Erik’s Treatment Plan

With the results from his sleep study and CT scan, Erik and Dr. Kandula are ready to formulate a treatment plan to deal with his sinus and sleep apnea issues.

 

 

If you haven't read the last part of Erik's journey, check it out here.

Transcript:

- [Dr. Kandula] So, if you can't breathe properly through your nose, you know, when you're sleeping at night, then any treatment that we try coming up to the sleep apnea, we might get lucky and it might be successful. We didn't get lucky the last time you tried with it. And I'd say, it's not surprising given now that we know the overall situation. Let's say we didn't even know you had sleep apnea. You know, this is problematic by itself. From a sleep apnea front, your throat is tight. So when I look in the back of your throat, you're tight all the way around the circle that they are meeting. Your tongue is big in relation to the size of the back of your throat. That actually seems to be the biggest issue you got, where the tongue is getting in your way, and when you're trying to breathe, it's not letting you. So when you're upright, like you are right now, this is as open as your airway is gonna be. When we lay you down, everything wants to collapse on itself. And so that tongue seems to be a big issue. So basically there's a circle in the back of your throat, which is your airway, from the bottom up your tongue is filling in space, and then you're crowded also from the sides and from the top down. The top down is where that little uvula comes in, so that part's elongated and kind of drawn in from the sides. And then the tongue is getting in your way. So when you're sleeping, the snoring is coming from typically the pallet. So that area where the uvula is, that's vibrating, that's creating the sound, but the tightness is coming all the way around that circle. Worst case scenario is the current case scenario is you can't breathe through your nose properly, your mouth comes up but your tongue falls backwards, takes tight and shuts it down. And then there's not really an out for you right now. I mean, your body is never getting into those deep, deep stages of sleep ever. You know because comas by definition is by the time your body relaxes enough to get into sleep, your tongue is now in your way, you can't breathe. Your body has to wake up. And so it's sort of this constant skirt of skimming the surface but never getting deep for years. And obviously that's not helping anything, you know, and it's probably hurting more things than even you can possibly be aware of because the impact of that, you know, untreated sleep apnea, it's just there's nothing good about it. It's bad for you, you know, meaning it drags you down and you know, you're conscious of that, but then it's obviously it's both scary and annoying for those around you. So there's nothing good about that. And then unfortunately, the other reality is given your degree of sleep apnea and the fact that we're just not able to treat it properly right now, it's really hard on your body. And so meaning it's really hard on your heart, it's really hard on your lungs, it's really just hard on your whole system. A couple of ways, one is, you know, you're never getting restful sleep and restful sleep is one of the few keys to kind of a healthy life, both mentally and physically. If you can sleep properly, that optimizes you as much as you can. Mentally and physically, if you cannot sleep properly it drains you. And just the exact time when your body's trying to rest and recover is instead of the time that your body's fighting for its life, literally. And so it's kind of this perfect storm of like your body going into battle mode when it should be going into, you know, rest and recovery mode, and that carries on through the day. Your body's wired in one of two ways, either fight or flight or kind of, you know, either things are really bad and you need to kind of, you know, get your defenses up and kind of be ready and get that adrenaline surge, or you can chill and everything's good. And you know, that's all fine. This first thing I was talking about is constantly going. And so most folks who have sleep apnea that isn't treated properly over time, their blood pressure tends to come up because their body is constantly, you know, sort of in intense tension mode. And then it can lead to other things too. So I'm not gonna dwell on that too much, but I would say the situation at hand sleep apnea wise is kind of creating the known issues that you know about, and then it's creating sort of a ticking time bomb behind the scenes and then on both fronts issues that you just I don't think can know about or will know about until we can get you where you need to be. So, long story short, I'd say, yep, sleep apnea, you got it. Your anatomy matches up with that. You know, I'd say on the weight front, it's both things coming together. So I'd say extra weight narrows your airway down, which makes the sleep apnea worse. Poor sleep and sleep apnea are guaranteed for gaining weight. You know, and it's just that vicious cycle. Our goal right now is break that cycle, get your airway, you know, on your side versus against you. And then, you know, come after things in a thoughtful manner. From the sleep and the sleep apnea standpoint, you know, you're tight in the back of your throat, conceptually, there are three different options that you've got. One that you kind of tried. I mean, you tried a version of it with the nose that was not helping you, but basically the CPAP machine or BIPAP machines or machines that you wear on your nose, your nose or your mouth, they're just basically pushing air back there to hold the back of your throat open. They're not oxygen machines, they're just tenting the space open. So in an ideal world with that CPAP option the best way to use a CPAP machine is through a nose that's open and a mouth that's shut. And so, the least common way to use a CPAP machine is through a nose that's open and a mouth that's shut because just like you, most folks who have sleep apnea also have noses that aren't working, but the typical medical model is blind to that. For whatever reason, it doesn't look at that and so most of