Episode 188: The Nose Knows with Dr. Amy Best, MD

Hi and welcome to episode 188 of the Untethered podcast. Today we have Dr. Amy Best joining us. Amy is a general ENT practicing in Indianapolis, Indiana. She's been in practice for five years and sees patients of all ages. She graduated from IU School of Medicine residency and has a 7 year old son. She started Eadtonose on Instagram as a passion project for patient and public health education and as a creative outlet. Go follow her 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 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. Amy, thank you so much for joining me on the podcast today.

Thank you for having me Hallie. It's nice to meet you.

Yeah, you too. I like I remember a friend shared one of your stories to her story or something one of your poster stories on Instagram and I saw your Instagram handle like eedtonose and I was like I have to follow this account and then I went down the rabbit hole of all things. So I would love for you just share with us, you know, what you do in your day to day. I know you're an ent, but you know what?

Yeah.

What you practice and so everybody can get to know you a little bit better.

Yes. Well it's so fun that you found me that way and of course I'm like happy to have you following me. I'm loving sharing all all things ent. So I am a general ent. So you may have noticed kind of if you look through my page that I'm not just like a pediatric ent. I don't just do obstructive sleep apnea. But I think that probably caught your eye like it did a lot of people because it's kind of a hot topic and there are a lot of oromyofunctional therapists who have found me, speech therapists who found me just by happenstance and yeah, so though that's a lot of My page. I do adults, I do kids. I do actually probably the most, like sinus and nasal surgery. That's probably my highest volume. And a lot of that does still kind of deal with some element of obstructive sleep apnea. Not necessarily pediatric, but some element of adults. But I do some ears, too. And I do thyroid surgery and parotid surgery and of course, then tonsillectomy and adenoidectomy. So just kind of all the bread and butter ent and then need to know that came about. It's kind of something I actually was thinking about in terms of, like, a blog for a couple of years. And then Instagram, obviously has. Social media has become bigger and bigger over the past couple of years. And about this time last year, I decided to do it. I was gonna do it. And I kind of started putting in some work, thinking on the logo and some of the different topics I wanted to hit not just medical topics, but, like, the themes and things like that kind of the creativity behind it. And then I launched it in March. So I'm pretty passionate about educating my patients. And I find myself telling my patients the same thing every day and telling my family members and my friends the same things every day. And so I thought, why not just put it out there for the world? So, yeah, that's.

I love it. And I think that when you have that passion to educate, that comes through, you know, like my. So we moved down to South Florida like, a little over a year ago, and I've been putting off my own nasal surgery for a while and, like, knowing I needed to do it, but I'm like, well, let me do the tongue tie release. I'm basically, you know, I'm an slp. Myotherapist. Like, I basically was living in Mayo at the time, like, daily treating. And then I did expansion as an adult, even though I had it as a kid, and it was a whole thing. And so I finally was like, you know, I just. I probably need to address the nose. So let's go, let's do it. And it was really hard to find somebody that I trusted where I lived before. And I think that was part of it too, because they were constantly turning away my adult and pediatric patients. And I was like, ah, yeah. So I did find somebody who was highly recommended. And I just. I remember the experience, like, going into the office and, you know, basically they were like, okay, let's get your full history with the, you know, the physician assistant. And then they sent me down the hall for my cbct. They had Me come immediately back. She pulled it up on the screen. The ENT came in and we had like a 30 minute conversation where she showed me everything. I mean, it was a true consult. And she said, here are all your options. And at the end I was like, so would I mess all this up if I, like threw in a rhinoplasty too? Like, she also is known for doing like really good rhinoplasties. And I'm like, if we're gonna do a septoplasty and terminate reduction and needle body reduction, I was like, we just do it all all at once. And so, I mean, the recovery is quite different.

It's quite different recovery. But, you know, if you're going to undergo the knife. Yes.

Yeah. I was kind of like, if we're doing this, like, let's just do the whole thing. And so anyway, so we did that April 5th. So it's been just over six months. And you know, being the patient on the other side of it now and having had that experience with someone who is. She was so educational and she talked about like the different ways and she showed me pictures and diagrams. And that was before the whole rhinoplasty question. And I was, you know, I was really floored. I was like, this is amazing. I haven't sent patients where they've reported back that they've gotten this kind of care where my practice is up north. And I was like, how much more of us we breathing better through our nose if we just had somebody who would sit with us for this long and explain? I mean, which I know I did pay for the time, but like, I know it's also not practices, but it makes such a difference because I trusted her and I felt like she had my best interest in mind. And she wasn't pushy, she was educational. And it was sort of like, okay, what do you want to do? And I was like, yeah, well, let's go, let's do it. And yeah, I will say it is so nice to be able to breathe out of like both sides of my nose.

Yay. It worked for you. Good.

It did. My septum was deviated posteriorly so you couldn't, you couldn't see it super well. Yeah, I mean, you like. I had some bumps on my nose from when I was pregnant. They developed because I think obviously with the added weight and I know with the hormones and everything that changes, I know sometimes your nose can also change in probably in reaction to sleep disordered breathing, that probably full gear at that point.

Right.

So I've just, I've watched my nose very closely over my lifetime. I was like, let's fix it up. Same here, I'm sure. I mean, that's what you do, right? So.

I know.

Yeah. But it's just, like I said, it's just incredible when you can get somebody who educates and who really is excited and passionate about the work they do. Because I again, I fully trusted her to take that good care of me and get the job done. And it's, you know, I, I like I was talking to somebody last week and they were like, you look like you've lost weight. And I was like, well, the eight hours, seven to eight hours of sleep that I am now getting, it's a differently is working because when I did a sleep study with a colleague who reviews the raw data, what we found was that my body was kicking. You know, when I had a sleep study done elsewhere, I was fine. I was fine. Yeah. When the raw data was reviewed, what we actually saw was I didn't have like true obstructive sleep apnea, but my body was kicking myself out of REM sleep every single time I entered it. So I never truly got restorative deep sleep. And yeah, I was, you know, it's like these things that you learn and. Yeah. Like, okay, well, I guess my body.

Makes a huge difference.

Yeah. So I'm like, I have such appreciation for the work.

Did you have. Were you diagnosed with upper airway resistance syndrome or not even that?

Yes. So at that point, I was diagnosed with UAS earlier this year when I. Following that home sleep test. And the individual who worked with the sleep surgeon to. Or not the sleep surgeon, who is it that reviews the final report and everything and signs off on it?

Not a sleep surgeon, but like a sleep medicine doctor. Sometimes it could be a sleep surgeon, but usually it's a medicine like pulmonology trained doctor.

Right. Yeah. So they signed off on it, but he read the raw data and basically interpreted everything and then went over it with me and. Yeah, so uars and you know, and that's, you know, that's the big thing now. You might not say, but you've got your.

Yeah, yeah, it's me as well. Yeah.

I always wrote it off to just being like a business owner and a mom and someone who just doesn't sleep enough. And quite honestly, I think my body has felt like I needed to not sleep as much because I wasn't getting quality sleep. It didn't matter if I slept four hours or eight. It was, it was awful. So. Right. Anyways, yeah, so that's.

