I will say 90% of the time we're able to find them somebody who is in the airway centric, myo, airway tot space. They also do pediatric feeding. So sometimes there are little ones under the age of four who aren't really MYO ready. And, you know, in my program, I do teach MYO and TOTS and how that can be adapted. And, you know, how we can work with birth to four, because I don't think we should be waiting. That's the other thing that's so frustrating is, you know, I've been told as a mom, oh, just wait till she's older. I'm like, no, why would I wait till she's older? When we have an issue now and when, you know, I know there's research out there too, that shows that some children with obstructive sleep apnea, and I don't know if it's just sleep apnea, I think it is obstructive, but that they have IQs that are, depending on the paper, it says anywhere between 10 to 16 points lower than their same age peers just because of their sleep quality. You know, are you Familiar with some of those papers as well.

I'm sure there are dozens of articles like that. I stopped counting those kind of articles because you can link sleep apnea to almost anything. And there's tons of studies about kids and development. And let me actually just mention one thing that I think you may find interesting. So are you aware of the Back to Sleep campaign that was started in 1980s to prevent SIDS? So it's kind of a complicated history, but basically they studied thousands of thousands of babies who died of SIDS and came to conclusion that sleeping on the stomach was bad to increase the risk of sids. But they also had other risk factors like smoking, loose bedding, some other variables to allergies, co sleeping, those kind of things. But they picked just the sleeping on the stomach. They recommended keeping babies on their backs for the first year of life. Now, when they started that, it lowered the SIDS rate by like 40% or 50%, so it's considered successful. But then we started to see all these developmental delays. Kids couldn't lift their heads. They had delays coordinating mental abilities. It makes sense because if you take a normal, healthy infant and keep them on their stomach and they sleep well and you put them on the back, you go into a lighter state of sleep, and so you're sleep depriving all these babies to save. I know obviously one death is too many, but to save 40% of SIDS cases was like a couple thousand a year. And I think that kind of elevated everything to be much worse a couple of decades ago.

Interesting. Yeah. This is actually a topic that. We've talked about it a couple times on the podcast way back when. And I've always said, look, I'm not a pediatrician, I didn't do the research, so I might be stepping out of line here, but I don't think that babies sleeping on their backs is necessarily a healthy thing to promote for several reasons. Right. If we have babies with airways that could potentially be collapsing on themselves when they're laying back, you know, babies with tongue ties, where the tongue is falling back into the airway babies, I'm like, we could just go on with a list of different examples of. I've seen some of these babies in my own included. So my daughters with their tongue ties, my first one had an extremely tight neck at birth. They could both hold their heads up at birth. You know, I was like, that's not. That's not so typical. They were very tight. And, you know, my first daughter, she as early as she could flip herself over, you know, A couple months. Like, she wasn't even. She wasn't even a couple months yet. Flipped herself over onto her belly while she was sleeping. And I was like. Like, as a new mom, I was like, oh, my gosh, she's supposed to sleep on her back. She would not stay there. And I was like, well, I'm not gonna fight it, because physically, for some reason, she is flipping herself onto her belly, and if that's where she needs to be, that's where she needs to be. And she was that child who slept with her, like, butt up in the air like that tripod, you know? And I was like, you know, now I look back and I'm like, I think she was opening up her own airway. Honestly, I think that's why she was positioning that way. So have you. Is there any merit to that? Because we talk about tripod sleep and how we should look into airway if we're doing that.

That's a classic sign of a sleep breathing problem. They're compensating, but the problem is that it's not good enough. It helps significantly, but it's not good enough.