the time, it's just like you, where you go in, get sleep study. You had and have, you know, significant nose and sinus issues that everybody just sort of said, well, whatever, we're not gonna ask you. Certainly didn't look. The typical model is weird. Basically, we don't care whether your nose works or doesn't work. We're going to assume that it doesn't work 'cause most of the time it doesn't, you're the typical situation that way. And so if it doesn't work well, we can't trust it. So let's put a full face mask on you and try to force you to breathe through that. And that's the most cumbersome way to use a CPAP machine or BIPAP machine. That's the most common way that it's prescribed because again, other than in situations like ours, where gonna address the nose, it's sort of like, okay, if you can't address it, just work around it. And a lot of people get kind of, you get in this blind alley of knowing you have an issue, knowing you want to treat it, knowing you can't treat it with the tools that they're given to you. So it's in the CPAP BIPAP front. I would, I know you had a bad experience there, but I'd say again, we'll talk about the nose in a second, but if I can get your nose where it needs to be, then that machine, it can be a good option and the best way, and the ideal way would be get your nose working, and if we wanted to go down that road, it would be using a nasal mask or a nasal pillow mask, so just use your nose, keep your mouth out of it and see what that feels like. If your nose is open and the machine is pushing air through an open nose it's as mellow and low key and as effective as it can be. And so, even though, I mean, a lot of times that bridge gets burned unfortunately, with experiences like yours. But if we, you know, if it's burned, it's burned, but hopefully it's not completely burned. So I'd say, you know, again, that's still a reasonable concept and something to consider and oftentimes, much more often than not, is in this sort of situation where we get your nose working and try a machine through that open nose, most folks find it actually, you know, tolerable, helpful, all that good stuff. So that's the machine option. Another option, you know, that very well might be a good one for you is an oral appliance, which is basically a retainer that you wear when you're sleeping at night. It's into your mouth between your upper and lower teeth. And what that's doing, it does a couple things. One is it helps to keep your mouth shut. Two is it basically tucks your lower jaw for a little bit. Your tongue's attached to your lower jaw. So when you pull that lower jaw forward, just a little bit, just a millimeter or two sometimes, that gets your tongue out of the back of your throat and all of a sudden, you know, you're able to breathe. That too, just like the CPAP machine option to tolerate an oral appliance, you've got to be able to breathe through your nose because if you can't, then you've got something sitting in your mouth that now you're fighting in a different way with a different object. So in your case too, I'd say, yeah, oral appliance could work. Could really only work if we can get that nose, you know, on track kind of thing. And then the final option, like with the final treatment option, you coming up the sleep apnea, would be procedures in the back of the throat to open things up back there. That generally speaking is the least likely option that we'd recommend and specific to you, I'd say, yeah, I'd put that number three on my list. The biggest issue you've got is your tongue. We can't do much procedure wise for the back of the tongue to have hope. Where we can do most, where we do more is on the pallet and the sides of the throat. And so there's some work we could do there to open that up. But if we can't kind of hit the key target procedurally, then in my opinion, you sort of kind of put it to the back burner because both the CPAP machine and the oral appliances, they really mainly work on the tongue area and that's the main issue you've got. So nose wise, and this is a ton of information, so I understand it's a lot coming at you, but nose wise, back to kind of where we're sitting with that is we've got anatomy issues and lining issues and treating the lining in your case, isn't both been proven based on what you've noticed, isn't gonna be doing enough, and from the likelihood, from what we're saying, isn't gonna do enough. And so it's really, how can we address the anatomy to get things open there? You know, both for its own sake, as well as to prepare you to move to the next step from a sleep apnea standpoint. And in your case, there's really two different roads you can go down. There's an office based road, so things you could do in the office when you're awake and then there's a surgical road, which is something you've gotta sleep to have done. There are really pros and cons to both. There's not like one's bad, one's good or vice versa. They're just sort of different and we can sort of, we're putting you through different things, we're expecting sort of different landing spots. So office based procedures are things we do here in the office, they're done with you awake. So our first step is just getting your nose numbed up. So we're spraying numbing medicine in your nose. Once that takes hold, we do numbing injections so that gets things frozen in there. And then we're doing a couple of things. One is looking at your nose with a camera up towards where the sinus areas are tight and what we end up doing up there is using a balloon to get into those tight spaces, and then we inflate that to expand those openings. So those a bony openings in your case, are either nearly shut or close to that. And so we're trying to do is take those tight spaces and open them up. Sinus wise, when we do that, when we open those spaces up, the area of the sinuses that's inflamed is able to drain through those openings. And oftentimes, usually that lining is able to kind of calm itself down over time. So even though we're not doing anything in lining itself, we are just getting plumbing work and getting that plumbing working is sort of the first step towards kind of getting back on a healthy road there. But anyway-