I would say that for my septoplasty patients, that's pretty. Probably the biggest piece of feedback that I get is they come in at that one month follow up, and they're like, I'm sleeping so much better. And one month out isn't even that far out. There's still, you know, six months out. Now you're at a point this. This should definitely be your new nose. And your sleep should have caught up by now and everything, and you really should be feeling the effects of it. But, yeah, I try to counsel. You know, so many patients are scared of surgery. And just like the surgeon that you talk to, I would say that that is exactly my approach. I maybe don't have all the diagrams, but if we have a CAT scan to go over, I go over that. I do have some diagrams in my. Can you hear me okay? Yep. Okay. It sounded. It started to sound funny. I do have some diagrams in my office, but as a facial plastic surgeon, she probably has a lot more detail in that way. But anyway, it's always my practice to give patients options. I very rarely am like, you have to do this one thing. Now. What's funny is some patients don't love that. For instance, I just had my last patient in the office this morning. I gave him kind of three options, and he was like, well, you're the. You're the expert. What do you think? And I said, you know, honestly, I don't think one of these is better than the other at this point. And then often patients will ask, what would I do? So then I give them. I tell them what I would do if I was the patient. But to me, it's so important to just provide full education about each thing and let you choose. And with septoplasty or surgery, there are some patients that come in and, you know, they want surgery out the gate. That's why they're here. And then there are others who. Surgery is a last resort. And for those patients who struggle to make that decision for surgery, it's funny because sometimes they're the ones with that huge septal spur, and it's like, if you would just let me. Let me take care of this, like, you're gonna feel a lot.

Quality of life would be amazing.

Yeah, yeah. So one of the phrases I use, you know, is I'm like, most patients after this surgery, if they've been correctly chosen for the surgery, most patients wish they would have done this 10 years ago. You know, it's me. Hi, me. Yeah, yeah, yeah, yeah.

I Have a family member who I won't name because I haven't asked permission, but this individual has like for years been told by various aunts that there is need for septic reduction. Right. And so finally, like in two weeks it's happening. And you know, but this has been years on years and it's one of those things where I'm like, I'm kind of excited because I just can't wait until like they feel the benefit of being able to breathe and not having a chronic sinus issues that come along with everything going on. And yeah, it's, you know, and then on the flip side, I've now looked at my kids being in this airway space and I'm like, okay, how do we prevent this? How do we. I know, airway, like, how do we, you know, both my kids were tongue tied and, you know, lip tied. Both my kids have higher narrow palates. They're both in early expansion. They both done some Maya one's four and a half, one seven. The seven year old is in her second round of like early seven year old too. So, yeah, it's just, it's like, how do we prevent this? How do we prevent the face from collapsing on itself, basically is what I'm looking at.

I know. And you know, I'll be honest, you're probably more in tune with all of the like craniofacial stuff and with you being an oral, oral myofunctional therapy, we don't study a ton of that in, in our training. But I really wonder, I'm like, is it genetics or is it, you know, if you're, if your breathing is obstructed in your mouth, breathing as you develop, is that part of how a septal, like, can a septal deviation occur because of a high arched palate from not having your tongue on the roof of your mouth? It's really hard because I don't think we know exactly which comes first, you know?

Right.

Genetics certainly plays a role. Right. Because tongue tie is something you're born with. There's really no way to prevent that. But these other things. Yeah. Could we prevent them if we somehow were able to open the airway? Whether that's releasing a tongue tie or lip tie, releasing or not releasing, removing tonsils, adenoids, that sort of thing. Yeah, yeah. And we're in such a unique setting. Right. Because this is so much of what we do all the time. And so you kind of just think that the public knows it. Right, right. But there, there's so much. And even, even Pediatricians, even, I shouldn't say ents, but pediatricians, primary care doctors, a lot of them probably don't necessarily think about those things. And it depends on their training and what, what schooling they came through, what schools of thought they came through.

Yeah, we're doing a lot of education a lot of the time. And. And it's interesting because some are open to it and some are like, they think we're completely like off our rockers. And, you know, and then patients actually come back to us and they're like, well, we went to. So this actually just happened. One of my therapists texted me this morning where she referred to one of three air, or basically gave a list of three airway center dentists who have done a lot of training on tots and airway and early expansion and working with the ENTs and the speech therapists and mayo and everything. And they have some wait lists, like a month, maybe it's not horrible, but, you know, so the family, hey, I found somebody who can get us in this weekend. We were like, okay. And so she's like, have you heard of this person? And I was like, no. I was like, but the bio sounds a little promising. Like, let's I guess, see what happens. And just came back and apparently the patient, the child's, you know, a Todd. And the patient, the parents were told like, oh, it's fine, that they're tongue tied. They're still young. We wouldn't address it till they're nine anyways. Like, what? Just nebulous age. I'm like, okay. And amongst other things as well. And we're like, no, you know, what we are seeing is that if we can intervene, right, as you mentioned, with the tether, oral tissues and genetics, and we know that there's definitely like an epigenetic component. There's like research being done by like, Mariana Evans. I don't know if you've heard of her.

No, I'm gonna have to write that down.

So Mariana Evans, and why am I forgetting his name right now? But I can get it to you. They're doing research on prehistoric skulls and looking at the evolution and obviously we. We can all look at our faces and know that our jaws are shrinking, our skulls are also shrinking. Right. You know, and so there's that epigenetic component in combination with just everything else. And, you know, so then we look into, like I teach in my courses, how we start swallowing about 12, 12 and a half weeks in utero, and that's a SW you're going to be born with and if apoptosis hasn't happened, you know, we haven't had that, those tethered, you know, we now have tethered tissues in place at 12 and a half weeks in utero. Well, hi, guess what else is going to form around that? So, you know, I definitely think that there is, there is so many factors and components and we've heard some ents in the space say, you know, that the roof of your mouth is the floor of your nose. And so what we are seeing, which is a little bit scary and it's not, it's not as drastic in every patient. But I have received three year olds who have high, narrow faces already and you know, because of like very serious airway obstruction, whereas, you know, their kids where you may not see it until 10 years down the road. But I definitely think that, you know, mouth breathing, tongue low and forward, you know, the nose blocked, whether it's from tissue inflammation, from actually enlarged adenoids, fonsils, or even potentially just allergies that have like kicked this all up or whatever the case may be, then the impacted sleep and how they're acting in school and you know, it's just, it's a whole conundrum and we're seeing it younger and younger and younger and that it's scary. It's like, okay, well how do we get in there now? How do we intervene now and try to get them on the right trajectory? And you know, and then that's where the ENT conversation often comes in.

Yes.

Parents are like, why don't surgery? And I'm like, well, I'm not an ent, so I don't get to tell you one way or the other. But I still think you should at least visit the ENT and just, and figure out what's going on. Right. So do you get a lot of those types of patients in your practice?

Oh, for sure. I mean, I can't say I get them as referrals from therapists, for instance. Frankly, the whole division of OMT is like new to me since being on Instagram. And I'm loving what I'm learning and I've been connected to one OMT here, but otherwise it's not been a part of my practice. So it's not necessarily therapists, but of course from pediatricians. But I see, you know, I will get to ear tube referrals for patients who are two or three years old. And first of all, you know, yes, at that age you still can be getting recurrent ear infections, but most children, most babies are going to get their recurrent ear infections from like, you know, 6 to 18 months old while their eustachian tube is still shorter and more horizontal. So as they get older and their eustachian tube should be elongating, then you start to wonder, okay, what are maybe other reasons for these recurrent ear infections? And I would say most of those patients, if they're, you know, 18 months or older and needing ear tubes, a lot of them come in with that exactly what you described. We call it adenoid facies. It's that like open mouth. They have that quiet starter which is kind of a snoring noise that we hear from the obstruction in their nose. And in most cases that that's going to be due to adenoid enlargement. I. Yes, so I do see that all the time. And, you know, we. It's. Adenoidectomy by itself is a relatively simple, straightforward, low risk surgery. Now you add tonsillectomy into there, and especially in that pediatric age group of three and under, that that increases the risk quite a bit. And I'm not going to do that on a patient unless we have a definitive diagnosis of obstructive sleep apnea by a sleep study. But if a kid comes into me and the parents endorse some snoring and they're constantly having runny nose and they've tried, they've been on antibiotics lots of times. They've already been on antibiotics for ear infections and they still have that chronic runny nose or that chronic nasal congestion. I'll have a conversation with the parents about adenoidectomy. And yeah, a lot of people are resistant to it, but I think in that age group, I think that's where a lot of the problem, frankly is allergies are possible. Okay, they definitely are possible. Yes. And I mean, at that age you can give them over the counter Zyrtec Claritin. They have lovely bubblegum syrups that the kids will love. You can start after two years old, safely, Very safely. Like a Flonase nasal steroid. You know, I recommend, and you'll see it all over my page, Flonase Sensimist because it's a more sensitive version that there's a. It's funny because there's a Flonase Children's. It's the Flonase Children's is marketed that way. It's the exact same medication.

