Episode 39: Tonsils: Should They Stay Or Should They Go? with David McIntosh, MBBS, PhD, FRACS (ORL)

Well, first, I want to welcome you to the Untethered Podcast. And thank you so much for joining us here today. I'm really excited to have you, as you're our first ENT to join the show.

It's a real pleasure. Thank you for asking.

Absolutely. So, first, I would love to know a little bit about what you do and what your focus is. As I know not all ents are created equal.

Sure. No, that's a fair comment. Sometimes the best way to explain the ENT point is to explain the process of how we get to where we get to. So my background is I'm in Australia, so we do our medical training, and then we do our surgical training. And the surgical training is pretty generic. You know, you've got to cover a lot of territory. Ear, nose, and throat is a big specialty. And then by the time you get through that training, you sort of, you know, within that specialty, find the bits that you gel with and the bits that you sort of, sort of not so keen on, and you continue to differentiate. So ent, you could have that, you know, being really interested in head and neck and throat cancer, or you could be really interested in sinus disease or ear disease. And for me, it was pediatrics and also airway. And airway actually includes pediatric and adult populations, but the big one was pediatrics. So when I finished all my ENT training, which also included doing a PhD along the way, went and did an extra year, just purely pediatrics, no adult ENT at all, just to really build upon that. And throughout that time, again, it was a major focus was on airway. And when I came out through that process, that's pretty much what I wanted to get out there. I wanted to get out there that we've got problems with airway. And I can remember when I would go and meet with medical, family doctors, and I'd say, look, you know, we've got to be on the lookout for kids with sleep apnea. And some of them were shocked to learn that kids even got sleep apnea. They'd never even known that that was a thing. So that's quite, I think, important, insightful to realize that across the medical spectrum, ENT or otherwise, there is a great diversity in terms of areas of interest and areas of knowledge. So when it comes to myself with ent, my, you know, my three big areas of focus basically, are pediatrics, airway, and nose and sinus disease. And they all actually come together quite nicely, so that there's a good integration there. And one of the things I noticed as I Sort of progressed through and has actually been a valuable part of my learning and education is that surgery doesn't fix everything. We can go and be the plumbers and get things unblocked, but that doesn't automatically default in it working again. And it wasn't until I stumbled across a few dentists that had an interest in airway above and beyond what my perception of what dental interest would be, that I could see that, you know, there's a lot of heavy hitters in the dental community that actually know a lot more about this than the medical general population do. So I started to work and integrate with them and then found these sort of, you know, areas where they thought they knew things about ENT that I could sort of just try and sort of guide and suggest that, look, I understand that that might be your understanding, your perception, but let me give you a different perspective and see, you know, how you might relate to that. And likewise, they've done the same for me. And then as you start sort of, you know, dipping your toe into that water, you start expanding your network, then you start to come across speech language therapists, myofunctional therapy. I remember doing a talk way back here in Australia in about 2009, and that was at a dental orthodontic meeting. We're talking about the importance of airway management as part of orthodontics. And the person that was running that seminar, you know, sort of just sitting there in the background, just sort of hearing what I've got to say, having never heard me speak before. And one person in the audience said, what do you do when your surgery doesn't work? And I just said, well, you got to look at myofunctional therapy. And it was like a pin dropped in the room because they were absolutely dumbfounded at a standard that an ENT that was never on their radar. You know, I was sort of obviously just, you know, coasting along in my own little world, as we often do, even, you know, had any insight or awareness. And I think that's really important is that unless you find these things, and sometimes you stumble upon these things by accident more than design, if it's not in your education, that will then lead to a better understanding and rounding of managing the problem. So that's your long answer?

Yeah. No, I love it. I think that's amazing because as I mentioned, we, you know, mentioned to you before we started, I polled some speech pathologists and myofunctional therapists and RDHs who are in the space, and I think that one of the issues, at least here in the US that we're up against is that there are not a lot of ents that are airway centric. And when we, when I discuss this with some of my patients, they look at me like I have five heads because they're going, but airway, Isn't that what an ENT does? Isn't that like, you know, in their job description? So, you know, it's, it's hard to explain that to patients because we're, you know, I know one of the big questions that we run into a lot is, well, what do we do when we have, let's say, enlarged adenoids, enlarged tonsils? I know, and I work with a lot of preschoolers and I know because I talk to ents locally, that there's a lot of risks that come with that surgery, at least for the tonsils. There's bleeding risk, there's dehydration risk. You know, I'm not sure there's other risks, but that's my understanding. And so I know they would prefer to not do a surgery if possible. But I think one of the biggest big questions we run into is, well, if we don't do the surgery, and we've now tried a round or two of antibiotics or, you know, Flonase or Nasonex or whatever we're using in the nose and you know, antibiotic wise, and they're not shrinking and they're still blocking the airway, but the ENT feels that the child's sleep is not interrupted or they don't get sick all the time, or they have a closed mouth posture, you know, when they're in their office, even though they're not necessarily looking at them while they're asleep or awake, and they have a orofacial myofunctional disorder, or they've got their selective eater because it hurts to swallow, or, you know, they've got functional impairment. We're up against the wall because then we go, well, how can we expect this child to close their mouth and make progress in therapy if their airway is not patent? So, you know, I guess my question for you is, like, what is your protocol? What, how do you address this? You know, and I guess the loaded question is, how do we talk to other ents or what do we introduce them to, to have them understand more of it from an airway centric perspective?

Yeah, so you put a great amount of detail on the table there, and I think that's going to fill out the rest of our chat.

Right, exactly.

But it's Good, because these are the common things. These are the things that come up repeatedly. So I'm going to do my best to rewind to what you reflected upon and try and start from the beginning as best I can, work through that. So the first thing you sort of mentioned is, you know, say, well, isn't that the domain of the ents? So it's all about understanding and perspective in terms of ENT being a big specialty, for starters. So. And it's interesting, ENT seems to be the specialty where people just in a general level don't get it. But when I give other examples, it clicks straight away. So the two examples that I give is that within general surgery, okay, you can differentiate into, for example, doing breast cancer work, or you could differentiate into doing bowel cancer work. Okay? They're both general surgeons. Okay. But if you're sitting in that chair and your family doctor says you got breast cancer, you don't for a second think about anything other than, I'm going to go and see the breast surgeon.

Right.

It doesn't, you know, it doesn't cross your mind that you're going to be sent to a general surgeon that does breast cancer work. You're going to go and see the breast surgeon. Likewise, the other analogy is that if you have a problem with your knee, you see an orthopedic surgeon, but you don't see the orthopedic surgeon that specializes in shoulders.

Right? Right.

You know, so you go, oh, so I need to go and see the knee surgeon. Okay. Now, sometimes there'll be a general surgeon that does a bit of both. Sometimes there'll be an orthopaedic surgeon that does a bit of both. But sometimes you have people that only do one and not the other. So we actually need to, in a way, reinvent the terminology of ent. You know, if you've got a sinus problem, you're going to go and see the sinus surgeon. If you've got throat cancer, you're going to go and see the throat cancer surgeon. You've got an airway problem, you're going to go and see the airway one. So it's not about having the ent. That's actually the wrong thing in terms of the specifics. The generalization is, yeah, you're going to go and see an ent, but you need to go and see the right one for the right reason. So likewise, if people come and see me with throat cancer, I sit in the to the throat cancer ENT because I don't do throat Cancer work. You know, they might come through my door, but I bounce them on. The problem we've got with airway is that people feel that they do airway, but they're not necessarily, you know, hitting with the same bat as some of us are. Okay? So that's. That's the first point, just to sort of understand an element of perception. So. So I think, you know, saying, oh, we need to send you to the ENT is actually as a starting point, undermining the progress you're trying to make. Okay, so you need to sort of, you know, reinvent the terminology, get people to understand that you're not sending them to the ent, you're sending them to the airway doc.

Yeah. And I say the air. I say an airway centric dentist, an airway centric ent, and people go, what does that. I think it's easier because we have dentists locally, to me, several dentists who are airway centric now, and this has even been within the last couple years, but we really don't. There's one guy I know about in Virginia who I would say is truly airway centric. There's another who I think is kind of. Kind of getting on board a little bit more local to me. But we still have a lot of kids turned away for services that we feel like they need to be treated for, you know, So I think that another question kind of going into that is, what other. What other terminology should we be looking for in, you know, is it just airway centric? Is it an airway ent? Is that pretty universal?

I mean, in a rough sort of nutshell, but I mean, they have to have some understanding and insight into sleep as well. And again, there's varying degrees of education on sleep and so forth. So, you know, you have these complicated things, and you've also got to know about allergies and so forth. One thing, again, just to give people some insight, is that if we sort of talk about surgeons as a general sort of thing, and I'm not being disparaging, I mean, the research and science is there collectively as a group, they tend to be on the narcissistic side of the spectrum, okay? And then coming with that is ego, and associated with that is a feeling of knowing it all. Okay? And then to sort of acknowledge that they don't know everything or that someone else knows more than they do is really not on their radar. And as a consequence of that, this is sort of following off where you finished is the analogy again, I use is religion And I don't mean to be disparaging. I think it sort of helps people understand something. So if I was to come to your home and tell you about my religion and tell you that you have to convert because I'm right and you're wrong on that level, it's not going to work.

Right?

Likewise, if you look at relationships, okay, so you're sitting down at a bar and I come up and talk to you and say, oh, you need to go out with me. Trust me, I know I'm good for you. You're just going to look at me and just go, no, actually, I think I'm just going to go join my friends, okay? You can't force relationships. And likewise, you can't be in the business of trying to convert people. What you need to find is those that have open to the suggestion and are happy to have that chat and have that conversation like this. I mean, you know, this. This came about by you asking me two days ago, can we have a chat?

Right?