- Are those bony structures actually like breaking and then-

- [Dr. Kandula] Mm hmm, yeah. Exactly. So it's bone, it's fairly pliable bone in the grand scheme of things. So it's not like, you know, rock hard or nearly rock hard, like this sort of bone. It's kinda more like cardboardish but stiff. And so works both ways, meaning when we get those areas open, it's open because it's bone, it stays where we put it. And so that's why that balloon can create a change that's lasting kind of a thing. But again, back to that procedure, it's getting in there, getting those sinus areas open to allow those guys to bay properly. And then the second part of that is where the turbinates are big we want to make them smaller. And so how we do that as you put a probe into them that's connected to a machine that creates radio frequency energy, which basically just means it allows us to shrink the turbinates down. So you take something that's big and you make it smaller. Turbinates, there's a few layers on them. It's bone underneath the surface. There's soft tissue overlying that. And then there's kind of the skin of the nose on top of that. And so when you lay down right now, what happens is the soft tissue swells up and that's what plugs you up. So what we end up doing when we're reducing those structures is we get into that soft tissue and we cause it to contract down and make it smaller. So we're kind of scarring it underneath the surface so it's both smaller day to day and decrease its ability to get big when you lay down or if allergies are kicking in. So we're just trying to get those guys out of your way. So with the office procedure, get the sinuses open with the balloon, get the turbinates reduced with copulation, is what it's called, but basically get them smaller back into something like that. It's something you had on our own. You can blow your nose, gonna do what you normally do. The negative afterwards is that makes you feel like we just gave you a cold. So you're extra stuffy. First weeks the worst of times. Once you get through that, then you're starting to move and then kind of week by week over the next month or so it where most of the changes are happening. So like once you get out of the sort of the first phase of things, it's things are opening up, things are settling down and then, you know, you and we are figuring out is that, you know, is that made as much of a change as we need. So by about six weeks after procedure, we should have a pretty good sense as to did we do what we wanted to do or needed to do, but that's office. Surgery is the other way you can go. Surgery is something you're asleep versus being awake. Everything still happens on the inside of your nose so nothing on the outside. With surgery, from a sinus front, same deal, just different techniques. So we look in the nose with a camera. We look up toward where the sinuses come in. Sometimes we'll use the balloon in surgery itself. Oftentimes we'll use different techniques, meaning that instead of using a balloon in surgery to dilate the opening, we're actually removing some that blocking tissue to open it a different way. We can be a little bit more aggressive in surgery, as far as how we want to open those sinuses up. Turbinates are pretty much the same, you know, same thing. Well, sometimes we'll use some different techniques in surgery versus what we do here, but conceptually, we're just trying to make them smaller. So get the turbinates reduced, the additional step that we can take in surgery that we can't take here is where that septum's bent, we could straighten it out. So to do that, what we do is on the inside of your nose, we make an incision into the skin, get access to that cartilage and then we're taking out little struts of that guide to get it back in the middle and then close it back up. So surgery that you go home the same day, it's more intense than the office is the sort of bottom line. So first couple of days it's messy. So it's just kind of bloody drainage. Then it's stuffy. Stuffy with surgery is a lot more stuffy than the office. Stuffy with surgery feels like you got a bad sinus infection, really stuffed up, really annoyed. First week's still the worst. Still needs to fade. It just takes kind of longer to get where it's going. So surgery, we're putting you through more and we're doing more. We're kind of being more aggressive in the things that we're doing, therefore, the recovery is more intense. You know, surgery gets you as open as you can possibly be both from a sinus standpoint and a nose standpoint because we're addressing the septum and addressing the sinuses differently. And so surgery is as open as you can be, but the recovery is more intense because the actual procedures are more intense. Office procedures are as open as you can be sort of surgery. The biggest differences between the two, the septum is, I'd say, the biggest difference. So, you know, you've got a deviated septum. The question with the office would be, can we leave your septum alone? Can we get enough space around the septum so that, you know, really what we need at the end of the day from your nose and the sinuses is can you breathe comfortably, you know, through your mouth or through your nose with your mouth shut day and night? And it looks doable with the office procedures. So I guess if that's the goal, I'd say that looks to be an achievable goal with the office. So if we went down the office road, it'd be do it, get you landed, and then we wouldn't have to guess at that point, you would be able to say, and we would be able to look and say, yep, that's good. We're good, we're good to go, that's great. Or alternatively and less likely but possible is if we do it, get you landed and it's just not as much of a difference as you're hoping for, we still have the option of going up a ladder to surgery and take care of the septum. Nose and sinus wise, any thoughts between those two different pathways?