Yeah. Yeah. And she was 24 months before I finally. So I took my Mayo course. I learned from Sandra Holtzman and Becky Ellsworth. I come back and I. I'm like, okay, I have to look at. I have to assess every child in my caseload. I'm just going to offer free evaluations in the next appointment. I'm just going to do it for every child, because I can't. Not now. But I went home and I flipped her over, and we were no longer breastfeeding at this point because while we did it for 13 months, it was extremely painful. She was always first percent on the growth curve, but she was on her own growth curve, so she was fine. Even though they marked her failure to thrive. She lost too much weight in the hospital. I mean, she fed around the clock. She wouldn't take a bottle. For my nanny, I only went back to work two part days a week treating, because I was like, my baby won't eat, and I own the practice, so I have the flexibility, thankfully, to do that. But she. It was just amazing to see overnight changes in her body. She had that tongue tie released. I took her to an oral surgeon that was highly well known in my area and who now has done many releases on our patients who need them. And the next day, you could just see her whole body just relax. And it was like. It was fascinating because we had not done any other body work or anything between that appointment. When I saw that her constipation went away the next day, I had no idea. I was like, hold on. And it hasn't come back. And she's six now. And I'm like, this is. We really struggled with that. And I refused to put her on Miralax because I was too, woo woo, holistic, crunchy mama who was like, no, we're going to deal with this in the natural way. We're not going to put a medication in you to solve a problem when I think this is caused by another problem. But it was just, it really opened up my eyes because when I started putting all the pieces to the puzzle, I went, huh? I used to work with children with autism, and a lot of them struggled with bowel movements, a lot of them. And they were the reason why I even got into the feeding space and became specialized in pediatric feeding because they all ate the same diet. They all, you know, they, they had a lot of similar mannerisms. And I think it has nothing to do with their diagnosis. I think it had a lot to do with a lot of the underlying etiologies that led to the diagnosis. And, and it's just been, you know, that's a whole other conversation. But they really opened up my eyes to kind of wanting to figure out the root cause of why they're eating the way they're eating, because it makes sense. They're constipated. I mean, one, they don't chew their food properly. Two, they're eating bland colored foods. They're not eating anything colorful. They're not eating anything really of much nutritious value most of the time. So, yeah, it. Just being able to come back, look at my own daughter, have these results, go back and work with my patients. You know, it changed the way I do therapy. It's totally changed the way I practice. And some of these kids who'd been on caseloads for a very long time were dismissed six months later because we took a different approach and we opened up our eyes to a different way of looking at things and getting down to the root cause. And it was, it was really like, it was life changing for me.

It seems like these kids with feeding difficulties is not just in kids with autism, but across the board. I mean, I can count at least five or six children in my neighborhood that have feeding difficulties. Young children. It's almost normal now to have some developmental problem.

Yeah, it's a very interesting state of affairs. So we look at these kiddos who parents often come to us as speech pathologists. One, either because the child has cut out so many foods, they're down to less than 20 and they're nervous that they're going to keep cutting more out, or they get to us when they have less than 10 or even less than five foods that they accept and the parents like really panicked, or they come to us because a child's speech is really hard to understand. And we take in either case, we look in their mouths, we do intraoral assessments, we do extraoral assessments, we look at full body, we collaborate with other providers. And I mean, most of the time, a lot of these kids, especially when it's an absence of a syndrome, a lot of these children that are otherwise typically developing, they were born with OMDs, they were born with orofacial myofunctional disorders. Their teeth came in and their teeth are a mess. They have malocclusion from eruption of teeth. It's just, we start to look at things from a structural standpoint and then we go, oh, well, it makes sense that their soft tissue's a mess because their bone isn't in the right place. It's really been, it's been an interesting journey. But yes, I will say a lot of these kiddos, unfortunately, presenting the way that they do, that's also what pushed me into going, hey, nobody's really talking about or teaching Mayo. As it applies to like infants, toddlers and preschoolers. We can't be waiting until they're four years of age. That drives me insane. And we, in my practice, we were working with these kids regardless of age, because we're speech pathologists and occupational therapists and we can. And so I basically said, let's take these, the goals of Mayo and apply it to our babies and our toddlers. And when we started to do that, and we still use more traditional oral motor interventions, which is sometimes more of a passive intervention initially, especially on our younger ones, than like, MYO is obviously a volitional type of exercise and you need to have a cognitive level of a four year old to really fully understand how to engage in traditional MYO program. It was just very, it was very fascinating to see the changes that we were able to make in these infants and toddlers lives and hopefully for some of them, put them on track to not need therapy down the road. That's really the end goal. And getting some of them into early expansion in their late toddler years versus waiting until they're 6 to 9 or even in their teens. I mean, if we can do this now, why Are we waiting? Right. And that's the next step is finding the dentists who are willing to put an appliance in when they have their two year old molars come in. I'm like, we don't need a else, we just need to work on the palate.

