The Heart Works for the Nose

In this episode of ADVENTing, Dr. Kandula and Dr. Handler debate who works for whom the heart or the nose.

- Hey, Dr. Madan Kandula with ADVENT, your host for ADVENTing, where we talk about everything ENT related and not ENT related sometimes too, with Dr. Ethan Handler. How are you doing?

- I'm doing well. It's Monday, happy to be alive.

- We always do sport. We do these icebreakers and it always happens to be sports. It always happens to be under COVID tyranny, which we are in right now. Sports.

- Nice to have sports back. It's nice to have Bucks back. I've been watching them. Well, they're one, one.

- So they won one, lost one in the bubble.

- Yeah, but they're looking good. They've got to fine tune. They're going to be in the playoffs, obviously. George Hill didn't have too good of a game yesterday. He was pretty instrumental. During the season, he was playing pretty well, but Bledsoe's still out. It'd be nice to get all the team back but, fortunately, we don't have to see the Rockets, unless they probably make the championships, so let somebody else deal with them.

- Yeah, it's interesting. They've got the virtual fans. I didn't really

- Yeah, what do you think

- pay attention to them.

- about that?

- I don't know. It's cool. I guess it's better than nothing.

- It's better than empty stands, right? Because that would seem really weird but what I thought was funny, and SportsCenter did this, there was a blowout and the virtual fans left. They made them leave the stands.

- That's appropriate I guess.

- Yeah, it was like, I'm outta here. I might be a computer program but screw it.

- So the fans are just watching the game on a Zoom thing probably.

- Are they real?

- Yeah.

- Oh, see, I just thought it was computer generated.

- No, no. Well, it depends on which fans. In the NBA, those are real people.

- Being piped in? Like their emoji or something?

- No, they're there. I don't sit there and watch them but they've had notable people.

- Oh, so they actually left the game but it was really people just turning it off?

- I'm not sure how that works. I don't know if you can just leave because I think for the Bucks, it's the crew that's loud, that crew, I think they're preferentially selected to be the Bucks' talking heads or whatever, fan heads.

- But I saw a guy lift up a baby, so he must have been doing that in his house. I was like, what are these people doing?

- Yeah, you have babies in your house.

- That's true.

- If you've got a baby, just lift it up.

- We've got babies in the house.

- Put it on a screen. Sports are good to be back.

- Sports are good to be back.

- There's definitely a massive, in my life, the first void ever. Although I fill the void, I don't think I've said it here on ADVENTing before, but I fill the void by going back to 2010 and watching the Packer season all the way through, which is awesome, and now I'm in 2011, so I can't actually get to the real sports now until I finish the 2011 season, which I know how it ends, which it ends very poorly.

- You'll have to remind me because I wasn't in Wisconsin at the time.

- All I'll remind you of is that Jermichael Finley was awesome.

- Didn't he have a terrible injury though in his career?

- Yeah, he had a neck injury the year, but 2011, they had the phenomenal receiving core. He was at the center. He was a guy that would change the field, actually him and Nick Collins. Nick Collins went out in 2011, and I remember this vaguely, but walking through the season, when Nick Collins went out, it was early in that 2011 season. The Packers, their defense just fell apart, until this day, and nobody really remembers Nick Collins and not many people remember much of Jermichael Finley, but that's why I'm at.

- I remember hearing about him, just because I was in, I was in residency, but he was around. I just remember hearing about him. Was he a game changer in the way that Gronk or--

- He wasn't as big as Gronk but he was very talented.

- Jimmy Graham in his heyday, that season?

- Like a Jimmy Graham-esque. He was a great player and then he just had an unfortunate injury and then he was down, but off of sports. On to medicine, which you know how to do a little bit of medicine.

- Sometimes.

- Sometimes, so the fundamentals. So if I stuck a piece of steak, I guess you could do the same thing, but I just shoved it into your trachea right now, and you went down and we call the paramedics, and the paramedics came, what do they need to follow? If you're rescuing somebody, what do you follow?

- Let's start with the first letter of the alphabet. It's A for airway.

- Yeah, it's ABCs.

- Yes, ABCs.

- You don't get to B before you get, A has to come before B.

- Correct.

- What's B?

- B is breathing.

- And C?

- Circulation.

- In that order.

- In that order, always in that order.

- A is the most important. B.

- Yeah.

- C is teeny tiny, although cardiologists and cardiothoracic surgeons, they might view this differently but we can all come in agreement that airway is super important.

- Right, we're testing out some strategies here for my wife, who's a pediatric cardiologist because I'm gonna use this on her later.

- You're the most important medical professional in that relationship?

- Yes, absolutely. 100%.

- Because you deal with the A.

- Right.

- She does B and C but mostly C.

- Right, who really saves lives here? It's the A guy, not the C person.

