This week on ADVENTing, Dr. Madan Kandula and Dr. Ethan Handler discuss what it means to have well-functioning airways and how simple in-office solutions can help you achieve them.
Dr. Kandula: So, a well-functioning nose and sinuses, that's the gold standard. That's that 20/20 standard. This is what we want. What does that mean? What does that mean? In all the years of training as a nose doctor, they must have pounded this thing in your head about this is how things are supposed to be, right?
Dr. Handler: Wrong. Yeah, I think that it can be a very subjective experience. It's a you do or you don't, and if you don't you know you don't, right? If you can't breathe through your nose at all, you're not moving any air. Then it's like, okay if I'm breathing through my nose what does that mean or feel like to me? What is my quality of life like when I'm breathing through my nose? As you know, every study that looks at actual volume of airflow through a nose and increasing or decreasing doesn't necessarily correlate with how a patient feels like they're breathing. You know, there's no good correlation there, and so what does that mean for a patient? What's our endpoint? What are we looking for when we're trying to get a patient better or best?
Dr. Kandula: To me, in my mind, it's getting them, even I don't have a good answer for this. I've been doing this a long time, I don't have a good answer for what does that means to me. It's optimally breathing through your nose. The challenge is there are times where we will talk with patients, more often than not, we'll talk with patients about procedural options, or when we talk with patients about procedural options, we'll talk about office-based approaches versus surgical approaches. The reality is, traditional surgery gets things as open as we can possibly be, but you pay the price of that, as far as a more intense recovery. Office-based, pretty well, basically almost every patient we take through an office-based procedure is not technically as open as true surgery, but I venture to bet that they're just as happy, if not more happy, than that more open. My sort of, how I've come to reconcile this in my head is the most crucial change that we can make for somebody is taking them from compromise, taking them from a nose and sinus areas that are too tight or that are shut down, and you take them from too tight or shut down and you make that open. That's a big change. That's the monumental, that's the earth-shattering epiphany kind of a change. Taking somebody from open to more open is sorta like, eh, it's fine. And so, that's where I think the sweet spot of a more office-based approach comes is there, is you're taking somebody who is compromised, who's really tight, and you're making that crucial first step in a forward direction. And the other deal with the nose is millimeters matter, sub millimeters matter. You get an exponential impact for openness. So when we're talking typical sinus openings, most folks are walking around in the world with sinus openings that are a millimeter maybe less, maybe a little bit more than that, but never as open as we can get things surgically, but they're doing okay. Now, you take that same person, you take them and you shut them down or you give them a little bit of inflammation, then they're nose and their sinuses are shouting at them that something's not right here. And, you know, for us to take that and open it up, it's the world. It's a world of difference for those individuals, and so back to that concept, it's really just trying to understand what's going on, and then using the tools that we have to get somebody where they can be.
Dr. Handler: Yeah, I feel like there are two major groups of patients here. There are ones that always breathe through their mouths and know their noses don't work, right? Then there's the groups of patients that have nose problems, obstruction, facial pressure, but their noses they think function okay, but they think about it a lot or they struggle with it a lot, you know? And so, for the group that their noses are kind of open, for them not to think about their breathing anymore is a win, right? They come in, and they're like, this isn't occupying time in my day anymore. My nose is just working. Great, and they're very happy. And then the patients who are completely shut down that breathe, are like I can hold my mouth closed and I can breathe through my nose and this is great and what have I been doing for the last 25 years of my life? And so, that's a big amount of all of our patients. There are some outliers on either end of other issues and things, but.
Dr. Kandula: Yeah, absolutely. Yeah, and I think the other part of that, back to kinda what I was saying is that the folks that tend to be most annoyed with their noses and sinuses, somebody whose nose or sinus areas are completely shut down, but constantly shut down, they kinda can sort of get in this rhythm of acceptance and okay, this is how it is. It sucks, but I'm just gonna roll with it here. The guy or gal who is stuck with this chitter-chatter in their nose and sinuses, it's a little open, oh now it's shut, now it's open, now it's shut. Those are the folks that are doing anything possible to get that little space, whether it's steam or Flonase or saline or whatever, they'll scour the ends of the earth to try to get things more open because it's that chatter in their heads, literally in their heads, it's frustrating and it's annoying because I think for those individuals they go from, if you get that little, if it's open enough where you can breathe with your mouth shut, things are functioning, sinuses are draining properly, if you're lacking that it's heaven. And then you take that away and it's hell, and you bounce between heaven and hell and heaven and hell and then you're like ugh! It's all-consuming after a while because your brain is focused here because it's the start of your ear way. So back to why does your brain care about your nose, because it wants to breathe because it wants to keep you alive kind of a thing. And those folks tend to be the most frustrated and annoyed. I'd say the most frustrated and annoyed people I've ever seen are folks who had a normal nose and sinuses, the folks who are really not okay with going from good to bad is somebody who breaks their nose. Say, your nose was fine, you broke your nose, it heals up and now it's jammed up. Those people are itching to get back to where they came from because they don't want to be in this hell that it is when you can't breathe through your nose.
Dr. Handler: But even those patients that broke their nose, do they have to go get a big surgery, necessarily?
Dr. Kandula: No, absolutely not. And I think, some of them, this is the challenge, some folks will break their nose, you know, big compromise. I was breathing fine, broke my nose, I can't breathe now properly, but the only way to unwind the situation is go through some massive surgery, and that's not the only way. There's typically multiple ways of trying to get somebody back up and running. It's just identifying the concept that it's really impactful both ways. It's massively impactful when somebody's nose and sinuses aren't working, and that's an ongoing, never-ending frustration that can be all-consuming, and then the flip side it's massively impactful when we take somebody out of that hell and get them out of there, you know?
Dr. Handler: And that's why what we do is a quality of life issue.
Dr. Kandula: Yeah, absolutely. But it's fundamental to life. It's a quality of life issue, period, end of sentence. Next sentence is, you cannot live if you cannot breathe. Okay, period. Next sentence is, how do you start breathing? You breathe through your nose, that's how you're supposed to start breathing, and so those sentences create a paragraph that says, yeah it's quality of life, it's not gonna do you in. All true. But on the flip side is, it's going to ruin your life if it's not working properly. It will take your life over if it's not working, and there's no reason for that. So, I guess final line, like I've said, we've gone between the two of us, we've spent decades focusing on how to get noses working, sinuses working properly, yet between the two of us, neither one of us has a good answer on what's the absolute definition of optimized and all I would say is I know what sub-optimal looks like, and that's something we are unwilling to accept and want to do something about.