Actually, I have a lot of dentists in our area that do that early expansion. And so I think that's a, it's a very, very good first step for these kids who kind of fit this mode. The other thing that I want to kind of point out is that we have a lot of options after you're born. And all these options, myofunctional therapy, the dentistry, ENT involvement, they all help when you combine everything together. And that will, I think honestly it'll help the vast majority of kids, but not everyone. And the problem is that your jaws are so small to begin with. No matter what you do, it's just not going to be enough. And especially with the expansion, like it says, expanding side to side, but it has less forward movement.

Right.

And so some people, I'm not recommending this, but some people will need jaw surgery later on just because it's so bad, because of just underdeveloped jaws to begin with or extract excessive extractions later on in life. Which is still happening.

Yeah. Yes, it is on our intakes and we just go, no, no. Yeah, that's. So my daughter went into an ALS appliance and I, you know, it really did a great job job for her maxilla. Thankfully, she does still have a little bit of a high palate, but she's not as narrow as she was. And at this point now we're looking into the next phase where we want to grow her, her mandible forward a little bit more because that's, you know, I was looking at her initially going like, okay, we think she's, she's good, she's great. And she really, she was in it from 4 to 5 and she's been able to hold that. She's, you know, she hasn't had any relapse and I'm monitoring closely. She went back into Maya with one of my therapists after her appliance was. And really because she still has a frontal lisp and we needed to address that. And so even though it sounds good, her speech sounds fine. You don't hear a lisp when she talks. But I see the tongue coming forward and I know too much. So I'm like, this is not okay, we have to correct this. But it's, I was Collaborating and speaking at a conference with Michael Gelb and Lane Martin and Lane. I had Lily in my presentation. And afterwards, you know, he didn't want to say anything. And I said, no, no, lay it on me. Tell me, like, what does she need? What do you think? And he said, I think she needs a lower lip bumper to bring her mandible forward a bit more. I said, fine, done. Who do I go to for that? So it is this really interesting space to be in right now, to be learning more and even to learn from you right now. And, you know, you've taught me a few new things today. And, you know, sometimes we do have those cases where we get in. We do all the things, and they still. They're still. Still a struggle. And we're going, okay, maybe it's just more time. Maybe we just need more time. We're going to follow the case. We're going to continue to try and figure out, put the pieces of the puzzle together here and bring in any necessary team members. But sometimes we still get those cases that they're tricky and it's hard. Yeah. So for those, let's go back to UARS a little bit. So just to delineate it a bit further. Right. Other than the sleep study scale, the sleep studies, are there other overt symptoms or ways that you can tell that somebody has UARS versus, let's say, sleep apnea, or is it hard to, like, differentiate?

Well, from a practical standpoint, you want to know whether or not you have sleep apnea versus urs, because if you have a sleep apnea diagnosis, then generally it's covered by insurance. The treatments are covered.

Okay.