A lot of kids stuff like I keep labels and I'm like, this is the exact same product, but the children's one cost. Yeah. Because they both were children's on it. Okay.

Yes. So to anyone out there, there listening, if you're looking for flonase for your children, do not do the flonase. Children's get the flonase sensimous. That one actually is gentler. They remove the alcohol, doesn't burn the nose, dry the nose, leads as many nosebleeds, and it doesn't have the fragrance or the taste. And that's what a lot of the kids don't like. So you can start flonase. And flonase can shrink down the turbinates, which can be swollen due to allergies. It can shrink down adenoid tissue, I would say. In my experience. Does it have that high of a success rate? No, but it can. And so for patients or for families who aren't eager for surgery, at least do something. At least try that. Or do the saline rinses, saline spray to wash out the mucus. What I feel I see a lot is when the adenoids are enlarged, they'll secrete mucus, right? And that mucus then irritates the turbinates, those bulges that stick out from the sidewalls of the nose. And, you know, kids, young kids will get diagnosed with sinusitis all the time. Okay, they may be having some sinus infections here or there, but your sinuses aren't fully developed. You're only born with two of your four sinuses. So your sinuses aren't fully developed as a kid. So more often than not, if they're having chronic nasal obstruction and runny nose, I believe it to be the adenoids more often than not. And so getting again the adenoids out of the way can improve that anterior nasal airway because you're not having that chronic mucus, which and causes the turbinates to swell up. I want to add, I mentioned. So flonase can shrink down adenoid tissue, can of course reduce turbulence, reduce drainage. But there was a recent, I forget what year it was published, but recently there was a study looking at the combination of flonase and astellin. Astellin's a nasal antihistamine spray, and I commonly use this in my adult patients for allergies and chronic sinusitis. But we've known for a long time that flonase and astelane together is better than a flonase alone or better than flonase with an oral antihistamine for nasal obstruction, runny nose, allergy symptoms. But this study showed in particular an actual reduction. So they did. X rays of the adenoid tissue before and after use. And it showed in pediatric patients that the combination of Flonase and Astelane together did reduce the adenoid burden. So that. That is interesting. It's a significant finding. The problem with astellin is it. Have you ever used it?

I don't think so.

It tastes. It's nasty. Yeah. I mean, very, very bitter. Have you ever used Afrin? It's very similar to Afrin.

Yeah, I've used it, but I find.

I've used Asyn before, and I have found that it lingers in the back of my throat for about, I would say, the whole morning. Oh, yeah.

And the kids that we like, they are just. Yeah, a lot of them are very sensory.

Yeah.

Impacted already because of being in fight or flight all the time. Because they're not. Yes. Well, I mean, it's like that whole catch 22. Right. It's like, how do we help you with all of these other things going on when we need to address this in order to fix those things? And, yeah, I mean, I use the phony Senso mist following my nose surgery. That was what was recommended to me, along with, like, the nasal rinsing and everything, because I couldn't blow my nose, obviously, after a rhinoplasty. But my daughter, at the same time, like, right before my surgery, she went to the ENT because she's had a history of croup. She, I think, has had it nine times this year. And it's. I mean, she had it when she was an infant. She's the one who's four and a half and is constantly sick. And I'm like, all right, we've got to figure this out before you go to kindergarten next year. Like, you're still in preschool. Like, let's try and see if we can, like, minimize how many days of school we miss.

Right.

So, you know, looking at all the colleagues and everything I know who do early intervention, as far as appliances go, I use an ALF appliance with Lily when she was 4, and that was right when the world was shutting down. And so we didn't do a lot of other surrounding therapies or anything else because nothing was open. It was literally like, she.

Oh, go ahead and. Sorry, what is als?

So the ALF appliance, it is. Oh, gosh. Advanced light wire functionals. So it is basically a. I'm gonna butcher this. It is. It's a. What do they call it? Not an orthotropic, but it's a. Another type of appliance that works on expansion, on. Okay. Both Forward growth and lateral growth. And also with the goal to bring the palette down slightly as well as you kind of open it and move it forward, upper and lower though. So we use it on both, you know, her maxilla and her mandible. And what we found was because she had no other treatments before or after, but she did have cbcts done before and after her sinuses, cleared her nose. I mean, everything just looked, all the inflammation was gone. And all of a sudden this kid went from not being able to breathe to having a nice open airway. Plus she got some expansion and she wasn't getting sick during cold and flu season. And I was like, okay, this is interesting. And now they're, they're finding. There's some research now that's been published just recently that, you know, several millimeters or so of expansion in children actually does open up the airway.

Makes a big difference.

Such a big difference. So, so that was exciting. So now we're on this journey with my youngest who is really more of the patient who's, you know, I put her in the car at night and she's like, I know where we're going. We're going to urgent care. And I'm like, oh my gosh. Like, like, yes. Because you cannot seem to your breath with all your barking, coughing going on. So. Yeah, yeah. I mean, it's just like, she knows. And so anyway, so I found a dentist down here to do the work with her. And we actually put her into like a rapid palatal expander upper and lower that's doing some forward growth as well because she's just sick so often. And that Alf is more of a, a longer term type of appliance. You know, nine months a year plus. And this is, you know, the dentist on here was like, she's got a deep bite. She's grinding her teeth down. You know, her airway is so compromised that we really. And we did the CBCT on her as well. And you know, she's like, we really want to build the bite up. So we should put some planus tracks on her back teeth to bring her molars up a little bit. So she's, you know, with the goal that we know she's going to grind that down. But in doing, we're like, great, build up the muscles in your face while we do. And then we'll put more on until.

Your bite is where it needs to be.

So it's so interesting because like her teachers are like in pre K and they're like, so like, is this for like Straight teeth. Is this like, why are you doing this?

Yeah.

I was like, well, if you really want an education, I'll give you an education. I was like, right now this is.

Nothing to do with my clinic. Yeah.

Nothing to do with straight teeth. But it is pretty cool because now I'm starting to see spaces. More spaces between her teeth. I can tell the expansion. And I'm like, fingers crossed. Like, we haven't, like, she'll get it. She got a cold, and whenever she would kick off a cold, it kicked off into croup. She got it cold last weekend and it's already gone. And I'm like, oh, my gosh. Like, I don't know what happened.

Yeah. It's probably because she's breathing through her nose. Right. So. Right. I mean, there's so many benefits to breathing through the nose. And part of that is, you know, the nose filters the air. So if she was a mouth breather before, that could have been exacerbating her croup by breathing in dry, non humidified, unfiltered air. And then, you know, we see. I see a lot of patients with like, laryngeal spasm and what we call vocal cord dysfunction. And I find that a lot of those patients have nasal obstruction. And it's. They're not breathing deeply through the nose. And so rather than. When they breathe in, rather than their vocal cords expanding like this, you know, they're slamming shut. And that's not the nature of croup per se. Croup is lower down in the airway where the swelling is. But. But that may be exacerbating her cough.