You know, it was just. And you know, you can vouch for the responses, like, sure, when you want to do it. How about now? Because I want to get this message out there, but I want to get more than just what I know, but I think people need to get an understanding. Like you're sort of wanting in terms of how can we make this work better? So I think the first thing is you're already onto it. People are different. The second thing then is the criteria that people have. So when it comes to taking tonsils out just to reflect on what you were noticing, The thing is that infection doesn't matter if there's a blockage, okay? And you're going to get lots of analogies from me today because it helps people have a mental picture, okay? So if you wake up and go to your bathroom and your toilet is blocked, okay? There's no stench yet, but you can see it's not flushing, it's not clearing properly. You've got an obstruction, okay? You don't wait for the sewage to build up and the flies to come in and fester the place and so forth before you know that you need to fix something. Okay?

Yeah, yeah.

So when we deal with ENT, if we look at 80% thereabouts of what we do as an ENT, regardless of which part of ENT you want to talk about, 80% of it falls into two categories, infection or obstruction, okay? So ears, ear infection, or something's obstructed and they got fluid and can't hear properly, okay? Sinus, they're getting lots of infections or their nose is blocked and they can't breathe properly. Tonsils, they're getting tonsillitis, or they're big and they can't breathe or swallow properly. Okay. So it's infection or obstruction are the indications. And some people have both. Okay. And what we know, if we sort of bring it back to things like tonsils and adenoids in terms of, you know, how does that 80% then split out between obstruction and infection? When we do surveys of ents in terms of what they do, why they've done it, if we look at tonsils and adenoids, general ents, it ends up sort of being a 50, 50 split. Okay. When you go to pediatric focused airway ents, it ends up being an 80, 20 split. 80% of the time it's because of obstruction. So the majority of the tonsils that I take out have zero history of clinically relevant tonsillitis. Zero. Okay. And antibiotics are not appropriate. Okay. It's not appropriate to use antibiotics in the lack of, you know, in the absence of an infection. So to say, oh, look, we're going to give them some antibiotics is not a logical approach to the problem. Now, one of the things that's come onto the radar is the use of steroids, which is what you alluded to with Flonase, Nasonex, and there's plenty others out there, there. And there's some evidence that suggests that using those medications can help shrink the tissue down. The problem is when that has been then sort of reviewed and meta analysis and looking at things is that research is biased and potentially flawed. And my take on this comes back to what is the ultimate consequence to a child that cannot breathe properly. And then we come back to the science, and the science shows in terms of general health, two really significant body organs that we can't replace. One is the brain and the second is the heart. And there are brain consequences and cardiovascular consequences of not being able to breathe properly. And some of those consequences are reversible. Some of those consequences are potentially lifelong and permanent. And one of the analogies that I use in terms of what we know about this from the brain point of view is a ship that's off course. So if we have a ship that starts at point A and it's got a straight line to port B, if that ship is off course very early on in the piece and allowed to continue for a long time course, by the time we realize how far away we are from our destination, we've got a lot further to Turn back. And this is what we know is that there's two things that determine how a child is affected by this. The younger that the problem starts, the worse off they are. The longer they are allowed to continue to have the problem, the worse off they are. And what the science is coming back repeatedly in terms of a time frame and an age, is that the kids, in terms of how we stratify the worst of the worst kids where airway Problems start before 18 months of age are the worst of the worst. The next group under that, in terms of where the line in the sand seems to be is 4, the next line in the sand is 6, and the next line of the sand is 12.

Wow.

So that's in terms of, you know, sort of look at, you know, how, what impact does this have on different age groups? That's how it stratifies out.

Yeah, I know. I've read research, I just jump in here real quick. I've read research about obstructive sleep apnea in younger children and how, you know, very quickly, because of the killing of brain cells, it drops their IQ by 10 points compared to their same age peers who have, you know, no obstructions and nothing else going on, which is just, it's fascinating and scary at the same time.

Yeah, yeah, yeah. So that's, that's the age side of it and then the duration. And the duration. There's a couple of good studies out there now that seem to be replicating because, you know, we want to replicate this knowledge, but I want to sort of just rely on one piece of information and hang a hat on it that there's a replication of information that's showing that it's six months, anything. It only takes six months of this problem to cause a problem within terms of the brain. And actually you've used an important term there. And this is where you'll have to tolerate me a little bit because I'm really pedantic about terminology because unless we're using the right terminology, we're going to go off course. And then this is part of what I want to sort of share and reflect on too, obviously.

Yeah.

So when I talk about children, when I talk about airway problems, I don't use the term obstructive sleep apnea because that's only one element. I use the term sleep disordered breathing because sleep disordered breathing covers the spectrum. And given that we put that on the table, I think, you know, we use these moments of time and definition because unless people understand the whole picture, they'll then not understand why we're tripping up on ourselves. So historically, in terms of what happened and evolved was that in adults, we noticed that those that were having car accidents were also having breathing and sleep problems, which we called obstructive sleep apnea. That was the invention of obstructive sleep apnea was because of adults being tired and having car accidents. It wasn't because of any other health issues or concerns. But we came to learn about those other issues and concerns as time went by with adults, such as blood pressure, obesity, diabetes, and so forth. What we noticed was that we had these kids that were stopping breathing at night, and, you know, they basically had the sleep apnea. And we're like, wow, these kids can have sleep apnea, too. And we sort of looked at them some more, and they were the kids in general that were waking up tired and grumpy and miserable and not having, you know, great school performance and education outcomes. And we started sort of exploring that and going, well, you know, why are these kids blocked? You know, they're not like these adults that we're seeing, which was the stereotype, typical massively obese person. You know, these. The kids were, you know, thin as a rake, you know, weedy little kids, sort of almost sort of, you know, failing to thrive in some regards. And we started to notice that they were getting blocked because of their tonsils and their adenoids were sort of, you know, the big ones. And we started clearing them out the way, and we noticed remarkable changes in those children. So we sort of, you know, reinvented the wheel a bit and said, well, you know, let's. Let's go back to doing operations for these kids even though they don't have tonsillitis, because the ones that we're doing on is making such a big difference that, you know, maybe there's. There's more to be had here. So that was the beginning. So the problem with medicine is that to, you know, to make a diagnosis is we feel the need to measure it. So we started doing sleep studies in kids and sort of saying, all right, we've got this line in the same with adults snoring, sleep apnea. Let's put the same light in the sand for kids, you know, do the sleep study. Yep, they stop breathing at night. Okay, we've got a reason to justify the surgery. It's got risks. And we'll come to that, because I think it's all about perspective and context. Do the surgery. But, you know, any kid that had a normal sleep study was like, oh, no, there's nothing wrong with them. But the problem was we could see that these kids were having similar problems. They just didn't register on the sleep study. So we started extending the idea a bit and sort of think, well, maybe they can have a normal sleep study, but they've still got a significant degree of obstruction. We need to invent a new term. As soon as we've got a name for it, we can actually fix it beforehand. You can't fix it if it doesn't have a name. So we call that upper airways resistance syndrome. And that basically is kids where they are struggling to breathe at night. They were passing the sleep studies, they weren't stopping, they weren't having apneas. But you could see just physically looking at them, there was a massive amount of effort and struggle just to get what should have been a normal, easy breath. And again, they were waking up tired and they were miserable. And we dipped our toe in the water and we started ignoring the sleep studies and started fixing them. And they started getting better. And then we sort of went next step along, said, look, we've got these kids that are snoring on a pretty regular basis. And we started doing the same thing. We started fixing those that had signs of sleep problems, daytime function problems, and they started getting better. So we thought, look, we got to invent a term for this. We can't just say it's snoring. We used to call it primary snoring. Sort of say, oh, look, they snore, but they're okay, but they weren't okay. So then we called it sleep disordered breathing. Sort of try and cover the spectrum. That wasn't enough because the next group that we caught hold of was the mouth breathers. And then now we've put mouth breathing into that spectrum as well. So when we talk about kids and the impact it has on them, it's actually not even the degree of severity of their sleep disordered breathing that necessarily relates to the impact upon them. Some kids are very vulnerable to low oxygen levels and some kids are very resilient. Just like again, analogy, some people can pick up a cigarette at the age of 6 and smoke to the age of 110 and it doesn't touch them. Other people, they're dead before they're 40. Okay? It's the same environmental insult, but your genetics have a role to play in terms of your susceptibility and protection to that insult. And I'm certainly not advocating that people take up smoking to find out which side of the fence they're on. So when it comes to kids, you need to be aware that there are going to be at times kids that have got big tonsils and they're actually okay. It's completely contrary to what we want to know and believe, but it's possible, but it's not the majority. So that's the spectrum. We talk about kids, we sort of go, let's talk about sleep disorder breathing, because that just covers everything that I've mentioned as a group. And then we can sort of, you know, pick those out and talk about those individually. But the kid's brain, the heart, you know, that sleep disorder breathing as a spectrum impacts on that. It doesn't have to be the sleep apnea. And I think that's important for people to realize because my understanding to some degree is in terms of how the American healthcare, which I'm guessing is the majority of your audience is driven, is that it's not driven so much by clinical decisions, but by health insurance protocols. And one of their protocols is that these kids need to have a sleep study to prove they've got sleep apnea before the surgery can be done.

That was one of my next questions is do we need sleep studies? Or I basically tell families, I'm good with you skipping the sleep study. We know there's an issue that needs to be treated and we're going to treat it. The only reason why the ENT may send you for a sleep study is if we need that for insurance to then cover the procedure to remove the tonsils or whatever the case may be. I mean, it sounds like where you're going with this.

Yeah, well, I just, I just want people to understand. So we don't have that requirement here in Australia. We're still allowed to apply clinical judgment rather than being dictated to by bureaucracy and being gang. Yeah, well, exactly. So for me personally, I can count the number of children that I have referred for a sleep study preoperatively on my fingers and still have fingers left over in, you know, 17 years of clinical ENT. Okay.