So I know that that should not be the main reason, but for practical reasons, you have to do it. So if they have sleep apnea, then at least you have other options to look at, even though they're not all very good options. But at least we have some treatment options. But let's say that you come in with these various symptoms. The classic URS patients are a little bit different. They tend to be younger, thinner, a little bit more women than men. Like 65, 35. Most of the time, they'll be on the thin side. Low blood pressure, dizzy, lightheaded, headaches, migraines, anxiety, sinus problems, digestive issues, cold hands, cold feet. That's just the tip of the iceberg. Hypothyroidism, these somatic syndromes. Actually, I talk about this in my book. I saw this young woman who was very, very vibrant and healthy, and then over many years, she started to Become really tired and fatigued. Headaches, migraines, irritable bowel syndrome, cold hands and feet, low blood pressure, dizzy and lightheaded. She came in for sinus infections, but they were not sinus infections. They were repeated sinus migraines. I treated her just conventionally. It didn't get better. Then she said she wasn't sleeping well. So I ordered a sleep test and she had just mild sleep apnea, which didn't explain all her symptoms. So she tried CPAP and she tried the mouth guard to move the jaw forward. Didn't help. And she was begging me for surgery. But at that time I was not convinced that she needed surgeries. Just like any other ent, you only have mild sleep apnea. You don't fit the typical picture. So I kind of blew her off a little bit and she kept coming back, just begging for surgery. And I just started doing sleep apnea surgery. And I just read this article about a tongue based suspension operation. So I said, well, this is new technique to move the tongue for, because he has a small mouth. So we did the operation along with the palatoplasty. Six weeks later, actually three months later, her sleep study showed that it went from 13 to 0.2. So she was cured from a sleep apnea standpoint. But what was more surprising and shocking was that every other one of her symptoms were gone. Headaches, migraines, ibs, cold hands, low blood pressure, depression. She was a completely new person just by changing the anatomy. I know that's an extreme example, but I have similar examples of children just stopping, just changing their diet alone. One six year old was bedwetting every night. He was having ice cream just before bedtime. So we stopped that and it went away.

Interesting. Yeah, I mean, I love this stuff. This stuff gets me excited because I think that food is absolutely the best medicine that we need to be looking at our diets, which so many are not willing to do. And I get it as a busy mom who runs two businesses and my husband works a lot too. You know, it's hard, it's hard to make gourmet custom meals for your family and your children. But I think our health and our livelihoods depend on it. And we need to make time to really feed our bodies properly and eliminate certain types of foods that are not so helpful too that cause a lot of inflammation in the body. I mean, I've learned myself. I've had a lactose intolerance for a long time, so I typically avoid dairy. I eliminated gluten about a year ago. And when I tried to add it back in this summer, this past summer, oh, my body was angry. It was not good. And I immediately took it back out and felt 100% better. But it's really interesting that you share these symptoms because I used to get dizzy spells, and they would be. I was sent to a whole bunch of different doctors. In the end, we thought it was related to, like, the birth control I was on. This was, like, back in my early 20s. I haven't taken that stuff since then. Like, I just. I don't like to take any medication. I have naturally low blood pressure. I have naturally. You know, it's like all the things you were saying. Like, my hands might get, you know, cold, my feet might get cold. But I don't. I don't test as a hypothyroid patient, even when they look at those additional markers. So I've always been, like, turned away as someone who's like, no, your thyroid's fine. But, yeah, the dizzy, the, you know, the ibs, the. All the things that I've pretty much learned I can manage from what I eat and, you know, But I do know I have a deviated septum. I've got, you know, turbulence that needs to be reduced. That's the next step in my journey. But beyond that, I had this bout of sinus issues at one point where, without fail, every spring and every fall, I would get diagnosed with a sinus, you know, with sinus issues, and they would put me on a Z pack, and then I would have to come back, and they put me on a second Z pack, and then I'd come back the third time. And this is, like, in the same season, right? And they put me on Augmentin. And so after three seasons of this, I finally was like, no, my body is resistant to Z Pak at this point. I'm not a doctor, but I'm telling you, it does nothing for me. Can you please go back and look at my chart and see that this is now the fourth time we're going to be going through this together in the last, like, spring, fall. Spring fall. And I'm not somebody. Normally I have dust mold, like, allergies, but, like, not horrible seasonal allergies otherwise. And so they put me on Augmentin that time, and that knocked it out, and it didn't come back after that, so I never really paid attention. I don't know. I don't know what that was. But when you just said, like, the sinus issues and that, you know, I don't have Anxiety, I don't have. Like, there's certain things that I don't completely fit that description. But, like, I check most of those boxes and I was like, oh, would you look at that? This has been. This has been going on for quite a long time, probably at least since high school, if I can think back to, you know, feeling these symptoms. And it's just, it's. It's interesting because nobody ever looked at my sleep. None of the specialists that I went to. I was tested for vertigo. I was tested for all kinds of things. But no, nobody ever wanted to look at my slee.