Yeah.

You know, if she's hacking cough and not breathing through her nose. And that's. I tell patients, like, when they gag in the clinic, when I'm doing a scope, or if they have these cough episodes, the training is to stop and take a deep breath through your nose to help those laryngeal muscles relax. So it. I believe it. It's probably helping her in a few different ways. Has she had. Was she ever intubated, like in the NICU or anything like that? She doesn't know. Previous airway surgery now, like full term baby.

No true airway, you know, medically complex airway type of issues or anything. She was. She just had tongue and lip tie. We did release it, like when she was five days of age with the oral surgeon who I use for myself and my kids.

Yeah.

And I worked with her and then she fed.

Great.

And then it was for her, a lot of her biggest issues Outside of like RSV group, you know, in her early, well, continuing onward for the group was really motor based and you know, she like dragged one leg behind her and she had some asymmetry stuff. And we did work through that with some professionals and, you know, got her on track there, but no, nothing else. And, you know, I would take her to the pediatrician. I. We went to an ENT, I had both my kids allergy tested around 2 and everything was fine. And then they would say, you know, they're two, so if it's like a low, you're not going to pick it up. And I was like, okay. You know, so it's like one of those things. I'm like, I'm glad they don't have these massive food allergies or environmental allergies that we know about at this time. But yeah, then it's like, okay, well now what? Now what do we do? Because she, she's not a kid who's ever really had big tonsils. My first one had like three plus tonsils, very veiny, they looked unhealthy. And I once took her to an ENT and his response was, she's sitting here breathing through her nose right now. So I think she's fine. And I was like, but she's constantly sick. Like, yeah, not always breathing through her nose. Like, you know, the work that I do, like, I'm a little bit stuck here. Like, what next? Like, no medication, no nasal spray suggestion, nothing. Just. Just like she seems okay, follow up. And I was just like. At that point I was like, okay, well I can't send her here. Where can I send her? Like, or like, where do I send my patients, even?

Right, right.

So it's been a journey to find people who will work with us. We're like, we don't want to. I was like, I don't want surgery for her. I mean, unless you tell me, like, I absolutely need it. I don't think she's obstructive sleep apnea, but how do we open the airway? And that's what also threw me down. This whole journey of like, what can we do for these young kids when maybe we either don't want surgery, surgery is not even an option. Maybe they're not responding to meds. Like my four and a half year old now, she was diagnosed by a pulmonologist who said, well, she either has allergy induced asthma or viral induced asthma. Leaning towards viral since, you know, she tends to get croup all the time in response, you know, she gets Cold symptoms turns into group and you know, she, for a couple summers up north, it was only during the summers she just had this like cough that would not go away. And, but it was also like she couldn't catch her breath and it happened anytime she ran or overexerted herself and that's what.

Reactive air.

Yeah. So we run flow vent for two months, for two summers. Then we moved away and it hasn't happened since. So I'm going to write that off to viral or allergy.

Allergy.

Allergy. Right. But yeah, it's just, I'm like, man, the rabbit hole. These kids send us down.

Yes, yes. It's hard being a mom sometimes and it's hard to know you want to advocate for your child, but you don't want to be overly worried about things. I, I find myself in that, that battle all the time. But. So yeah, I'm, I'm curious because you kind of, you mentioned what can we do for these young kids? Like I said, so ont is like a whole new division for me. What can't, what do you guys, what can you do for young kids? Like you know, 4 or 5 years old? They can start following instructions pretty well. But what exactly what do you guys do to work with the young, young kiddos?

Yeah, so traditionally like four plus, like we say you should have the cognitive level of a four year old at least to be able to do traditional myo. And so under the age of four, I actually have a course, Feed the Peds where I teach SLPs and OTs. How to address this in the underage, in like the 0 to 4 crowd. Because we're seeing so much of it. Yeah, but it's not truly myo. It's actually like sensory motor feeding therapy. We do a lot of the same principles where we're working on the orofacial structures. We're doing a lot of passive exercises like neuromuscular re education or education for the first time. There's a lot of compensatory strategies. We find that a lot of these kiddos that land in our practices with airway concerns or open mouth postures have a tongue like we were talking about, that lays like low and forward. Well, a lot of them don't chew their food properly or their tongue, if it's tied, can't move around to properly crop a bolus and swallow the bolus. So we'll address that. We'll see. Like can we avoid a release, you know, or is it something that is inevitable, in which case we'll prep them for the procedure and then we continue to work with them afterwards as well. But it's always secondary to airway. So can they breathe through their nose? Because if they can't breathe through their nose, we can expect them to chew and swallow properly. We can't expect them to get restorative sleep. And so that's again where we are. We've turned to a lot of, you know, either a ts or even some of these airway centric dentists. Some of them are using early appliances as young as like 2 years of age. And you're doing some like early expansion. And obviously the child has to be semi compliant. Like it's not going to work for every child, unfortunately. But as soon as they have like the two year molars, like that ALF appliance can be used. Invisalign has created a product. There is this myo munchy myo brace. Like different things that, you know, I tried myobrace for example with my daughter and what it looks like, if you're not familiar, is basically like a big mouth guard. It, you know, okay, you know, it's, it's not, it's not, you know, when you play sports and you melt the mouth guard to fit your mouth, that's not happening here. Like that's, this is a big old piece of plastic that's going in your mouth. It is semi pliable. But the idea is that you wear it for so much time every day and it helps to guide the jaw development. And I have seen instances of people posting online where their children got great results. Now I will tell you, my super compliant child would not wear it. And to me that made me take a step back and go like, okay, if she can't plug her mouth with this appliance because that's exactly what it's doing. It actually like goes up in front of your teeth and below and you have to put your lips around this. I can't expect what's going on, an obstructed airway to use and use something like this. So I've been very hesitant to like to recommend product like that because I prefer something that either is fixed, especially in that age group, like an ALF appliance. It's a little light wire. It barely goes anywhere. And where it touches on the palette is supposed to be like, supposed to feel good, like create endorphins just like your tongue would be if it was up there.

Interesting.

Yeah, so because like it's up on the spot, you know, behind your, your upper central incisors. And so I Like, the mouth open. If they need to breathe, they should be able to breathe through their mouth. It's not. It's not ideal, but we can't take away their only source of breathing. And so I think it was truly sending my daughter into fight or flight and freaking her out. And here I am trying, I'm being told, well, let's see if she'll just.

Keep it in when you read a.

Book to her, and then maybe she'll.

Fall asleep with it in her mouth.

And, like, she keep it in for 10 minutes. And after, like, 10 minutes and 20. 20 minutes after that, she was like, I. I'm done. I mean, and this is a kid who will sit in a dental chair for an hour and let them put fixed appliance in her mouth. So, yeah, I was like, all right.

Yeah, she's tolerant. Yeah.

So I'm like, this is telling me something else. And that's. I think that's one of the biggest messages that's been so educational to SLPs and OTS who are working with these little ones. You can't force things if the nose is not open. We, like, that is number one over everything else. And so that it is. It's tricky, right? I mean, and we get kiddos with medical complexities. I've worked. I mean, some of my most complicated cases were kids with laryngomalasia. Those infants, you know, it's. It's challenging. It's takes a toll on everybody.

Yeah.

Yeah. So there's definitely things we can do, and we can definitely direct things, but I think, you know, we have to assess to figure out, like, what is their tolerance. Tolerance level. If we put their tongue and close their jaw and put their tongue up on the top of their mouth by pushing, you know, below the jaw and guiding that tongue up there, and they immediately pop their mouth back open. We need to look into airway, because they should at least hold it there for a moment until that habit kind of resets itself.