Because I also just wonder, you know, the impact on the child putting them through that sleep study. And I've had client, I've had patients where three year old who was one of the worst cases that the ENT had ever seen. He said worse than overweight middle aged men. As far as her obstructive sleep, he said it was absolutely obstructive. He sent her for an emergency sleep study and then put her in for an emergency. I mean, he had to apply these words to the case to make it happen. Within two weeks of initially seeing her. That was an emergency, was two weeks.

And we see kids like that.

Yeah, yeah. But you know, it was just, it was incredible to see the hoops they had to jump through because of the American health care system.

So, yeah, yeah, look, and look, I'm not going to be disparaging about countries and health care systems because no country's got it right. But I think it's important for people to understand the differences that exist because I can talk about things and people can be like, that's a very foreign environment to be working within. So I think it just, you know, if I just appreciate, I do know these things exist over there and they're different to over here. And personally, I think they're ridiculous to say the least in terms of how it all works, you know, and you know, the other nonsense is just how expensive it is over there. Like, I've sat down and done the math, having talked to people. When you look at your CO pays and everything, it's cheaper. And people are astounded by this. It's cheaper sometimes with your co pays in terms of if you've got to do the co pay for your sleep study, then you've got to do your co pay for your surgery. It's cheaper to jump on a plane with your child, fly to Australia, pay someone in Australia to do it, stay here for two weeks to sort of have your post op recovery, fly back home, you've still got change left over than if you'd gone through your insurer in the United States. So, you know, it's a bizarre scenario where that can actually even exist. But that's politics. We're going to stick to clinical stuff. Yes, but part of that then is actually deliberate leading because of what you reflected on. What is the reluctance to doing the surgery. Now there's a couple of things about surgery, regardless of how you want to talk about it, that need to be clear in people's minds. Okay. The first one is that there are always risks, always risks. We need to move away from this idea, is it a risky procedure or not? Or how risky is it? Because that's very subjective and we can compare, we can say, well, look, you're comparing it to like brain surgery or heart surgery. You know, we can say, look, you know, within the spectrum of surgery, or there's varying degrees of risks, but there's also benefits. Okay? And if you've had a heart attack and you're faced with a choice of look, you can have the surgery, it may not work and you'll die or don't have the surgery, in which case we know you will die. You accept that there's a risk of death with heart surgery because there's a benefit there that doesn't exist by doing nothing. So everything comes down to a risk versus benefit equation. So if we're going to focus specifically on tonsils, in terms of why is there a reluctance? Well, a lot of it comes down to personal choice and preference. Some ents are really uncomfortable just with operating on little kids. It's not been their familiar territory. Just like I wouldn't be comfortable operating and doing brain surgery. It's not my thing. Okay. So some people just have a certain age that they feel comfortable with. And that's not to say the surgery is inappropriate or appropriate based on age. It's based on their preferences. So there's no magic age in terms of when it needs to be done. Okay. There's no like, oh, we need to wait until they're two, or we need to wait until they're four. There is no waiting in terms of relieving these obstructions. And the thing that. In terms of risks, I'll go backwards to what you mentioned, because you mentioned dehydration first. The reality is dehydration, in all truth and honesty, and I'm not trying to sound callous, is no big deal. We know that the kids will get sore and they'll get miserable and they'll have trouble eating and they'll have trouble drinking and they will lose maybe even 10% of their body weight in the process of just getting through it. But they will get better. And, you know, if your worst case scenario, and this is your worst case scenario for that scenario, is that they need to come in, have an IV put in, have a top up of fluids, that's no big deal.

Yeah. You know, that's just kind of a scare tactic that I feel like they use. Oh, you know, we might have to end up in the emergency room with an iv. And I'm thinking, yep, yep.

Well, if your child gets. No, but if your child gets bad gastroenteritis and significant vomiting and diarrhea, you know what they're going to get? They're going to get an IV influence. People panic about that scenario. No, not the slightest. So we shouldn't be generating unnecessary panic about the same scenario.

Thank you.

In a different context, because that is scaremongering at the end of the day. All right, so that's one element to it. And then, you know, everyone has different experiences to it all. So again, 17 years. And I've done countless tonsillectomies in a wide spectrum of ages. In terms of my personal numbers that have then had to come back under this scenario into hospital and need a drip with IV fluids is less than 20 cases. Okay, all right. So it's all right to talk about how bad it is, but also how often does this actually really happen?

Right?

So that's that scenario. The scenario that is actually more significant is bleeding. And again, there's an element of understanding and context to it all, because otherwise it gets lost in terms of translation. Anytime we cut something, it bleeds, okay? And that needs to heal. Then once it's fully healed, then we're back to how we were. And in the meantime, if where we've cut ourselves, becomes traumatized or re injured, it can bleed again. When we take out the tonsils, they're at the back of the throat. We can't put a band aid over that. There's no magic dressing that we can put on there to cover and protect it. So we're left with a scenario where we leave a raw surface area. Now, one of the remarkable things about the oral cavity is how well it heals. People know that because when a tooth falls out, it bleeds a little bit, and then it's done, it's starting to heal. You bite your tongue today, you have a look at it tomorrow, most of the time you'd never know it would happen. Certainly two or three days later, you would never know it has happened. It has a remarkable ability to heal. So we can use that in our back pocket as sort of saying, well, look, it's not great that we're leaving an open wound, but we're doing it in an environment where it's actually going to cope really well. And there's a time period, usually roughly around about day four to day six, where the surface scar starts to fall off. The scab, sorry, starts to fall off. Not the scar, the scab starts to fall away. And you can have a raw surface underneath. And with that raw surface, if it's still in the process of healing, you can get some bleeding. And when we do sort of, you know, thorough, rigorous assessments of bleeding, you know, probably close to half of people that have their tonsils out will have some form of evidence of blood show up. So having some form of bleeding is normal, but we've got to look at when is that element of bleeding significant. And that element of bleeding is significant when it's a large volume. And, you know, depending on the age and the size the smaller you are, the less you've got to lose. So one of the important things to understand is that, yes, definitely, in children in pediatrics, it's actually a riskier operation in terms of the potential consequence of blood loss. But let's look at the scenario. So what happens if they have a significant amount of blood loss? And for me, like, you know, depending on the age and the person, I sort of try and give parents sort of some sort of sense of parameter that they can relate to. And I say, look, you know, if it's a teaspoon or a tablespoon of blood, that's nothing. You know, that's a small. Don't panic. But if they've got a, you know, a good mouth full of blood, that's a volume that's worthy of attending the hospital to have an assessment. And when we look at the numbers and so forth, that's roughly about 4% of the time where the parent will feel the need to go to hospital to get things checked over. So 96% of the time, this child never sees the inside of a hospital again. And then of that 4%, where they turn up, the majority of the time, that bleeding stops by itself. They don't need any intervention. They stayed, they're observed, they've had an episode, it's spontaneously resolved, they go home, that's the end of the story. There's a small group where there's a persistent ooze. It's not a major amount of bleeding, but it's oozing a little bit. We can put an IV in and we can give them medication to thicken up the blood, to help it form a new scab. Okay. If it's not settling, if it's significant, then, yeah, we take them back into the OR into the operating theatre and we go in there and reseal it. And in that scenario, you know, depending on where you're looking at, you're looking at overall about 1 to 2% of children. So 98 to 99% of children never see the inside of the OR again. So that's the risk in context. Okay. So you can't. You can't change the fact that those risks exist. You have to accept that they are real and you're ready to manage them.

Yeah. Much more of a benefit to do the procedure.

Yeah. So that's. That's the next. That's the next bit that we swing around is like, why?

Before we go into that, I have one more question. Because we have ents locally who will do a partial tonsillectomy where they are telling the families they're taking out 80% or 70% of the tonsils, but it's less of a bleeding risk, and that's why they do that. But then my question is, can't they. Can't regrowth happen at that point? Much easier. Or, you know what, is there a benefit to that? Or is that. What's your opinion on that?

So again, I'll just help you with the terminology just so that people can explore the topic further. So the removal of the tonsils is called a tonsillectomy. The partial removal is called a tonsillotomy. Okay, so it's a partial, you know, we could call it a partial tonsillectomy, but it's technically, it's a tonsillotomy. If we go back historically, history is a great teacher. Tonsillotomy as a word exists in the literature in the early 1900s. Okay. So they were looking and exploring at doing this sort of thing for these sorts of reasons, and they abandoned it. Okay. And if we. And then, you know, as technology has come about and we have new tools and instruments, we go back and revisit ideas and try things. And that's where tonsillotomy is, having a reemergence of things. And if we look at the literature and so forth, on the surface, it sounds really appealing for the reasons that are espoused. Yes, it is less painful. Yes, there is less bleeding problems. Yes, it contributes to relieving the airway obstruction. But what is the longer term viewpoint of these things? And people don't want to look at that because one that takes effort. It's just like, I've seen that one, I fixed you. I want to move on to the next one. But the stuff that's coming out is showing that if you go back and then three years post surgery, okay, three years down the track, go and look at these kids. There's one paper that shows 19, that's 1 9. 19% of the children, their tonsils have grown back to the point that they're obstructive again. Okay, that's a pretty high failure rate. You know, you can sort of say, well, 80% don't we go, yeah, but 20% do. So if I had a treatment for cancer that was 80% effective, 20% failure, you probably go, you know, look, that's pretty good, but you'd be looking for something better. Yeah, okay, that something better is a full surgery. Because there's an irony to this, because one of the issues with taking the adenoids out is the problem of them growing back again. And a lot of that's got to do with technique and experience and all sorts of variables. So, you know, one of the problems we lament is, oh, no, the adenoids have grown back. You know, we were so focused and determined on getting these adenoids out as best we can, as thoroughly as we can to limit or mitigate that risk. But at the same time, we then go and accept deliberately a partial operation. There's a. There's a logical disconnect there. And, you know, in some regard, it's probably marketing more than science that people are falling back to. And I'm not trying to be disparaging, just trying to say, look, this is it. And what's really insightful is that there's a research paper that's published where they present their survey parents and say, look, this is, in truth, everything you need to know about a tonsillectomy. The whole picture, not just our, you know, the good bits, these are the bad bits. This is the whole picture on tonsillotomy. Okay, you know, these are the good bits, which, you know, you're hearing, but this is the downside bits, which get underplayed. And then they said, you know, if faced with the choice, if your child needed the operation and you could choose from one or the other because they're, you know, there's no half ways it is one or the other, which one would you favor? Most of them favored the tonsillectomy. So you can be sold a story of, you know, it's less pain, it's less bleeding, it's a much better recovery and so forth, and you'll do it. And you go, wow, that was so right. That was so much better than my next door neighbor that went and saw someone else that did the tonsillectomy. I feel validated and happy that I made the right choice and did the right thing and so forth. And you sort of get, you know, that confirmation that, yep, you know, this was excellent. You're so glad that you were led down that pathway until the problem comes back. And then you got to go through the OR again and an anesthetic again and the full proper surgery again. And that's one in five kids that. That, you know, when it could have just been done once. So. So that's. That's, you know, my perspective. That's my perspective. If you will look at it from a scientific point of view. You know, I don't know what history is going to teach us this time, you know, around. But, you know, part of the problem is the people doing these procedures are not watching these kids for the next three years. You know, they're not coming back and getting, you know, six month reviews to see if they're growing back to see if they're in that 20% failure group. So you know, as you can sort of read between the lines, I'm not a fan.