- [Patient] If you feel like there's a good chance that my septum will not preclude us for the office-based stuff from working, I would love to start there.

- [Dr Kandula] Okay, that's fine. Okay, that's fine. That's fine. And I do, our next step down that road would be really just getting things authorized, insurance wise, you know, basically getting their blessing and getting it done, getting things moving, and then, you know, going from there. Sleep wise, you can make an argument to say, you know, let's, you know, once the nose is working, let's try that machine, give it a fair shake through a nose that's open, see where that takes us. Go from there. You can make an argument to say, well, we've tried the machine, didn't go so well. Yep, let's get the nose working. Let's go towards an oral appliance and then go from there. The difference is the proof is gonna be in the reality. Get your nose working. And whether it's an oral appliance or a CPAP machine, they need to be working and working means you're sleeping quietly, resting comfortably, you know, so forth and so on. The difference between the two things is an oral appliance doesn't record data. It's not telling us whether it's working or not definitively on a night-by-night basis. The CPAP machines or BIPAP machines do. So if we went down that road, it'd be get your nose working, get you in a machine. And then every night that machine is recording data on, you know, how long did you sleep, any pauses and all that sort of stuff. And so there's not like a right or wrong between the two, there's a little bit of extra nuance, a CPAP machine that, you know, that that has that the appliance doesn't, but I'd say on the back end of the nose, I'd really kind of put it in your court as far as, you know, which direction we go, knowing that if whatever direction we choose, isn't going so well we can always kind of pivot to the other. So any thoughts on that part of the equation?

- [Patient] I'm certainly willing to try CPAP again, but I also do like the idea of the oral appliance

- [Dr Kandula] Either is fine, either is reasonable, neither can work right now with the nose the way it is. And so we're not gonna mess around with them until we get the nose on our side. And then the final component of all this, I'd say back to the weight, get your nose working, get the sleep apnea treated, you know, so basically get your airway working day and night and see what that feels like. Then it's the ultimate would be now that you're having that restful sleep, sort of start a game plan to dial that weight the other direction. Because if you are getting restful sleep, there's a fighting chance of, you know, getting weight off. Basically, if you're not getting restful sleep, it's almost impossible to make any dents in that.

- [Patient] Well, I feel like we got three or four episodes of "Erik's Journey."

- [Meghan] Well, you had your visit with Dr. Kandula. My name is Meghan. I am his treatment coordinator here at ADVENT Wauwatosa Clinic. So after meeting with him, he did provide his recommendations and he is recommending an office procedure. So we're gonna go ahead and get you scheduled today. And do you have any questions before we get that started?

- No, I don't think so.

- Okay, perfect.

- Yeah, works good.

- All right, perfect.

- [Patient] There's an all terminating but you know. Hopefully get an excuse to get one of those.

- [Meghan] So right now we don't have a confirmed time. We'll be calling you one week prior to provide that to you. So just prepare for that to be in the morning though.

- Okay.

- Did Dr. Kandula talk about premeds with you in the room today?

- Yes.

- Okay. And is that something that you're gonna be interested in-

- I don't think so.

- No.

- [Meghan] That works. And then we're gonna schedule your one-week follow up to the procedure just to make sure everything's going well for that healing process.

- [Patient] Okay. Give us another all time.

- [Meghan] Two weeks in a row, they're gonna love you. Okay, so now that we have everything scheduled, I'm gonna go ahead and create your consent form, print that out and we'll go through everything.

- Okay.

- Keep in mind that everything that you're signing today, you're also gonna be going home with a copy of in a folder.

- Okay. Okay, great.

- And then you'll hear back from either myself or someone within our department one week prior to your procedure.

- Perfect.

- Great. That's all yours.

- Awesome.

- Thank you.

- Thank you so much.

- You're welcome.

- Thanks for all the help.

- [Meghan] Have a good rest of your day.

- You too.

- Thanks.

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