Yeah. And that's where it is so multidisciplinary. And that's where I feel. I'm like, how are you? We as ent so late to this game. And of course, it may just be dependent on my training, my upbringing. I mean, I've been in Indiana my whole life. This is where I trained. This is where I practice. So, you know, certain things take hold in certain locations, and eventually it spreads. I. I think I've seen, like, down in North Carolina, I know there are some. Some ents working with some OMTs there with that Appliance that is fixed. Do you crank it?

So the alf? No. Basically, for that one, it's. It's like semi fixed. Like, you can take it out, but like, my daughter never did. Most kids don't because they think it's a fixed appliance. It has like, a little button that kind of holds it in place. It's not like, fixed glued in there. Yeah. But the dentist adjusts it between appointments versus, like, the rapid palatal expanders that my daughters have now that were custom made for them. Most rapid palate spanners only grow laterally, and so usually we also need forward growth of the maxilla and. Or mandible. Right. So my daughter's appliances now that are, you know, like I said, they're custom to them. So we are getting, you know, full dimensional growth here. But those do have, like, a crank factor to them. There's a key, you know, we do the crank.

I had that when I was a kid.

Me too.

Yep.

Yeah, me too. But it's so fascinating because there's like hundreds of different appliances out there. And. And that was one of the things that I appreciated about the dentists that we went to up in Maryland. They had a whole variety, and they really tried. They picked based on the goals of the patient as well as what they felt would be best for that patient. And so it was a really comprehensive, holistic approach to, like, what are your goals? What do you want for yourself? Also, what do we think makes the most sense, you know, holistically, health wise, to make you most functional? And so it was really nice to have those options. And because not everybody has such a wide arsenal of options when you go to people who are trained in this. But yeah, no, it's. It's hard to find an ENT who looks through a similar, like, lens like we do.

Yeah.

And I think that it's growing. I also find that, like, in my own profession, it's the same thing. It's such a split. There are people who think myofunctional therapy is voodoo and it's not research based. And we're like, Mayo is more than 115 years old. Like, like, I've done the reading. I've done the research. There's been turmoil back and forth over the time in history and everything, but the one thing we know is that we should be breathing through our nose with our tongue on the roof of our palate closed and our teeth slightly apart at rest. So can we all agree that working on that in therapy is useful? Who cares what you call it, like, that's part of what we do. It's. We're licensed to do this work. So it's. It's fascinating because I feel, and this is my opinion, but I still feel like there's a 50. 50 split, like amongst.

Interesting. Yeah, that's so interesting. I mean, and again, I'm learning about it, but to me, it all makes sense. I think. I actually was communicating with another ENT who has a page on Instagram, and I said, I don't know about you, but I feel like we did not learn enough about the physiology behind nasal breathing in residency. You know, as surgeons, ent, a lot of people do, they don't understand this. I mean, of course, whoever's listening to this podcast certainly gets it by now because we talked about surgery. But ENTs are surgeons. It's a surgical subspecialty. It's not just a medical specialty. And, you know, as surgeons, you're very anatomically based also. I mean, when we go through training, though, the ear, nose, and throat are all connected. And that's a lot of what I see. You know, I see a lot of. Of problems in patients that affect all things. There are subspecialties of, you know, gestotology and that. That microsurgery that's very. Actually kind of neurosurgery based. Not necessarily anything like sinus surgery and then, you know, head and neck cancer. That's nothing like sinus surgery and nothing like ear surgery. So we do have a lot to learn in residency, and a lot of that is the anatomy and the actual surgeries and. And we cover some physiological aspects, but not much. And especially, at least where I trained, especially not the nose. I think that the nose, in my opinion, has kind of been the more overlooked aspect of ENT over the years. Ear surgery, when cochlear implants were developed and all that, you know, that's. That's kind of. That was one of the Cadillac sort of things of ent, you know what I mean? Like, very highly specialized, requires a lot of skill. And then head and neck surgery with head and neck cancers, that's really grown as well, because now we can, you know, resect these tumors and replace them with these huge free flaps. There's a lot of research, a lot of learning about that. But the nose has kind of been overlooked, I would say, because it's kind of this simple, seemingly simple organ among these other crazy problems. And, yeah, we just didn't learn much about the physiology, and nor did, again, we learned much about, like, the maxillofacial skeleton, at least in my department. You know, we had oral maxillofacial surgery there. And so I think we talk about turf wars and, and stuff like they take care of a lot of the TMJ problems and things like that. We had some facial plastics training and that's probably as much as we talked about, you know, the palate and the mandible and the relation to each other in terms of facial aesthetics. But yeah, yeah. So I think, I think within ent, we have a ton to learn. And I'm like, I said, I'm learning so much. And to me, I appreciate that there's research behind it, of course. Not that I've done that I've done any deep dives to find out what that research is. But kind of like you said, I mean, what is the harm in doing these things or trying these things? And I don't know, you recently saw that. I, I've been trying the mouth tape because I'm like, what is the harm in me trying this and seeing what good could come from it? I feel like I know that I feel better. I feel like my face looks different when I'm breathing through my nose properly, when I'm less congested, when I get a good night's sleep. And I know that it's been with my mouth closed rather than my mouth open. Yeah. I also have become more of a believer because I actually. So I had braces, I had an expander when I was a kid. I had braces into my teens and I, I had very nice teeth. But as I got older, my bottom teeth had shifted some due to wisdom teeth that came in. And then that actually shifted my top teeth a little bit. And cosmetically it bothered me, but also my jaw really bothered me. And so I think three years ago, not three to four years ago, I got adult full on adult briefing. Not like Invisalign did actual braces. My friends thought I was crazy because they're like, your teeth are already really straight. And you know, they know I'm a perfectionist. So they're like, you, you are insane. But, but I said, you know, I am doing it for the cosmetic reason. And that was the only thing that he could guarantee. But I said, I'm hopeful, you know, he said, it may help your jaw. I was like, I'm hopeful it helps my jaw. I understand that it may not. But that's. That was really like the primary reason I was doing it, with the hope it would help it. And I could, I can tell even in pictures, looking back when I had my braces on. My maxilla was. It was wider.

It was.

And now I've had them off for two to three years. And I wear my retainer, but I'm like, I look back at pictures and I think I have. I think I had a little more space in there when I had those braces on. And so I believe in the plasticity of our tissues. I believe in the forces, whether that's the tongue or braces actually, you know, pulling things apart. I believe in that. So.

And there's so many different appliances now. So I had tried. So I had all the same things you did. And then I had had permanent wires put behind my upper teeth, my lower teeth to hold. And they were like, yeah, like, oh, it'll fall out by the time you're 20. And like, by the time I turned 30, I was like, so can you guys take these off my teeth? Because it's really hard to clean. You constantly are telling me how there's all this plaque buildup due to all the salivary glands, you know, in the bot.

Yeah.

Anyways, so they took it off and within, within several weeks I noticed that my teeth started to shift. And this was like, way before I was ever in this part of this realm because like you, we didn't learn anything on pediatric feeding or, or official myofunctional therapy. You know, we talked about airway to a certain extent because I had adult dysphagia training, but I didn't have peds and I didn't have anything related to myo or how we're actually supposed to have, you know, correct oral rest posture. So fast forward, you know, I remember just like my dentist being like, oh, you're crazy. You're crazy. Like, nothing's moving, it's fine. And over time, I watched as my teeth turned and I was like, like, what the heck is going on? Right? And my kids then threw me into this. And I remember sitting in my course and my, my first intro to my course and I'm sitting there and I'm like, so I have an orocacional myofunctional disorder. I have orthodontic relapse. I have a low lying tongue. I am sometimes a mouth breather, mostly at night, but possibly during the day when I'm really hyper focused and congested. My dv, I have a deviated septum. Okay, well, like check all the box.