And building on that a little bit too, we get a lot of, we refer to them for airway and we would really like somebody else to maybe do the frenectomy at a different time because we'd like healing to occur for the airway first and then let's deal with the tongue. But the issue that we run into a lot in the US is well, they're now seeing the ENT who notices from our report or notices when they look in the mouth that the child also has a tongue tie and or lip tie. And then they decide let's do the tonsils, the adenoids and the tongue all at the same time. Which in my opinion from having seen some of these cases is just a major disservice to the child because when you release the tongue and then they're dealing with a major, you know, healing of the throat, they don't want to move their tongue around. And now we have a, you know, a child whose tongue wasn't functioning well beforehand. We got them ready, we got them to the point of being as ready as they could be for the frenectomy with the pre op myofunctional therapy and now we're sending, I just feel like we're setting them up for complete failure. That's my opinion. I'm not an ent, but you know, I'd love to hear your opinion on that.

Yeah, no, no, no. It's a perspective that's held in some circles and I totally understand where it's coming from. And I'll be honest, I personally don't have a reluctance or a concern about doing it all in one setting. Partly because I want to limit the anesthetic exposure the child. And secondly. Yeah, yeah. And if you actually look at what you can achieve with a frenectomy under a general anesthetic versus under some form of office based procedure, we can really get down to those deep fibres then that genioglossus attachments with so little effort under a general anaesthetic. The problem as you're alluding to though is the rehab. That's the problem. So one of the perspectives that I might sort of spin around in terms of just Reframing the thought process is that you have, you know, in terms of how you're looking at it, you've got, you know, two scenarios that you could possibly, you know, recalibrate here. One is we just do the tonsils and adenoids as step one with a planned frenectomy. Down the track is step two, you know, so there's definitely two procedures. That's an accepted plan. The other alternative is, look, whilst we're there, let's just do the frenectomy. There's going to be a group of kids where that's actually going to be successful. They're actually going to do just fine out of it and they're not going to need that second procedure. But in that group where that doesn't play out and we need to go back and do it again. Well, in your original scenario, you were going to be doing it again regardless. So we change the scenario from two definites to one definite and a maybe. So it's not necessarily always going to be, you know, successful, but when it is, you've spared that child a second procedure.

Yeah, and that does make sense. I think what we run into though is we also feel like if it is local and I'm very fortunate because I have an oral surgeon who does do procedures in office, but he does procedures all day long in the mouth and so he's highly safe, skilled and so I'm very lucky. So, you know, whereas I know some people in office may not have the same, you know, level of sedatives or I don't know. But he's highly skilled with the tool that he uses and, you know, so I. Much so, I guess, yes. We're putting them through two procedures. It's a local anesthetic in his office he can do general, but it's, you know, we're only doing that with certain kids and if we were doing general, it makes sense. You might know that a lot of the ents have shared with us we don't want to put especially a child under general anesthetic twice. We want to, you know, especially you.

Want to try and limit much longer.

Road if we have to do it a second time because we have to wait for a certain period. So I get that. So that does make a lot of sense.

Yeah, well, that comment about anesthetic is actually not true in terms of the modern agents. So in the past that was true. So anesthetic agents, we did have to wait, like ideally had to wait a month before you could accept someone a second time. The anesthetic medications that we use these days, you could have it every day for a week. And there's no cumulative effect in terms of the things that used to happen in the past. The concern though is whether there is an impact of these drugs on the brain that we're not fully aware of. So like any medication, you've got to realize an anesthetic is a medication. Any medication you want to use the least amount possible for the least amount of time on the least amount of episodes. But if you've got to use it, you've got to use it. So if you've got diabetes, you need insulin. Well, look, you're going to use insulin, you've got high blood pressure and you need medication for that, you're going to do that. But if you need an operation, well how can we limit it, how can we moderate it? And I do do in office frenectomies as well is just that if that child has other ent things and they're going to have a ga anyway, well there's an opportunity there for the sake of what's involved to just make the most of that opportunity. Whether that always plays out successfully or not is acceptable in terms of when it does play out and you know, it works, it's the second procedure they don't need, you know, and we worry about, you know, putting IVs into children for fluids. Well, you know, you've got to be mindful about putting needles into kids mouths and coming with, you know, scissors and lasers and you know, whatever scenario that you want to portray, there is an awareness there of sorts that can have an impact on them psychologically. Under a general anesthetic you've mitigated that. So I think it, you know, I'm always mindful of talking about absolutes. I think you sort of look at these, you know, sort of different shades of grey and you just say, look, you know, you can be absolutely opposed to all these things being done all at once because of the times it doesn't work can blind you to the times that it does. So like I said, you know, I'm not, I totally understand, you know, the background to it, terms of the concerns and why, you know, on paper it's, it's nice to do them separately, but I wouldn't be overly dismissive of the benefits of doing them concurrently either. Just to give a different view.

Yeah, yeah. Thank you. Thank you.

No, no, that's all right. So. All right. So just going back again to sort of what we were talking about before. Sort of trying to get your sort of early opening statement. I think I've covered most things other than how do we sort of get them on board, but we can come to that. But we were going to talk about the benefits, so I'll do the benefits really quick and easy. The Sentinel paper that this came out in 2006 and it's one of the papers that I sent to you preemptively, and it was talking about kids with adhd. So when this paper came out, that was actually the same year that I was doing that year of pediatric ENT, just pediatric ENT. That paper came out and when it came out and I read it, I took it to the people I was working with and I said, guys, we've got this all wrong. And the reason we got it all wrong is that paper was talking about children being given a diagnosis of ADHD or add, depending on how you want to describe it, and showing that these children were turning up to an ENT clinic because of sleep apnea. And at that time they were talking about sleep apnea just to sort of talk about things in the context of history. So they were talking about sleep apnoea being the pathology then. So they're turning up and they were scheduled for adenotonsillectomy. Those children were assessed by a childhood psychologist, psychiatrist for the criteria of ADHD, and a lot of them were meeting that criteria 12 months after their surgery. Next to none of those kids were meeting that same criteria. So we have a problem with where a child with behavioural problems, concentration problems, education problems, depending on where they first present and end up, will determine if they've got sleep disorder. Breathing will determine whether they get drugs or whether they get surgery. And the drugs are known to disrupt sleep patterns. These amphetamine drugs are not good for sleep patterns. They're calming during the day, but they're additionally not good for sleep.

I actually took them as a college student when I got diagnosed with adhd and probably because of my tongue tie, I was probably actually having sleep issues since I had never had a problem prior to the age of 19. They said, well, this is very bizarre because you have a high iq, except you're, you know, you're matching all the symptoms of. You're not the typical profile and you made it with great grades and no behavior problems through most of your life. Yeah. And so. And now, now that I know better, it's fascinating. But I've also read about this research and I would agree with you, and with this research that a lot of our kids who are, you know, presenting With a lot of these behaviors all have sleep disordered breathing, and they're all being medicated. And I know from being on those meds, you don't want to eat, you're very irritable, you're not. It basically changes you as a person. And then you have sleep issues at night because you're so wired from, you know, the stimulation of these medications. And then, you know, whether it's time released or it's every four hours that you're taking it, it's still. They're not healthy drugs. And I think they're now figuring out the long, they didn't know the long term effects of them either back when it put me on them, when they put tons of these kits on them. And so, you know, I think that there's still time for us to even figure out what the true, true long term effects of these medications are.

Yeah, absolutely. And, you know, we're treating the wrong, we're treating symptoms, we're actually treating the wrong, wrong diagnosis. So in some countries, and mine is not one of them, and I suspect yours is the same, but in some countries, you cannot make the diagnosis of ADHD until the sleep has actually been formally assessed. You're actually not allowed to make that diagnosis or prescribe any medication for the same.

I think they do. They're not doing sleep studies here or looking at sleep necessarily. Yeah. And pediatricians are now apparently just handing out these medications without even doing complete workups and actual assessments on adhd.