It's interesting you mentioned your experience with gluten. So I was. I'm not. I don't think I'm gluten sensitive. I mean, obviously I don't have celiac, but up until about five years ago, about four years ago, I was eating bread, gluten, still eating healthy. But then for my 50th birthday, I got a colonoscopy, and because that's what they recommended, after that, my gut just went crazy. I lost like 10 pounds.

Wow.

It just really messed up my gut. And then I became gluten sensitive, huh? Yeah. After colonoscopy and I asked my doctor about this, he had no idea what was going on. They never heard of it. I kept testing myself, going on and off. It was definitely gluten. So I went gluten free. And then my wife and I went on this complete health transformation with our diets or habits toxin elimination. I mean, we went all out. Yeah, we take our supplements regularly. And this past year, I think about a year ago, I noticed that my allergies, my spring and flow allergies were gone. I had really severe allergies. And so. And then I just happened to just start. I started making sourdough bread, which is a little bit safer for gluten sensitive people. No problem. So then I started to eat some bread with my sons and had no problem. So right now I'm not gluten sensitive anymore just because of a change in my diet.

Interesting. That's so fascinating. Yeah, I've seen. There's. Somebody turned me on to this, like, Instagram account. I think she's called, like the food nanny. And she has a farm and she makes all of her own food and she uses, like, spelt, I think, to make bread. So for a lot of people who have gluten issues, I think she's got different alternatives that you can use. And so I've looked at it. I'm like, that's Just so much work. I'm just not going to eat it. But it's fascinating because I'm like, clearly my gut is still angry. We're still in that anger state right now, and things need to change and be done. We moved and there is just a lot of changes in life and taking on way too much in both of my businesses at the moment. So I'm like, while we're hiring and I'm like, we're going to start to focus on getting everything back on track. But it's tricky, it's challenging. And we live in such a society where everything is like, go, go, go all the time. And it doesn't allow for us to turn inward and focus on ourselves and our health most of the time. And I refuse to be a part of that. You know, I'm not about that daily grind. I'm like, no, I really want daily peace. I want to be in a place of peace where I'm not running my kids from like one thing to the next thing all the time, because that also create that same daily grind concept for them. And so anyways, I go against the grain in a lot of places in my life that don't necessarily match up with many others, and that's okay. But I think that's also why I'm so open to so much of these discussions, UARs, these topics, and truly trying, you know, helping patients get to the bottom of it, connecting them with providers. I think that's where that passion comes from. Like, connect them with providers who are going to look at things differently. And if it doesn't fit the narrative that they know currently, are they open to having a different conversation and maybe figuring out what else we can do to help this patient? Even if it's not something we've done before, can we find somebody else who can help us? Can we read a few articles or just trial a few things, even if the science doesn't have anything to say about it yet? So, yeah, it seems like URS is so hard to identify, maybe also for lack of providers looking for it, but then also it's hard to treat. I mean, I feel like OSA had so many more documented treatments. Comparatively.

I'm being a little bit pessimistic, but having treated sleep apnea for many years, yes, we have some amazing results from treating sleep apnea, but overall, long term, it's somewhat disappointing. For example, I just did a blog post on the fact that if you use cpap, there's a statistically increased risk of weight gain.

Oh, excellent.

A lot of my patients commented on this blog post, they gained 10, 15, even 70 pounds using CPAP.

Okay. I have a family member who would fit that bill. So, yeah, okay, I just saw and I. I'm not as familiar with this appliance, but I know Vivos has an mmrna, which is their nighttime appliance, that just got approved for Medicare as an alternative treatment compared like, you know, to use in place, I guess, of a CPAP for some patients. Again, I don't know anything about it. I just saw them post and he got an email on this like two nights ago. And I was like, huh, okay, well, maybe this is progress in the right direction. If we can get Medicare to look at alternatives to cpap, this, this could open some doors. We could argue that other appliances should be covered as well for, you know, forward. And.