And this is so classic, right? Of anyone going through any training. I remember in medical school, I mean, I diagnosed myself with like 10 things, but. But yeah, yeah. You truly had all this.

Oh, my God, all the things. Well, and the best part was I came home and I was just like, talking to one of my, like, childhood friends who's a dentist, and she's like a holistic, airway focused dentist, and learned that she had just, like, joined into a practice where this is exactly what she was doing. And I was like, like, okay, great. Like, help. How do I do this? And so anyways, I ended up the practice for a while, I think, actually by the time I took the course. But I realized at that point that's what she was doing. And so she. They recommended a this Vivos DNA appliance. And so I wore this big clunky thing in my mouth. It was removable while I was sleeping. And, you know, they said, oh, wear it 16 hours a day. And I'm like, do you know, like, who you're talking to for a living? Like, I can't talk with it. And I'm like, I treat patients. I can't wear it all day. So I wore it maybe for like, like eight hours a day, if that's pretty good. It was pretty good. And then I had it for, like, two years, which it probably would have gone a lot faster had I not, you know, only wanted eight hours a day, but I was okay with that. I had a lot of growth. And then I. Because was a little vain afterwards because I also had very straight, beautiful teeth to start. I was like, so how do we close the gaps? Like, how do we get everything kind of looking pretty again? And they were like, well, we can do Invisalign. And so I did Invisalign, which is used for expansion in a certain regard. But some of my airway dentist colleagues, about a year ago, like, after I just finished my last couple trays, they're like, yeah, just don't do the last couple trays because they retract. And I was like, you could have told me this, like, a month ago. And they're like, we're seeing that the last couple of trays are retracting too much. And it's like you're losing ground. And I'm like, so all this expansion I just got. I just re. I didn't lose all of it, but I was definitely wider than when I finished Invisalign. And I was like, okay, yeah, yeah, again, yeah. So wait.

Okay, so when you say retract, the. The teeth retract or the gums retract.

So the belief is. And there's a whole, like, big discussion on Whether it's tipping teeth or actually causing the suture lines to open and creating, you know, new growth and cells, you know, growth and everything, the belief is that it is that this appliance is supposedly helping to open the suture line and create, even in adults, because they say they fuse, and you can't do that. And now the research supposedly shows that, yes, you can actually do that in adults.

Right.

So I do still have a lot more space. My teeth did not tip, but I had actual, like, spaces in between my teeth, like a big gap here. And I was like, I don't like that because got to fix.

Right.

And so, you know, I think that what ended up happening was it retracted some of these teeth back into the space. Pulling. Actually pulling the teeth, like, the bone back in a little bit.

Yeah, yeah. It reverses everything.

Yeah. I mean, I've got a lot more room for my tongue now. The other thing that was really interesting, too, is with my appliance, I was going and seeing this physical therapist who was in their office, like, one day a week, who is trained by the Postural Restoration Institute and does, like. Like, he calls it matte, modern counterstring technique. And about 50% of the way through my treatment, like, I couldn't crank my appliance because that was, like, you take it out, you crank it, like, once a week or whatever, every three days, and you put it back in when you're wearing it eight hours a day or more. And, yeah. So I got to a point where I was like, I can't actually get this back in my mouth. It's not because it hurts. Like, it just will not go. And I feel like my palate was, like, locked up, and my maxilla is actually turned in on this side. And I think that was probably highly connected to how I was breathing and my septum.

Yeah.

So, I mean, like, it all makes sense. And so here I am going, like, I probably should have the nasal surgery first, followed by some myo and maybe a tongue tie release or expansion, then the tongue tie release. And so it's like all these things that I've learned by going through this process. And I keep saying I'm like, I'm not done, but right now I can only handle, like, taking care of my so much. Yeah. Like, I can breathe that better. My body's functioning so much better than it was six months ago. So I'm gonna live on that for a while, and we'll revisit the teeth shortly.

And who knows, maybe with you breathing through your nose better eventually that it. It could reverse itself. Who knows? I'm not saying data to prove that. I'm just saying.

Right. Yeah, no, One of my colleagues who does myo. I actually did a consult with her and I was like, okay, like, friend to friend. Professional. Professional. Like, like, what would you do if you got a patient who looked like this? I, like, smiled and I was like, look, my Max was, like, turned in. And so it's kind of shifted things over. And she's like, oh, yeah, it's. It's like totally off center because of that. And I'm like, yeah, like, what do we do? So she gave me some things to try, which, admittedly I haven't done yet. But now that I feel, you know, from the nose, I'm like, I feel like now is a good time to revisit that. But it's interesting because I do think, you know, a lot of people will say, like, oh, tongue thrust thrusts cause open bites. And we're over here going, tongue thrusts when you swallow or speak, that that's not enough force continuously to cause your teeth to move. It's when your tongue sits against your teeth all day. Right, right. Over time. Absolutely. So it's such an interesting conversation. But, you know, and it's one week. We treat adults too, so we see in a lot of adults the whole gamut. You know, some people come and they say, I just don't want my teeth to get any worse. Course, I don't want to go through all of that. Like, just, how do you. How can you help me?

How do I maintain as is?

Yeah. And then we have people come and they're like, you know, you're the first professional in 12 that I've gone to who's actually, like, listening to me and has a plan of action. Everyone else thinks I'm crazy. And I'm like, you probably have obstructive sleep apnea. From everything that we're looking at. You're like, let's have you tested and let's figure out if that's, you know, possibly going on. And then there's other people who can help. You know, there's a lot of people in this, this puzzle, this equation. So do you get a lot of adult, like, OSA cases in your practice as well?

So not as many surgically. Really. All I have to offer patients besides nasal surgery is a up 3. So uvula pallidopharyngoplasty. I have a colleague who does the inspire. Are you familiar with inspire? So the hypoglossal nerve stimulator detaches to the diaphragm and then to the hypoglossal nerve, which stimulates the tongue and causes it to protrude forward. So I have a. Yeah, a colleague who, he completed residency a few years behind me, and so he was able to learn that as part of his training. I could go through training for that, but honestly, I don't really have interest on. It's even a minor surgery, doing a minor surgery on the diaphragm and. And the potential complications that come along with that and everything. And I think now, since kind of learning about omt, I think that getting someone set up, you know, with a therapist as a good adjunct, maybe even could prevent them from needing something like Inspire. But. Yeah. So up three, which is, you know, removal of the tonsils, the uvula, kind of tightening up the back of the throat. That's a sleep surgery that I offer. That's the only sleep surgery that I really offer besides the nose. But I do get referred a decent amount. And we. We talk about options. And there's one other surgeon in town who does some other sleep stuff like base of tongue reduction and things like that. Frankly, I try to keep most of my practice, like, outpatient. And so some of those procedures do require a little bit more overnight monitoring, have higher risks of, you know, whether it's bleeding or airway things where just can become very acute, serious issues. So I send those patients out. But yeah, I mean, for adults, of course, the treatment of sleep apnea is different than children. So the treatment pathway, you know, for children, the gold standard, they say, is adenotonsillectomy.

And.