Yeah. And the other interesting thing is that there's a whole range and spectrum of sleep assessment. So when we talk about sleep study, we sort of have the mindset of looking at it from the breathing point of view. But there's a whole range of other sleep assessment tools. And if we, and this is published research is if you use all the battery of those tests, which is, you know, pretty, pretty intense process to put a kid through. When we do that in the ADHD kids, we can subtype the kids into five separate groups based on the outcomes of their sleep assessments. So we've made, you know, history, you know, is all about making mistakes. The future is all about correcting those mistakes.

Yeah.

So when I, you know, look at, you know, what impact is it having on the child? Because you sort of also had that and said, oh, look, the child's okay and so forth. Well, it depends what questions you ask before you can be certain that they're okay. So at nighttime, the things that I look at is, are they sleepwalking, are they sleep talking? Do they have night terrors? Do they grind their teeth at night? Are they tossing and turning at night? Are they sweating at night? Are they moving around the bed at night? Are they having to wake up and go to the toilet frequently? Are they having, you know, waking up and coming into their parents bedroom at night? Are they waking up tired? And then during the day, do they have troubles with their concentration or their behavior or their energy levels or their emotions or their education? You know, there's a spectrum of things that can have, you know, an impact on those things. But there's any suggestion that breathing is part of it in terms of a sleep disordered breathing, you know, issue? Well, we've got to get that out of the equation. You know, not every kid with ADHD that has sleep disorder breathing, when they have the tonsils and adenoids out, has their ADHD disappear. They actually happen to have both. Kids can have more than one thing going on. But let's get the obvious stuff out of the room first and then you can see what's in the corners.

Right. How do you make a differential diagnosis until you've ruled out all the underlying possible causes?

Well, if you get the big things out there, the way, and then you can deal with the other stuff. But the other thing is dealing with that other stuff then becomes a lot easier too because one, you know, it's there, you know, so for example, we know that kids that have true ADHD and sleep disordered breathing that need medication and you know, the medication works quite well and when it's used in the right scenarios, when we deal with their sleep disordered breathing, they still got the adhd, they need less medication as a group. So you know, we're using the least amount of medication to achieve the same effect because we're not having to over medicate on top of the sleep disordered breathing.

Yeah.

So that's that part of it. And then the problem too then is the parents and it's not their fault. But parents really don't know understand that these are problems until someone tells them that, you know, they, you know, oh yeah, they've snored for a long time and always thought it was cute. You know, all they, yeah, they snort terribly just like their dad does.

Yeah.

And they all, they go, oh geez, they're miserable and grumpy things in the morning. You know, just to sort of saying that's just who they are without realizing that that may be a manifestation of something underneath.

Yeah.

So that, that's that side of things. So, so when, you know, when The ENT say they're up. Okay, well, are they okay based on that full and thorough assessment or they're okay because they don't stop breathing at night? Because that's not the same. Okay. In my book.

Right. Yeah. Well, I know that the scale that was even created, that Gilliam and he created with the. I think he. I don't know if it was just three levels or if there were four, but I know it was like mild, moderate, severe, you know, sleep disorder, breathing, or sleep apnea or whatever he termed it. I know he's actually. And he's since passed, but I know that he had made a statement that he was sorry he ever created that because even mild is still a problem. However, in the US it seems that people get a mild diagnosis of sleep apnea and they get written off like, oh, you're fine. Send you on your way, which, no, you're not fine. You shouldn't be showing up with anything.

This is where the mistake truly lies, is that if, you know, let's focus on this part of it. Again, this is all scientific in terms of what's out there. Yeah. Normally with a disease process. Okay. Like diabetes is a perfect example. So with diabetes, that all relates to your blood sugar or your blood glucose, blood level. You know, you go to a lab, they measure it after you've been fasting for a while and a certain number is the threshold. That threshold is a statistically derived number and it's based on the higher your blood sugar goes. At what point is the tipping point where the risk of the consequences becomes so significant that it's worth treating and say it depends on which lab and countries and so forth. So let me just use an artificial number for a moment. So let's say the threshold is 6. Okay. And then you measure 5.9 and I measure 6.1. Okay. You know, statistically, I'm on the bad side of the fence and you're on the good side of the fence. So we need to have a line in the sand. Okay. That land of sand was created scientifically. Now for me, they would start going, look, you're actually, you've jumped over that side. We're going to try and start pulling you back. For you, they'd say, look, you're really close to it. You know, there are medications for it. You know, we're going to have to monitor this closely. But, you know, heads up, you're on the verge of us calling you diabetic. You need to reevaluate your diet, your lifestyle and start, you know, Trying to moderate things so we can get you away from this line and get you away from the need for medication. So that's how we come to something like diabetes.

Yeah.

When you look at the sleep apnea criteria, you know, 5, 10, 15, 30, all very round, nice, comfortable numbers. Absolutely zero correlation with risk. They were just nice round numbers in terms of representing the quantity of episodes. Because the theory is that the worse you are on the spectrum of those, the more at risk you are. There's a very poor relationship between your sleep study result and your degree of risk for consequences of having sleep apnea. So that's one thing. The second thing is that sleep is not a constant experience. So if we take you and we do a sleep study tonight and we do another one tomorrow night, so we do same person, same environment, two in a row, 44, 0, 40% of the time, we'll get a completely different measurement. Okay. What that means is that if, for example, today. And these are things that can have an impact. All right, so today you went to the gym, did a big workout, you came home, had a lot of work to do, stayed up a bit later than normal, had a few extra glasses of red wine than you normally would have, went to sleep. We did the sleep study. We go, oh, my gosh, you got sleep apnea. We got to fix this without checking it the next night, which could be perfectly normal. Okay, so the things that actually change the sleep, it changes with the day of the week that we do it. So people tend to run a bit of a sleep debt because of the way that we live these days. So by Friday, you tend to be tired more. So your sleep study result will be more towards representing the fact that you've got some tiredness and fatigue within your sleep. Whether you've done exercise the day before affects your sleep study the next night. Whether you work shift work affects your sleep study result. Whether you've had alcohol affects your result. For women, where they are in their menstrual cycle affects their result. So what we've actually look at, if we want to get a good representation running average of sleep, is we actually need to do four nights in a row and then average those four nights out to sort of say, look collectively, this is where you're at. But we don't do that. We take snapshots which can be misrepresented in either direction. We can be saying people are perfectly normal when they're not. We can be misrepresenting where they are on the spectrum. On average, when people do these sleep studies they may not drink the red wine or alcohol that they would normally have because they're all wired up and they're just like, stuff this, I'm just going to go to bed. And they'll look perfectly fine. But, you know, the alcohol is their tipping point. It's the thing that knocks them over the other side. But they didn't do it because it was an abnormal situation. So we have these sorts of variables that come into the mix that actually make this story a lot more complicated than it is on the surface. And then the other thing is that if we sort of rewind and look at the experience we had in children, we sort of borrowed the adult stuff and then we kept rewinding the, you know, pushing that line in the sand back further and further and further until we said, look, they don't even need to snore. They're just. The mouth breathing's enough. What we now know in adults that are snoring, that have normal sleep studies, and you've got to be mindful of what a normal sleep study does based on what I just explained, but they are snorers. With normal sleep studies, they are at increased risk of having thickening of the blood vessels to the brain. So that plaque that builds up, we call it atherosclerosis or atherogenesis. So it's those fat plaques that build up within the blood vessels to the brain in snorers. Increased risk between 7 to 11 times the increased risk with a normal sleep study when you take all other variables into account. So we have a problem with relying on sleep studies. If you had a blood test for anemia, which is a low blood count, and it came back as normal today, but that you're anemic tomorrow, nothing else has changed. There's a problem with the test. The problem with this test is we're measuring something that varies. And this is where, you know, people say, look, you know, I had whatever and it cured my sleep apnea. Well, did it really cure your sleep apnea? Or did you have a different night's sleep that night compared to the one where they showed you that it had sleep apnea? So you can get caught out with these, with these measurements just because of the variation that sleep entails. So that actually makes this story a lot more complicated rather than simplifies it. But it also brings awareness to it so that people know that, you know what, I don't care what anyone says. I know that people telling me that I'm snoring terribly and I'm waking up feeling really bad. The sleep study might be saying that everything's okay, but that everything that is okay isn't necessarily the be all and end all in terms of what the sleep study is trying to tell us.

Yeah, yeah, that makes a lot of sense. And so. And I know you have a whole book on sleep disorder and breathing and the like, and I don't know if you want to share anything about that, but you can show us the book so we can see it. For those who are watching this, bring that up there.

Hopefully that comes through. It's always hard to know how the resolution is on the end of these things.

It's great.

So people, one of the first things they notice is the title is Snort to Death and find that all a bit intimidating at one level. But as you read the book, I explain why I chose that title. Because it's a play on words. Play on two words. One is bored to death. Sorry? Bored to death. People that are sort of sitting around, lacking energy, lacking enthusiasm. They're bored. They're just dead bored. Yeah, that's people with sleep apnea, with sleep disordered breathing. The other one that you know that is out there is, you know, bored to tears. So these are the people that are upset and emotional. That's your people with sleep disorder breathing too. And the cumulative effect of not breathing properly is an early death. It's an impact on not only your health quantity, but your health quality. We're talking about a propensity to putting on weight, a propensity to high blood pressure, a propensity towards diabetes, propensity towards dementia, propensity towards heart attacks and strokes, kidney disease, liver disease, every single body organization impacted by not breathing properly. And the analogy that's in the book that you know is something that resonates with people is that if you put your bed to child, you know, your child to bed at night and someone walks in through the front door, walks past you into their bedroom and starts choking your child at night. How many parents are going to accept and tolerate that scenario? Repeatedly? The consequence of what that person is doing to the child, choking them, is obstructing their airway. That's the consequence of it giving me chills. This is the point of it. I mean, this is what you have to do sometimes to drive it home. It's exactly what the child is doing to themselves. Yeah, it's exactly the same scenario, but the mindset is approached differently. That person walking in there, that person's going to be at the end of a shotgun or a 22 real quick, that person's going to be, you know, incarcerated and jailed and imprisoned and so forth.