So the advancement devices are covered by Medicare and that's what the MRNA is. It's a combination DNA plus advancement.

Okay. So, yeah, I mean, I was like, I need to look further into this to see is it just advancing for sleep or are we also growing the palate with this appliance? That's what I was not.

It is the other. That's a pallo component. Yes. It's a hybrid of the PALO expander plus moving the lower jaw forward.

So glad I brought it up and that, you know. So you had mentioned there's a common condition that's usually missed by sleep doctors and ENTs that can mimic UARs. What is that?

So it's called. It's a fancy term called epiglottic laryngomalacia, meaning that your epiglottis, which is the top part of your voice box that covers your voice box behind your tongue. So if this is your tongue tipped like this, and the tongue goes down this way, the epiglottis looks like this at the base, and the voice box is right here behind the epiglottis. So as you breathe in, if the anatomy is not right, the epiglottis flops in like a valve. Typically, we see this quite often in young infants when they're first born because they can't breathe, they get to turn blue. And in general, in our field, we say that most kids outgrow it, and maybe they do, but my opinion is that they really never outgrow it, just morphs into something else.

Interesting.

And what I'm finding. Yeah, and so what's happening is that because the lower jaw is not developing fully, the hyoid bone, which sits right underneath your jaw, that's where the Epiglitis attaches to. And so if the hyoid is positioned more backwards, then the epigelitis goes more towards the back of the throat. And that suction effect from breathing, it just flops in whenever I do. I've done quite a number of surgeries on these kids. What I find is that the epigloss itself, the cartilage, is really, really weak and flimsy. So it's lost that structure, rigidity of structure of normal cartilage. So something is happening not just to our bones, but also our soft tissues.

Yeah, it's interesting and scary at the same time. I've worked with some of these babies and it's frustrating. I feel like I said that a lot today because they will often be told, oh, they'll grow out of it around 18 months. They just, we just got to make it to that 18 month part. And you know, that 18 month mark. And I'm over here going like, this is not helpful for a parent to think like, okay, as soon as we hit 18 months, like, my baby's going to be fine. Because more often than not, they're not. It's not actually changing. And a lot of these babies are continuing to struggle into toddlerhood. And so I am like, you know, as a feeding therapist, working with these children who they're very challenging babies to feed because their body's constantly in a state of fight or flight. They are just trying to protect their airway and, you know, it's impacting their swallow and then they're not getting enough nutrition or they are feeding and then half the feeds are coming up. You know, I've seen so many different presentations, but they are honestly probably one of the most challenging to feed.

Right. And ents in general, I mean, they know about it and we say that we treat it, but we really don't. And so it's hard to find ents that's willing to do sleep endoscopies, drug induced sleep endoscopy. And that's one of the better ways of diagnosing it. And I was shocked how often I saw that when I saw it in kids. Whenever I do any kind of procedure for kids, I do the endoscopy routinely. And a very high number of these kids have incidental epigolitic laryngomalacia.

And it's interesting to hear that you feel like it's not really resolving. They're probably learning to compensate and then it's snowballing into greater issues throughout life. For those who continue to have an issue with it is that, am I understanding that correctly?

Right. So when I say morphing, so like you said, if you don't treat it for 18 months, then you're going to increase your sleep deprivation. So they're not going to sleep well, so the brain's not going to develop properly. And then eventually the jaws do grow, so they grow out of it. But then they're already behind eight ball.

Yeah, yeah. Oh, goodness. These babies, like, so what do we do? What do we do? So do you recommend or. I mean, obviously you can't make recommendations for cases that are, that you're not treating or they're not sitting in front of you. But do most of these babies, like, would they benefit from a surgical procedure in infancy?