That'S been the practice for a long time. Of course, there are other potential sources, and I always talk about that with my patients. But in my practice as a general ent, really, I would do tonsillectomy, adenoidectomy, and turbinate reduction. If they have large turbulence on a child. Beyond that, if they have sleep apnea despite those measures, then they require a referral to a dedicated pediatric ENT at one of our local children's hospitals because of the anesthesia that's required that you really need a pediatric anesthesiologist. You do kind of this sleep endoscopy where the patient's asleep but not fully intubated. And that coordination is tricky. You know, you really need someone dedicated for that. So I send kids out for further evaluation if needed, after tonsilectomy, adenoidectomy, and possible turbinate reduction. But for adults, you have to start with cpap. Therapy, that's the gold standard of treatment. And then for adults who don't tolerate CPAP therapy, then we can start to talk about surgical issues. And part of that is being. Because, I mean, CPAP is safe and it's proven to be effective and it doesn't have, you know, any of those major risks of surgery. And also that's because of insurance. Right. So insurance often keeps us from being able to do surgery up front. But yeah, so the treatment paradigm is different between each and it can be hard to, to have adults understand that. And honestly, sometimes it's difficult even as a surgeon, especially if I see a very thin patient with really big tonsils and an obstructed nose. And, you know, it's like, we should just be able to jump right to surgery, but we can't. You have to go through the whole hoopla of getting your sleep study, doing your cpap, failing your cpap and then coming to see me.

It's the whole gamut of. Yeah, it's interesting though, because they recently got a client, I think they call it the MRNA appliance through vivo. Okay. Approved. And I don't know if it was Medicare that approved it, but it's basically now an insurance approved appliance for sleep apnea for osa, for adults. So it's, you know, it's still new and I'm kind of curious to like, see people use it and see what happens. But, but it's, you know, I think that we have so many patients that come to us that are like, so I'm supposed to use my cpap, but I don't use my CPAP and. Or I don't want to use it anymore. And we're like, okay, well, right.

What do you do?

Yeah, we can help you, but we also need to pull in the ENT who prescribe, you know, or the doctor. Yes, Doctor who prescribed that. We need to. Yeah, we need to have like a whole conversation here about, like, what, what's the risk benefit of, you know, taking.

Of you not using that.

Right. Like, we can't give you permission to stop using your C. Papanol. So what kind of, of sleep apnea do you have? Is it obstructive? Is it central? Is it, you know, so there's a whole.

How bad is it? Yeah, because, you know, technically, like, mild sleep apnea doesn't necessarily have to be treated, but a lot of patients will have improved quality of life with treatment of it. But in terms of, you know, CPAP compliance, I'm sure that you're familiar with this and already think about it, but we do know that improving the nasal airway improve CPAP compliance. I think, and there could be some newer research out there that I am not privy to yet since residency, but I know that there has definitely been a study that proves that improving the nasal airway improves CPAP compliance, but did not necessarily prove reversal of sleep apnea. Okay. But I think a lot of us do wonder sometimes times if just improving the nasal airway can reverse obstructive sleep apnea. I don't know that there's data out there yet to prove that, but we do know. We do know that it improves CPAP compliance. So for those patients who. They can't tolerate their cpap, they're pulling it off. Sometimes it is just a claustrophobia issue. Other times it's because their nose is obstructed. And that's why they can't tolerate it, because they have to turn the pressures up so high on the CPAP to get past the nasal obstruction. And so we. If we relieve that obstruction, it can make their CPAP a lot more comfortable. So I would. I would say, if you don't already do this, definitely for those patients, if they don't have an ent, they should see an ENT and be considered for nasal airway surgery to. To even just improve their CPAP compliance.

Yeah. Well, then for some of them, if they can improve also that nasal airway, then we can also. Also treat them through MYO as well. And so if it's an issue of where the tongue is falling when they're sleeping, if they have a tongue tie, if they are overweight because they're not getting restorative sleep, and they can't lose weight despite trying. You know, it's like all these things. We've worked with some of our adult patients and they've told us about this. We have had some patients get off of cpap, obviously, working with the medical providers, like, we're not, you know, dismissing cpap, but that was. They were super motivated and they did all the procedures, they did all the therapy, they did all that. I mean, it's a journey, right? It was all the things that were prescribed they did, and they basically opened their airway and they trained their tongue where to exist at night, and, you know, worked really hard on creating new oral habits. So they truly had proper oral rest, posture for sleep during the day. And so, yes, they no longer needed that cpap. But, yeah, it's.

Which is amazing.

It is.

It's amazing that that can be Accomplished just by therapy. I mean, how many months of their weeks or months does that take of therapy to accomplish that, that.

So if someone came to us and they had had an open nasal air, you know, they were totally patent. An adult. It could be anywhere from like a couple of months to four months to six months, just depending on how compliant they are. I've had adults move through in just a couple, you know, like six sessions split over like two months. Whereas, you know, our younger pediatric cases might take six months to a year. Just by nature being younger and, you.

Know, practicing is harder. Yeah.

But yeah, I mean, it's. In more severe cases it's going to take longer just by default of having different professionals involved in different things that need to happen before we even maybe can revisit myofunctional therapy. And. Or we might be doing myo alongside other treatments. And so it is so variable. But yeah, I mean, some adults. Couple of months to. Yeah, four months.

Yeah, that's pretty great.

Which is cool.

Do you, do you know what the, what insurance coverage looks like for omt?

So when you go through like a speech pathologist, for example, we bill it under feeding therapy. So we have codes that we can diagnose like the oral phase dysphasia because they're not able to chew and prep a bolus properly and swallow bolus. They are with the. Or with the tongue tie. If they get diagnosed with, you know, that diagnosis, they have a sleep apnea diagnosis with all of those plus, you know, our diagnostic codes. And just feeding and swallowing therapy, it can get covered. And we've written plenty of. My entire practice is out of network, but we've written plenty of medical necessity clutters.

Sure.

You know, because it's airway I'm feeding and like, we're like, this is not necessary, especially for pediatrics. But, you know, adults with OSA and so on and so forth, and most of the time they get it covered. They get either a gap exception or they just agree, you know, to cover it at a network and they really don't end up paying anything more than they would have if they got in that work, which is really, really nice. So, yeah, it, it depends who you go to. I know if you go to like a dental hygienist who does myo, they can't provide the super bill with those codes because they're slp.

Yeah.

Type codes. So that's, you know, it truly is private pay without any expectation of reimbursement there.

But yeah, that's. And that's like you know, such a limitation for so many patients to getting the proper care for this sort of stuff. You know, with the expanders that we talked about, the dentist, dental stuff, orthodontics, unfortunately, so much of that is you pay out of pocket. And that's, you know, probably where we see a lot of discrepancy in socio, socioeconomic status and race in terms of the, the frequency or the incidence of obstructive sleep apnea and other symptoms. So, yeah, yeah, it's. I, I work in, I, I don't want to say say the wrong word here, but the area of town that I work in is a more underserved part of town. And so contrary to my north side counterparts, I have to think about a lot of those things when I'm talking with patients about options. Even, you know, Flonase sensimist, I tout all day, every day. But I also recognize that many of them can't even afford that 15 to $20 bottle or that extra $10 a month for something like that. And yeah, so though I have so much interest in this, in learning about all these alternative methods to opening the airway besides just what we can surgically do, I do recognize that for a lot of my patients, it's tricky.

Yeah, yeah, there is, there is a mom who was on my podcast, passed like way back when, who, I think her child was on Medicaid and she bought Medicaid and she got his ALF appliance covered fully. His osteopathic care covered fully. His mind, everything, everything was covered. She. But I mean, she also was like, she advocated and was like a beast. Like, and that's the biggest thing. It's going like toe to toe with insurance. And I think that even takes, not.

Everyone has the time to do that, right?