You don't put up with it. You don't tolerate it. You would not tolerate it, would not.

Tolerate it that night, let alone let it persist. Know that that's not good, that's not acceptable. If you don't know that your child is doing exactly the same thing to themselves, if you're unaware, then it's very easy to be dismissive. And that's not a criticism. You don't know what you don't know. But as soon as you know and you fail to act and you fail to follow through, that's when you're taking some responsibility and ownership for the problems that your child then is going to develop later on in life. And that's what I go through within the book. I sort of say, look, you know, this is what happens when things go wrong at an early age and this is how it projects out in terms of how the brain works, how the heart works, how the cardiovascular system works, how the jaw grows, how the teeth develop, how all these things start to spiral on themselves, allergies, reflux, you know, everything that you know, that comes into play. And then I explain, you know, the issues with assessing it and diagnosing it and then how basically it's all about unraveling the ball of string that's all tangled upon itself. And, you know, you're trying to get that string out straight and you sort of, you know, if you've got too many people pulling it too many times at too many directions, you're not going to make progress. So you need to have a, you know, a plan of attack and a pathway that makes sense. And in my book, and I'm biased because of what I do, the first thing that these children need to do is they need to be seen by an ENT that will look and assess the airway for obstruction. Also know what the ENT obstructions are, but also know what the craniofacial ones are. Okay. Because, you know, I send these kids off to dentists for palatal expansion and jaw and orthodontic things because I can make the most of the space. But if there's not enough space there initially, we need to improve upon that as well.

Yeah.

And, but because of that time frame that I talked about, that six month time frame, the reason that surgery goes in first is because it's the quick pressure release valve. People talk about it, oh, it doesn't work or they relapse and, you know, they have problems later on. That's not the right part of the conversation. The right part of the conversation is that there is someone in the room choking the child. The ent is the person. They're the law enforcement people coming in and removing that person. Then we can pick up the pieces of everything else. But we need to optimize whatever we've got first so that can facilitate everything else happening. Because as you alluded to, you can do all the myofunctional therapy in the world, but for someone that's got big tonsils and adenoids, you're walking up Mount Everest with a 40 kilogram or 80 pound rucksack, okay? You might get somewhere. You are not going to get to the top, okay? That child is going to tap out well beforehand and lose interest and you're not going to get anywhere. That is more where you're setting these children up for failure. So that's where the ENTs come into the picture. But they've also got to know that they're not the whole story. You know, there's something that all you got to do is I just got to take them out and that fixes them. That's, that's, that's not a reality. The bit that we went lucky is, is often that actually does play out to be the case. So we've got to be careful about sort of having a selection bias in what we see. Because, you know, when it's second opinion or follow up stuff, it's in the context where there's still ongoing problems. The successful ones don't come and see me and say, look, my kid had their tonsils and adenoids out. It worked really well. But I just want you to double check it. That doesn't happen. So you've got to be mindful that we don't see that part of the picture. So we don't want to get too focused on thinking that what we're seeing is the whole picture.

I mean, I do see a lot of these, especially preschoolers who have had tonsils and adenoids out or one or the other. And we have seen sleep dramatically improve. We've seen their behavior dramatically improve. We've seen their interest in eating improve. They may still have oral motor deficits because they also had a tongue tie and they have other, you know, orofacial myofunctional things going on, you know, or we just have to, you know, work on certain factors. But, you know, we do see a lot of improvements, even when there is sometimes other things to be addressed. And like you said, you know, we're working, we're looking at anatomy. What is what Airway first is what I always tell everybody is step one is airway. Step two, is there enough space in the palate like you mentioned, because we may start palatal expansion before I will treat a child for myo as well. And I think that's, you know, those are both two very good points. And, you know, I have two other things that I say to my families, and I posted this all over social media, but I say snoring is never normal. I don't care to what degree. And that's actually had a lot of local moms, friends of mine, and just people who follow me on Facebook go, well, what do you mean snoring is not normal? I mean, even just like a little bit, you know, the baby. No, let's talk about what's going on here. So I'm glad that this public service announcement has actually led. You know, it was just a post that I put up one day more for my colleagues and people in the space. And I'm really happy to see that people are paying attention. But then the other one I always say is airway is life. If you can't breathe your bed. And it sounds so morbid, but I feel like you have to, like you said, you have to drive it home. That example that you use is powerful and it's what people need, that knock on the head. Realize how serious of an issue this is and how we can't just brush it under the table and treat them anyways. Just because somebody won't touch their tonsils or their adenoids. That's not fair. So I really appreciate, you know, the book and we will link to all of this in the show notes. You also have a class. I know you want to say something.

I just want to build on one thing that you just said then, because again, I'm going to extend the analogy.

Yeah. Okay.

So the mum said, oh, they only snore a little bit. Okay, I'm going to change the scenario. Keep your anxiety levels down. We're just talking conceptually so that you get a visual. Okay. Sort of. If you get. Sometimes you get these sort of quite marked visuals. It just like all of a sudden the penny drops. So I'm going to come and stand behind you and I'm going to start choking you. Okay, now if I choke you a little bit, you yell and scream and make noise. If I choke you a lot, you're silent. Snoring a little bit may be representative that this child is extremely blocked and Only shifting a small amount of air because they are that blocked. So the saying is that all noisy breathing is obstructed, but not all obstructed breathing is noisy. So snoring a little bit. Snoring a little bit could represent one of two scenarios. Little bit of blockage or a lot. Because the amount of noise that you make is representative of how blocked you are. And the only time you stop making noise is if you are not obstructed or you're completely obstructed.

Yeah. And I think there's also a misconception, too, just from a parent standpoint, because I've had kids who snore, but the parents say, oh, they're great sleepers. They sleep all night, they don't wake up. And I have had to have conversations with them and say, well, they're probably sleeping all night because they're so exhausted that their body is just not able to. They're not waking up because they're never getting good sleep. So the quality of sleep is what we're looking at now. And the airway. Impact on the airway.

Yeah, exactly. So it's quality and quantity. And four good hours is better than 12 bad hours when that snow rises. I have a very easy question for those parents. I say, well, does your kid wake up tired or refreshed? They're easy to get up and go in the morning. Or they. You got to push them out of bed and really, you know, get them moving. And they go, oh, no, they always wake up tired.

Yeah.

You know, the parents have not clicked. This child's got a problem. Yeah, it's not normal, but, you know, and then I say to him, well, look, if you put your phone on the charger at night and you wake up in the morning and the battery's on 3%, you go, oh, crap. You know, two things. You know, your charge is no good, and you know that your phone is not going to get through the day. Yep. Same with your child. They're waking up tired, they didn't recharge, and they're not going to go well during the day.

That's a great point.

Yeah. And this, you know, you just got to put it in terms that people can relate to and understand, and it doesn't always have to be, you know, quite so confronting. It's amazing how people get upset with the idea that their phone won't work during the day. It's just like.

That'S a great one. I'll use that because that'll resonate with a lot of A lot of people.

Yeah, yeah, yeah, exactly, yeah.

So tell me about. I know you have an upcoming class in March in the us. I don't know if you also teach in Australia as well, but tell us, what is it that you teach on? Is it what we're talking about today or.

Yeah, yeah. So I've been doing this for. To be honest, I've lost count. It must be seven or eight years now. But basically it's a course where I try and bring a lot of what we've talked about to the table and then try and share it from an ENT medically trained point of view, but also integrates with what, as I've said, had the benefit and opportunity of learning from others. So initially I start off with just a general overview and where I sort of say, look, you know, these are all the ENT things that have an impact on, you know, a whole range of disease conditions, asthma, diabetes, blood pressure, obesity, all sorts of things. And then I just go through, this is some basic ENT anatomy, just so we make sure that people know, you know, what's going on. Because it's interesting sometimes where you can make assumptions and find that they were flawed, that people don't necessarily know where the tonsils are, are, or where the adenoids are, or they haven't heard of the septum or they haven't heard of turbinates. So go through the anatomy and then I sort of go through a bit of the physiology and say, look, this is actually how breathing works. It's all good. Well, to sort of, you know, talk about how breathing is a problem, but if you don't actually know how it works, then you can't understand how it's dysfunctional. So go through that and talk about how the nose and the sinuses work and then we sort of start walking into the pathology, talking about pediatric sleep disordered breathing, talk about reflux, talk about allergies, talk about tongue tie, talk about adult sleep apnea, talk about the investigations, the treatment options, the management options, and really give a big, broad, integrated picture of how this all comes into play. And also just reflecting on a lot of the evidence as well, just to sort of, sort of say, you know, what people sort of, you know, want to walk away with what you asked me early on, how can I try and convince people? The only real way you're going to convince people at the end of the day is first of all, find some that's open to being convinced, open to say, look, if you can come in and you can show me stuff that I haven't seen before. That is reasonable and I can make sense of it. Then, you know, I'm going to go and look at it. People to say, look, I already know this stuff, you're not going to teach me anything. There's no point barking up that tree. Yeah, so one of the things I do is it's, I think it's 92 pages or whatever of references. So you've got 92 pages of references that come with the course that are all on this topic. So that you can sort of pick out whatever you want and just go, all right, well that's that one. Or you can use it however you want. You know, if you're sitting with the mom and she's saying, oh, can't believe my kids got ADHD and going to go on this medication and, you know, and you want to try and sort of help them, but they sort of look and go, well, you're not a pediatrician, what do you know? And you say, well, here's, here's this really interesting science paper that, you know, came out 14 years ago showing that children like yours could actually be normal if we find the right person to take them seriously and get them better. You know, that's, that's, that's, you know, that's where we change lives. So that's the premise of the course. It's not just for healthcare professionals. I've had non healthcare professionals. I've had doctors, dentists, myologists, dental therapists, dental hygienists. I've had physiotherapists, chiropractors, osteopaths, nurses. It's really suited for everyone because at the end of the day, it's scary what walks inside my head in terms of how much I know. But it's useless within my own mind if I can give it to other people and have these ambassadors that can go out there and have something of more substance rather than just a gut feeling or, you know, and so forth and go, you know what? I've got a whole book of references now that I can cherry pick out and so forth and share in a non confrontation, confrontational way, trying to be collegial and to say, look, I'm not disparaging what you're saying, I'm not disparaging what you're doing, but I need someone to explain what I'm reading to me because this is what I'm reading, you know, can you explain this to me? You know, why is what they're saying in this wrong? Why wouldn't we want to change based on what they're starting to see in, you know, in what they're publishing. You know, you might go further that way, but the first thing, you've got to find someone that's open to the suggestion. And part of that too is making sure you are barking up the right tree to start with. There's no good walking into the ENT that just does throat cancer work. That's not their dance. You're not going to get them to change partners. So it's easier said than done in terms of it all. But they're out there, you know, they don't necessarily call themselves airway centric per se. You know, they just, they do it and they just, you know, like I said, you know, go back 10 years. I was just flying under the radar for a lot of people because, you know, I was just doing what I did, you know, and I was just doing it at the local level. And then I sort of realized that there's other people out there that are sort of, you know, doing the same thing, but they're not ents. But they're frustrated, like, you know, your frustrations that other ents. And I'm going, like you thought. I actually thought everyone did this too. And then you start going, you go, actually, no, they don't. And you go, why is that? You go, then the penny drops. Why? Because I don't do everything either. So you just got to find them and so forth. And, and when you find them, you know, everyone's on different curves. So, you know, if you had me 12 years ago, probably 5% of this conversation would have happened and 95% wouldn't. And the reason that it's happened is because I've stumbled across these people and I've stumbled across these things and I've been open minded to take it on board and go, all right, it's more than, you know, just, just them saying it. They've actually can, you know, walk the walk and talk the talk with backing it up. Let's dig into this a bit deeper. And then as you do, you look underneath that rock and you go, I'm glad I found this.