Is that, that's the only thing that I found that helps. Unfortunately, it's a little bit drastic and the thought of, I mean, the procedure itself is really simple, but just the concept of trimming the epiglottis or stiffening or modifying it, it's terrifying for parents. The biggest fear is that there's a risk of aspiration or coughing or swallowing problems. That may be true, although I haven't seen it in my series of patients. I think we did a review of 50 patients a couple of years ago. No long term complications. Now 5, 10%. Do you have it temporary for a couple of days, but it goes away. There are some smaller case studies showing that the incidence of complications is very, very small.

That's good to know. It's good to know that it's an option and that we could potentially have families advocate for finding a specialist that might be able to help their infant. Because a surgery is scary from a parental standpoint and we never wish surgery on any baby. But if that could potentially change them from a health standpoint, because laryngo Malaysia is a big deal and amount of time and energy these families spend just trying to feed their babies. I mean, I think more parents, if they were properly educated and they had the right professionals and specialists alongside them, they might be more willing to entertain that procedure. I know I can think of some families that if they had been advised to do that, they definitely would have jumped on that bandwagon.

And I can tell you too from experience, some of the results are just dramatic, life changing for the parents and the child.

Yeah. Even if the parent isn't breastfeeding, because a lot of them struggle and can't. These babies with laryngomalasia, despite their goals, I mean, these are the moms that, I mean, a lot of the moms do, because it's a very. It's a very highly emotional time period for everybody. But they're in tears, you know, in my office frequently, not just at the beginning. And not just because, okay, we found the issue and now we know how to proceed. And I'm so grateful and thankful. And, you know, we get a lot of moms who come to us and it's this, you know, it's highly emotionally driven conversation because it's this feeding dyad. But these parents with laryngeal Malaysia, these babies with laryngeal Malaysia, I just see that it's. There's another level of stress for these families that I don't in my other families. Anyway, so let's circle back to uars again. What can we do, right? Like, let's say we go to an ENT and they turn us away. Or let's say even we're headed to an ENT who maybe is known for treating uars. Is there anything that we can do as, you know, adults to help ourselves before we land ourselves in the ENT's office?

So first thing I would tell you not to do is to say Dr. Park said you should do this. That's the million dollar question. It really depends on what your support networks are. Obviously, if they come to you, they're already a couple steps ahead because you know how to navigate a system and you have a network of providers that you can send to. But for the average person in the middle of the us they may not have the resources. I mean, there's a number of conservative steps you can take. For example, just sleep hygiene. For example, some of the older kids just stop having them snack late at night. Optimize nasal breathing. Now, even if the ENT isn't on board with Ursula, they'll help you with the nasal congestion, whether with medical therapy or surgery, or they don't really consider dietary therapy for the nose, but that's something you have to do on your own.

Yeah, yeah, yeah, we've seen it. I've seen families where they have totally pulled kids off of dairy, like just dairy alone. And we have seen changes in airway and sleep and behavior. And I mean, it's like that trickle down effect. We see these massive changes and parents, you know, then they come back to me and go, wow, why do they even sell this stuff? Why is this on the shelves? And I'm like, well, part of the issue is how highly modified our foods are. And even when you think you're getting organic or you think you're getting a 2 milk from the grocery store shelves, it's very different than getting it from the farmer. It's also very different. These organic fields are next to not organic fields. We can't control through the soil from one farm to the next farm. So we may be paying for and thinking we're getting past, you know, pasture raised organic foods. But there's only so much we can control. So we do our best and we eliminate the things that are harmful to our bodies. And that's, you know, I think unfortunately for so many, dairy is a culprit of a lot of health issues.

Usually it's number one dairy, number two, gluten.

Yeah, Yeah. I love that you've been able to heal yourself though, in order to be able to eat gluten again. That's exciting.

I don't go crazy with it though. I just, I'm very selective. Even the type of bread I eat, like I said, I cook my own sourdough with the starter and it's pretty good. My wife is very gluten sensitive and she's fine with it too.

That's good to hear. It's good to know. It makes me hopeful. It makes me hopeful. So how does somebody go about finding a doctor who might know how to manage UARs, especially if, let's say they've had a sleep study and they were told everything's fine, you're fine, go along your merry way. But maybe they actually have mild sleep apnea or URS that was not diagnosed. Any tips there?