Time, education, knowing what to say. I mean, so we actually provide all of our patients, we offer this on intake, a insurance guide. And it basically has, it's a two page thing. It has all the questions, go and ask your insurance about this. Here are the codes, here are the fees. Ask them how to submit. You know, you need pre authorization, even though it's out of network. Can you request a gap exception? Can you, you know, all these things. And then we have a second one that, you know, we send also that just says like, here's how to submit your invoice. And knowing that this terminology is a little different from one company to the other and you know, find out from your insurance, what, what do you need? Can you just send in the super bill or do you need to attach a form or you know, what does that look like? So we really try to. Without even having like that kind of a billing department. Like we try to support our patients in getting access because we are in the D.C. metro area and we get a range. You know, there are some very wealthy patients and there are some who really are having a hard time accessing care. But you know, they will go to insurance and submit and they. And it's interesting too because sometimes the out of network reimbursement that they receive, whether it's through a GAP exception or just their traditional out of network benefits, they actually get more back than they would get sometimes if they go in network, we have found. And so they end up saving money and we travel to them in my practice or provide virtual cases too. So. And we don't charge like a travel fee. It's just kind of all built into our fee. And so, so yeah, it's. Once families kind of figure that out, they're like, oh my gosh, like we're never letting you go. This is so great. But of course, you know, it does, like you said, it takes time. They have to resubmit every three, six months, you know. And yeah, I was just helping a patient last night who had gotten a GAP exception and then apparently it expired. But we didn't get anything in the mail. They didn't get anything in the mail. And we're like, come on, uhc. Like, this is bs. Like, well, this is not okay.

That's what they do though, right?

So I'm like, I've been here before, you know, I was like, you need to ask for a retro authorization. Here's all the stuff. And so, you know, occasionally they'll, they'll tell me, well, here's an email they said it could be sent to. And I'm like, send me everything. I will send it from my email because maybe coming from the provider, maybe we'll carry more weight, even though I'm out of network and don't contract with them. But it's just, it's, it's really an insurance game and it's whoever is willing to play it. And it's true, even if you are going to in network because, you know, like, I know one of my family members went to a lab to have blood work drawn for that nasal surgery and other stuff. And because of the lab that they went to, even though in office they said that this person was in network, they got like a bill for 500 plus dollars for some blood work that was supposed to be Covered. And there was this whole, like, fight back and forth over, like. No, no, you said it was covered. And if it's not, because you told me it was covered and you checked my benefits, like you pay it. It was just, you know. And anyways, at the end of the day. Yeah, at the end of the day, like, it all got sorted out, but it's like, like, even when you go and network these days. Yeah, that's a run around with insurance. It's like we need a whole people of our healthcare system. That's a whole nother conversation.

I know.

Well.

Well, yeah. Yes, it is. And you know, they have, they have their own people working for them, their own actuaries working for them to find all those loopholes for us, for them to, you know, spend less money. But that is a very frustrating part of, you know, being a provider of any sort. But that's good to know about Medicaid because I just learned the other day, and I'm gonna post about this soon on my account, so I learned that like 50% of the pediatric population is Medicaid. On Medicaid.

Wow.

And. And that is. So I'm digressing a bit and I, I guess this is what I'm going to talk about, but our, my network recently made the decision to close their final pediatric inpatient unit, which, frankly, I was not happy about at all. And I shared my concerns and my thoughts about that. But I came across a New York Times article last week that talked about how many hospitals across the nation are closing their pediatric units. And when we kind of heard about the first bit of this, you know, it's like, well, it's all because money. It's all because money. And I, I didn't fully understand what that means. And actually one of my anesthesiologists that I worked with last week, we were talking about in the or, and he said, well, it's because the, the pediatric population is mostly Medicaid and the hospitals don't make enough money off of it to actually be able to employ pediatric specialists, to employ nurses. They said, really the only way that, you know, bigger children's hospitals here in Indianapolis, it's Riley children's hospital in St. Vincent's the only way that they really stay afloat is from the donations they get, get and the government funding that they get. And so it's, it's wild because, I mean, you know, here I think I, I work for this network that really just should serve the general community. We're not trying to take care of complicated Pediatric patients, but simple pediatric things. An appendectomy for me, a patient with severe obstructive sleep apnea that I do a tonsilectomy, adenoidectomy on, and they need to stay the night. Those should be able to be managed at our hospital. You know, and it seems silly to send all of that to those. To the tertiary children's hospitals, but it seems like it's not just here in our city. It's kind of happening across the country. And that was his explanation. So that's a completely different topic. But.

No, but it speaks to also the struggle to get kids the services they need. And especially when there's, like, airway patients concerns. You know, I hear you're saying this, and all I can think of, like, those wait lists are already like a year plus long, and now we're gonna have kids with airways wait even longer. I mean, not to downplay the other medical needs. Right. Of other children on those wait lists too. But it's. Yeah, it's just, it's.

I know, I know. I've already. So we got news of this a little over a month ago, and I've already sent six. Six or so patients that I would have treated. Yeah, I've had to send them elsewhere. And yeah, it's unfortunate because one of our children's hospitals has gotten a lot better recently. They've hired several pediatric ents. So I don't think the wait list is near as bad as it used to be, but it used to be, you know, three months to get in or longer to get in just to see a doctor. And you think for tertiary care centers like that, really a lot of those kids, they do need to see. Be seen more expeditiously. So, yeah, seems like such a burden on them. And then we're losing some volume, too. And I love doing the kids, so I will miss some of that pediatric population. But, yeah, so it's, It's. It's interesting and it is apparently the part of the dynamic of health care.

And it makes sense. I mean, I've seen. I have seen a little bit of that happening. And, you know, I know in some of the big cities especially, it's just so hard to access care, even though there's so many hospitals or there's so many doctors. And, you know, it's like, I know pediatric gastroenterologists are, like, few and far between. Like you would think. Washington, D. D.C. metro area, you could find one. And my uncle's in that space. And I was like, hey, who do you refer to? And he's like, well, like, there's only like a couple thousand in the entire, you know, United States of America. I'm like, right, right.

Yeah.

It's like, I feel like this day and age, things should become more accessible, not less accessible. I completely agree.

I completely agree. Especially what's interesting about that is, I mean, the expectation is definitely that things are more accessible. Right. We all want instant gratification. And it's funny, I'll hear patients will come in and they'll be like, I had to wait forever to get in to see you. And it's three to four weeks. And I think for. For an ent, like, pretty good, pretty good, you know, but they're thinking that they should be seeing me within the tomorrow, two weeks or. Yes, that I. That I am your urgent care, primary care doctor. I'm like, no, no, I'm the. I know. I'm a specialist. I'm who you get referred to. So, yeah, the expectation. And of course, with patients being able to access their records and everything, which is great in its own right, but there are some problems with that, too. Just that expediency and the urgency of everything. And so, yes, I agree that, that we. We should be moving forward, but to. To a degree, in a lot of ways, we're almost like the. The expectations, not just in medicine, but in general, like the business workplace. People are expected to work all the time and be at their email all the time. You know, the world is moving faster and faster. Medicine's not keeping up. I'm not sure that the world should be moving as fast as it should, but. Or as it is. But. Yeah, but, yeah. It seems like there should be more availability and better access for patients, and that shouldn't be going backwards, but.

But here we are. Here we are. Here we are. Well, this has been amazing. I don't want to keep.

Yeah.

But thank you, like, so much for sharing about your practice and what you do and how you work with your patients. This has been such a fun conversation. And I know, like, our listeners are always so excited when we have, like, an ENT on who can talk about different, you know, things. I think it also helps to arm them with a little bit more knowledge of, like, options and things that are out there. So thank you.

Yes, it's my pleasure. And of course, you know, I'm always available for questions, and I try and do like a Friday Q A every couple weeks. I started out doing it every week. It's too much, but, yeah, it's a lot. You know, I try to do a Q and A. So please you know I anyone listening? If you guys have further questions. There's so much that we didn't talk about but I appreciate Amy go to.

At need to nose on Instagram so they can they can link to you. But yes, thank you again so much.

This has been amazing. Yes, we'll stay in touch.

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