Yeah.

And then all of a sudden, you know, I'm, I'm sitting here going, you know what, I'm a surgeon and my surgery does not fix everybody. But I've got the insight to know that and also to know what else they need.

Yeah.

And that takes time.

Yeah. But that's what makes a practitioner. Right? When you can admit that I can't fix or heal everybody, I don't know everything. There's always more to learn. You know what you don't know, you don't know what you don't know. But I think that's what's been so amazing. Also on the flip side, just in this space and ever since starting this podcast, is meeting the people who are open to learning from others. And, you know, I learned a lot from you here today. And so thank you so much for sharing all this and imparting this wisdom, because I know there was just a lot of questions and frustrations shared among some of my colleagues that it's hard to get an answer sometimes.

Yeah. And that's interesting when I do the course is that one of the common things that people say, apart from having a little bit of a blank expression on their face, because they're just having this stuff in a different way that's a little bit wow. Is they'll preface and say, but I thought so they had these preconceived ideas and so forth. But when I sort of say what I say and present it with the evidence, it's sort of like a wow. Actually, I need to reconsider this. So, you know, it's not just about, you know, building on what people already know. It's. It's part of. It's challenging what they think they know. You know, like I did with you today about the sleep studies.

Yeah.

You know, it's just like.

And with the tongue tie at the same time as, you know, tonsillectomy, I'm kind of sitting here going, okay, I guess, you know, maybe those are the cases that I have experienced and sometimes I get more involved. Cases that are so far off already that, you know, we're dealing with so many other symptoms as well, that it's. They really have. They struggle after they've had it all done at once. And so my perception is we're doing a disservice to them. But maybe in 99% of the cases, we're not doing it. You know, it's so that definitely whatever.

The number is, you know. Right, right.

It's totally rain made up numbers. But, yes.

We may not have to work on absolutes.

Right, Absolutely.

You know, there's a spectrum out there. And then, you know, the things that I see are, you know, if I relied on what I see, then I would think that every child out there is walking around with big tonsils.

And I. And everybody that I would see has. Has a tongue tie.

So. So, you know, we have those moments. We have those moments when we're sitting in our chairs and, you know, those big tonsils, those tongue ties, walk in front of us, sit down, you just go, how the hell did anyone miss this?

Right? And then the parent goes, why has nobody else said anything?

This is so obvious. Why hasn't anyone else brought this up? You know, so again, you know, so don't worry, we have similar experiences there, but you just got to back away from that experience and just go, all right, yeah, just that scenario. There's plenty still coming my way for the right reasons at the right time. It's just that those ones are the ones that our brains latch onto and we sort of, you know, hold on to those cases you've forgotten about those hundred other tongue ties that you saw last year that were just. Yeah, this is all straightforward. Yeah, off we go. This is, you know, so, yeah, so look, I'll be in Texas, it'll be in Dallas. I chose Dallas because I. From Australia. It's a fair flight directly from Australia into Dallas. I have friends in Texas. I've spoken in Dallas previously. And Dallas is a good hub for people, you know, throughout that part of the world. You know, we've got people from Canada that are coming down. So, you know, people sort of say, oh, can you come here and you come there and you say, look, there's only one of me. You know, I'm already making the biggest part of the trip. Mine's already the most expensive part of the whole thing. So those that are sort of, you know, floating around that, you know, happy to sort of just, you know, give this a chance and give it a go.

Yeah. The course is actually nominal. It's not.

I honestly did that deliberately. It's a hundred. Yeah, it's 150 US. Well, look, part of the reality is that I'm an unknown. You know, people sort of, if you're gonna roll the dice and to do this sort of thing, you don't want to be rolling the dice with your life savings on the table, you know, so, you know, you genuinely walk away from this not thinking that you got your money's worth, well, then you've got expectations that I can't meet already.

But if it's anything beyond, you know, obviously it'll be a much beyond today since you'll have a lot more time to speak with them, but you obviously have a lot of knowledge to share in this space. So.

Yeah, yeah, yeah. This is just a warm up to.

It all, to be honest.

Yeah, yeah, yeah.

Well, then I think, then I can't see how anybody would honestly walk away without learning something yet.

And I've had some pretty smart people.

In the room, but they can't at least take away one thing. Right. You know, I always say it's a good course if you walk away with one new thing that you didn't have going in. So 100%.

Yeah, you reflected that you had a few questions. We'll make sure to tick those boxes because at the end of the day, this is not my benefit, it's yours and your audiences. So were there any other questions that you just wanted to just double check over just to nip those in the bud?

Yeah, let me just, let me take a peek here. I think people had questions about, on an ent side of things, what is helpful for a like myofunctional therapist or something, speech pathologist to put in a report that we're sending you? Because we know you don't want a 10 page report from us. So if we were to send you something with bullet points, like what is.

The most helpful information in my book? One of the inserts that I have, and to be honest, this book has its own Facebook page, which I think you've got the details for. So that insert is actually on the page. You can actually cheat and deprive me of a book sale if you just want to get the checklist. But you know, it's on there. So, you know, a tick the box thing makes it really easy because you don't need to explain. You know, there's a bit there for comments and so forth if you want to make comments. But you know, sometimes it's just tick the box. You know, sometimes these things come to me and it basically would have been easier to tick the boxes that were. Okay, the boxes that were a problem because there's so many things that get ticked. But basically, if you write us a 10 page report, as respectful as we are of everything that you know and how you want to sort of write and share it, we won't read it.

Right, right.

And we won't absorb it. So I have a rule if, if you cannot condense and consolidate everything that you know into one page. Don't know the topic well enough.

Yeah.

Because you need to work out what is the, you know, distill what is the most important thing and how can I get that across to someone in the quickest and most succinct way.

So I'm going to show everybody this and I can share it on social media. I basically created a referral pad where I actually check off the boxes of what my concerns are. And I have additional comments here because I know you guys are not going to read a report you're probably looking for, what is the why is the child here? Just tell me in like one sentence or a couple boxes.

And yeah, we're going to go through the process regardless of, you know, generating our own history in our own exam. So, yeah, the 25 word or less scenario is going to be more warmly received than the essay and it's going to be absorbed better too, you know, something like that. And just goes, look, I'm worried about this child because they've got speech problems, they're snoring, their mouth breathing, and I think they've got allergies as well. Or that lets us know that you've got some concerns. We need to make sure that we assess those things and see what our perspective is on that so that we can feed back to you and say, look, you know what? Yeah, look, I agree. I can see what this is. I think actually this tongue is actually able to move. Okay. But it's a tone problem because their adenoids are so big, their mouth and mouth posturing and their tone's dropping down. You know, maybe we can, you know, get this function better by getting the breathing sorted and then you can rehab them. We may not need to release the tongue tie at all, but if we don't quite get there, then we can do that as a second stage, you know, so we don't always sort of just go and do stuff for the sake of it just because we're there. Sort of just, you know, so that's how I think, you know, sort of, you know, we worked together quite well in terms of the relationships that you can have. And likewise, you know, you sitting there, you don't want a 20 page report from the ENT each time. So, you know, it's a matter of going, you know, how much do I actually need to talk about this and how much is actually, do I need people to listen to it?

Right.

It's what they listen to that's going to count more than what you've got to say.

Yeah, awesome. We also have a question about child went to the ent. They had their tonsillectomy in December. Mom filled out the Pediatric Sleep questionnaire and Sleep Disordered Breathing questionnaire for Children before going in for this. How quickly should we see changes to these questionnaires or changes on these questionnaires per se if we were to give them again after procedure?

Three months.

Three months.