So honestly, a traditional medical doctor won't be able to help you unless you meet certain criteria. Or if you have huge tonsils, they may offer it to you, but sometimes they won't. There's some other hesitancy by ENTs offer tonsil surgery. Yeah, I think that's a whole other discussion why later on. But because actually, I can tell you one study that kind of swung the pendulum to be more conservative. I think it was called the children's adenotoxectomy study or something like a chat study. Don't quote me on that. But there's a study looking at children who had large tonsils. Like older children, I think five or six, up to nine. They combined them, they split them into two groups. One group got the tonsillectomy, one got just watchful waiting. And the tonsillectomy group, the kids did much better. Parents are very happy. But what was surprising was that in the watchful waiting group, about I think like 30, 40%, it resolved on their own. So just based on that Data, there's been this pendulum has swung towards more conservative. And this depends on our field swings back and forth every 10 years. Right now, swinging back, more conservative that overall, the kids who would benefit from tossectomy are not getting treated.

Yeah.

But my question, my answer to parents is, which one should I do? Should I take the tonsils out or the palatal expansion? My honest answer is both. And they've shown in that original study I mentioned, between tons, like demi polyplocks mentioned, when you combine the two together, you get even better results. Yeah.

Yeah. I mean, if someone had said, we need to take out Lily's tonsils, I would have said, okay, I'm a little scared of what's to come because I know it's not an easy recovery, but let's. If you think we need to do it, like, let's open up our airway. So I'm grateful and I monitor her tonsils closely, but it's, you know, how do we know which children are going to grow out of it? And then how long is it fair to wait for these kids? You know, that's what I always come back to, like, how many.

My opinion on that. Sorry. Is that the tonsils are lymphoid tissues in your throat and helps to develop your immune system. But after. After a certain number of years, if it gets inflamed, it causes more breathing problems, which actually lowers your immune system. There's studies showing that they measured immune immune function before, not transectomy. They found it actually improves after transectomy.

Ah, okay. Well, you know, I've heard this argument, and I've gone like, okay, well, I can. I can also understand why people would be more conservative because, you know, but that's. That's interesting data.

Well, my theory as to why tunic will stay inflamed is because if you have a sick breathing problem, it's like a vicious cycle. If you obstruct once in a while, you're going to have acid reflux, microscopic subclinical reflux, which can cause your lymphoid tissues to get bigger, causing more obstruction, cause sucking out more stomach juices. And what comes up is not just acid, but also bioenzymes and bacteria, even pepsin. They found pepsin in ear, sinus and lung fluid.

Interesting. Well, that. It makes sense. Yeah, it makes sense. Thank you for that. That's very helpful.

That's why when you palatal expansion, you have less obstructive episodes and tonsils shrink. And I see that happening all the time.

We're opening up that airway, I mean, it makes, yeah, it really makes sense when we start to, like, look at everything. And I always say we're connected from the tip of our tongue down to the tip of our toes. And when you look at the fascia lines, we truly are. And it's, you know, I feel like so many professionals try to treat in silos and we just can't do that. We have to come together and treat the human body as I know, as a whole. And that's why we have to pull in so many specialists, because we all have our scopes and our areas that we specialize in. But it's, you know, we have a journey ahead of us. Right. So how can somebody get in touch with you to learn more about, you know, what you do now that you've moved on to the next step in your career? How do they get in touch with you?

Well, they can touch me through my website, DrStevenPark.com that's D O C T O R StevenPark.com and I do have this starter guide on. It's called energize your day Starter guide. Five simple steps to wake up refreshed and ready to go. So it's like five quick tips that you get to help you sleep better, breathe better, feel better. And you can get it at EnergizeYourDay today. EnergizeYourDay today.

Perfect. And we will put that in the show notes so that anybody who is listening can go and download those and get any of the links that you've shared with us as well. I appreciate you joining me on the podcast. This has been extremely enlightening and informational and I know our listeners are going to love this one. So thank you so much, Steve for joining me today.

So my pleasure.

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