Okay, Three months. People think it's like flicking a light switch. It's not okay now. Sometimes we'll see it earlier than that. And it's the same with the myofunctional issues as well. You know, if you wait three months there's a very high rate of spontaneous resolution because they're allowed to resolve because. Because the things that would underlying and driving it had been removed from the equation. So I set parents on a three month timeframe. I said between now and the next three months is a recovery and reset period. If there's any problems after three months or beyond then we need to start looking into this more. What hasn't resolved that should have resolved in theory. What is the handbrake that is still holding us back. So that's the time frame that I use to have some sense of it all. Because part of what we're dealing with is what's called neural plasticity or neuroplasticity and that is that the way that the brain has adapted to what's going on. And whenever you're dealing with that sort of thing, you know, it has learned certain things. And the nice thing about the brain is that it can re educate itself and it will do that by itself. It's, it's why for example, if someone who is right handed for some reason loses function in that and they pick up a pen in their left hand, they will be terrible to start with but over time they will improve. They, you know, that brain goes alright, I've got to do something about this, you know, and that it will come with time. It won't happen straight away. Even though that person knows how to write, they don't know how to write that way. The whole re education process and you got to let the brain sort itself out first so that it, it's then got a mechanism to then respond to anything that it's trained to do thereafter.

Okay, awesome, awesome. People are asking about your take on I guess assessing the tonsils or, and, or the adenoids and like imaging because they find that there's ents that they've sent kids to and we know we want to obviously look for somebody who's specialized in this but they're finding that ents are saying that they're airway centric and then they're not scope, they're not doing you know, any, any imaging at all to even look at adenoids. So.

Okay, so for me personally I do not send kids for X rays to look at the airway. I don't need to because I've got my own eyes and I've got my scope, and that's the gold standard of assessment. X ray is a radiation dose, for starters, and we know it's an unreliable one. So a lateral kephalogram to look at the adenoids is notoriously unreliable. CBCT is a far more accurate thing. And if they're having it for other reasons, you know, dental reasons, orthodontic reasons, and they just happen to get the airway as part of the field, sure, that's very valuable information, but it's a substitute to the real thing. And the real thing is looking. It's looking, you know, inside the nose, inside the mouth, using the lights, using the tongue depressors and using the scope.

What if you have like a, let's say 2 to 4, 2, 3 or 4 year old who's super fidgety and won't let you near their face? How do you handle that?

Yep, we know they exist. They're also the exception to the rule. You know, most of the time these kids are actually, if you sort of make a bit of fun and a game of it, which is what I do, you know, I tell them that we're going to look inside their nose. We're looking for dinosaurs, we're looking for dragons, you know, giraffes, elephants, monkeys, crocodiles. You know, that distraction moment just gives you that opportunity to look. And I'll just use a normal sort of base grade torch to start with. It's not as good as a scope, but sometimes you get enough information out there to sort of say, you know what, this kid, that's mouth breathing, their nasal passages are clear, I think can see those adenoids in the distance. Those adenoids are coming out.

Awesome. Very helpful. Looking to see, everyone keeps going. How do we find a good ent? We talked about that. What else? Let's see. I think we covered. Someone said, well, when do you recommend removal of tonsils and adenoids? Is there like a certain percentage of blockage or.

Okay, all right, so.

Or is it all symptoms?

I think one thing we possibly can rewind from is that for these children, that's not the only operation. If we want to talk about surgical interventions, tonsil adenoids by far is the majority of what we're talking about. But we need to know about other elements of the anatomy. So within the nasal passages, there can be obstructions there that we need to address. And if they haven't been addressed, that can be one of the reasons that tonsils and adenoid surgery fails too. Okay. If you sort of have a, have a cookie cutter approach, to these kids and all you do is that they snore, so it's automatically tonsils and adenoids. Then that's really not directed treatment to the pathology and it's just a generic approach. So to answer your question, if I'd sort of rephrase the question slightly.

Yeah.

When do I relieve a child of their obstruction? As soon as possible. And there's no issue there in terms of what if they're six or what if they're two, or what if they're, you know, that that's not, that's not part of the answer.

It's 40% blocking the airway or 80% blocking the airway. Or it. Based on the symptoms.

If a child has symptomatic obstruction, then the answer to the question is as soon as possible. And that doesn't necessarily mean that it's surgical. Sometimes. If it's nasal allergies and swelling from that, then, yeah, we'll try some nasal sprays, for example. But if I look at a child and they've got obstructive symptoms and they've got huge tonsils, I'm not going to be mucking around with medication. I'm not, you know, as I've said, I'm not going to be mucking around with a sleep study. One, there's a delay with getting a stick sleep study, and two, it doesn't change it. And if you actually look at the published literature within the U.S. if you look at pediatric ents that actually get sleep studies, it's less than 20% of them. The majority of the time they're getting them is because the insurance is mandating. That it's done, to me is a weird scenario because it's actually costing the insurance company more money.

You would think, right? Nothing surprises me anymore in the US.

When I go over there and I have these conversations, it's, yeah, people can. We're all just shaking our heads just like, you know what it is, what it is. So does that answer that question? I just have sort of, sort of partly rephrased the question. When do I relieve it? Child with airway obstruction? As soon as possible, by whatever means is appropriate.

Perfect. Looking through Instagram now to see what other questions there were. I think we hit a lot of them. Is there any type of coursework other than yours, for example, that you're aware of that can enlighten ents on this topic if they're not already in the space? Do you know of.

So, again, we're going back to what we talked about. It's really hard to tell someone that thinks they know it.

Right.

How to suck eggs and that and that. And that's the problem. So one is that they have to have insight. You know, like I said, most of my insight came into the fact that I knew it wasn't fixing everyone and that, you know, there are other people out there that have worked that out as well, but they had other things to do. It's just like, you know, this is not stuff that I was doing. The biggest insight I had was nearly three years ago there's a big pediatric ENT conference held in the US that I went to. And one of the speakers was the lead author and runs the major sleep lab that did a 10 million US dollar study on children and sleep disordered breathing. And one of his slides that he put up was of a palatal expander. And his comment was, I'm starting to see more of these. I think it has something to do with pushing the teeth out. Okay, okay. So that was the perception of someone that is top of the tree research funding, clinic lab in terms of their insight. So, you know, for me it was very disconcerting because I, you more than everyone else in the room, and these are the people who are writing and publishing the papers.

Got it.

So it makes me sound damn arrogant when I sort of say these things. And that's not my intention. I'm just reflecting on what I know and so forth. So to answer your question, is there stuff out there? Look, I'm sure that there is.

Yeah. Come to your course. So we're going to link that here.

And this is the thing, I know.

That you're saying that's what I'm saying.

No, but, you know, if people, you know, you know, sort of knew half of this. Yeah. Then we wouldn't have the struggles that we've got. And the problem is the half they don't know is the half that's never taught. We're never taught about my functional therapy. We're never taught about PLATO expansion in order. Taught about our emotor dysfunctions. Yeah.

You know, we're not taught about pediatric dysphagia in, in the U.S. in our speech pathology courses yet. That's in our scope of practice. We're just taught about how to work with adults, which is a completely different beast. So, you know, we're not taught about tongue ties in grad school. We're not talking about, taught about oral motor work and that a lot of this is supposedly changing, but how long will that take? You know, so it's.

Yeah, yeah, like all these things. It's a time thing. Yeah. So in terms of, you know, what's out there. Look, to be honest, I think most of the good stuff is actually within dental circles at the moment. The dental element is far more switched onto this and far more receptive to this because they are seeing the consequences of what is being neglected.

Yeah, that makes sense.

So that would be the thing. And the thing again, and I'm not trying to be disparaging, but just so that people are cautious, is that it's not unusual that people will go to these dental run things and there will be someone who is dental teaching about the ENT stuff. And then people will come back and they'll ask me about this and that and they're wrong. It would be like me trying to teach about speech therapy. You know, I could bumble my way through it, but anyone that's got any insight like you would call me out in a heartbeat.

Well, I appreciate that, because there are Ents locally who will comment and say, there's no tongue tie. We're not releasing it because the speech sounds great. We're going, wait, what? That's not even why we sent them to you to look at the tongue tie. You didn't read anything that, you know, we sent over on the three little bullet points that were on this paper.

Yeah. So I think the important thing at the end of the day is that learn your speech therapy from speech therapy. Learn your dental from dental. Learn your ENT from ent. Have a wide range of sources. When someone starts talking outside of their lane, treat it as interesting, but don't treat it as gospel. And then, you know what you find interesting, Then go and sort of background check it with someone where that is their line. You know, say, look, I went to this course and this person was talking about this. And I'll just go, I don't know what they're talking about, because this is actually what the story is. So, again, not being disparaging, but just always just have a degree of skepticism rather than automatic acceptance. Especially when people either can't present the evidence and it's okay to present opinion, but if they can't present the evidence, then you sort of just gotta have a little bit of a red flag to what's going on. And likewise, when they're talking about things, that really is not their gig. You know, I can, you know, when I do these things, especially when do it for dentist. You know, one of my opening things I say is, look, if you want to, you know, I am ENT trained. I'm not dentally trained. If you want to make me look to be the dumbest person in the room, ask me a truth question. Okay.

Yeah. I always go, that's out of scope for me. I can't comment on that. Or, you know, it's, you know.

You know, all I'm going to do is just give it, you know, from the end perspective as to how these two things meet in the middle.

Yeah.

And then you fill in the rest.

So I think that answers all the questions. I don't think there was anything else. And this has been amazing. We'll definitely split this into a couple episodes, but thank you so much for joining us. This has been fantastic. And I know we could probably talk for five more hours, but I want to keep you.

Well, I will be. Give me march. I'll be talking for eight hours.

Right.

Yeah.

Well, thank you. It's been an absolute pleasure having you on the podcast.

My pleasure has been mine. Thank you.