- Correct. B and C don't matter if you can't save, but on the airway front, airway people think of your trachea, which is your windpipe, but your airway starts up top. It starts with your nose and your throat, which happen to be in our wheelhouse. That's all we do, are nose and throat issues. When you think about it in that sequence, basically, if your nose isn't working, you drop your mouth open, you can breathe through your mouth. Okay, fine. If your nose and mouth are not working, if you can't get air in your nose and your mouth, then you're dead, period, end of sentence kind of a thing, and so it's fundamental, although many, many, many people walk around with restricted airways, mostly all that we deal with are folks who are dealing with airway issues. They're not shut completely, most of the time, but it's compromised, which has a downstream effect, but the reality is, if your airway isn't working, then you can't breathe, obviously. If you can't bring oxygen into your system, your heart can pump for a little bit, but not for very long. It's just going to stop. Now you can have cardiac issues, that are impactful and very, very common as well, but all those things relate to each other. I guess the reason we bring it up, the reason we're talking about this specific topic, is I don't think people recognize the importance of the airway, because we don't often talk about it. Everybody hears about and knows about folks who have heart attacks and strokes and circulation issues. You don't hear so much about the airway issues, although the airway issues, this is where it gets a little--

- Well, it's because we take them for granted.

- We take them for granted but--

- A lot of people just assume it's working, it's functioning.

- But many people, they're not, and then a lot of folks that we treat have sleep apnea. Sleep apnea, by its definition, is an airway issue, but it creates breathing and circulation issues, so that, to me, I'd say it's going in a little bit of different direction, but on a chronic basis, if you compromise somebody's airway, it is going to impact the downstream issues, circulation specifically. Again, I don't think people think about it in this way, but for somebody who has sleep apnea, what we're doing is establishing an open airway for them when they're sleeping at night, so that they can live their fullest life in the moment, but they can take away some of these downstream effects from the Bs and the Cs, the breathing and circulation. If you want to create a test kitchen for what happens when airways are compromised, you look at folks who have sleep apnea and the sleep apnea is not treated, and you look at the shortened lives and the compromised lives and the compromised days that happen, from sleep apnea, but back to more recent right now, I'd say, yeah. The ABC's, it's not part of it, we're saying it jokingly, but much of it, I'm not. I'm dead serious, where airways, healthy airways, are massively important for kids and adults. Correct?

- Correct, 100%.

- It's not like there's a debate about it, but I think that the challenge is, is that people don't say that with clarity enough and because people don't say it with clarity enough, it doesn't ever get said, and then people who should be saying it are us. It should be us, at ADVENT certainly, but certainly other folks in the ENT space. A lot of the loudest voices I hear, in this day and age, are dentists who work in the airway as well and I'm thankful for them. I'm thankful for that community to step up and say, "Airways are important," and they really have embraced that fact, more so than our community. Our lowly, lowly, lowly, I said three lowlys, ENT community has not recognized the importance of our specialty, which is a shame.

- No, I think from a dentist standpoint too, and especially as you and I have realized, dentists have had a challenge, trying to find partners in this community that are going to listen to them and actually partner with them, to do something about it because there's only so much they can do, and they can see all the downstream effects, especially from a crowding in the mouth and sleep apnea, but, man, for dentists to try and get the ear of an ENT, it's a challenge.

- Why is that?

- It's a challenge.

- Here's the deal.

- It shouldn't be that way.

- It shouldn't be that way, but ENT is the airway specialty. The upper airway. There are pulmonologists that deal with the lungs, but they have nothing to do with noses and throats and tracheas. If you think about medical specialties, it's EMT. Whose domain is the airway? It's ENT, but we have, for whatever reason, I don't know what that reason is, decided that we, when I say we, I mean my specialty, we don't really care about it. It's almost like we've seated our concern for it, for no reason I can understand. What are ENTs doing, who are abdicating the airway space and they're not doing their job, in my opinion.

- Right, no, unless they're taking arm. It's not just us, but hopefully there are some out there that are taking a very strong mindset to getting the airway open, because, again, I also think that most people and patients don't really understand. They may have COPD or asthma or some lung issue, and when this doesn't work, this ain't gonna work well, and so it's trying to connect the dots that seems so clear and logical, but even the medical community doesn't really connect those dots. So, okay, well, if you have a lung problem and a nose that doesn't work, get the nose working, it's only going to help things downstream. It's kind of this unified airway.

- Yeah, I almost feel like, I'm trying to get back into my, my ENT head is not in the normal ENT place anymore, because what we do has deviated from the typical ENT practice, but the typical ENT practice, who sees a nose that isn't working, doesn't think, "Hey, I can fix that." They think, "It's not that big a deal. "Deal with it." When in fact, it's a huge deal, and if you don't fix that thing, I mean, so you take that patient you just described, who's got COPD and a nose issue, I think a typical ENT practice would look at that patient and say, "Well, that COPD issue's, that's a big deal. "Your nose is not that big a deal. "We'll just leave it alone. "Here's some FLONASE. "Good luck to you, buddy." And on the flip side, they'd say, we're not saying, and I'm not saying, and you're not saying, you fix somebody's nose and their COPD goes away, but I'd say if somebody has COPD or asthma or lung issues, and we're just using this for example, they're compromised, and if their nose is compromised, you're double A compromised, and so if somebody's airway is compromised, why wouldn't you? And you could easily eliminate one area of compromise, why wouldn't you do that? There's no reason why you shouldn't, other than you don't feel confident in your skillset to deliver a result or you don't believe in it. One of the two has to be, or both, probably.

- How many times in a textbook, whether it's Bailey's or Cummings, which are the Bibles for ENT, did you ever see a statement that was like the nose should work well, day, night, period.

- Yeah, I know. It doesn't happen.

- I didn't really ever hear that until we started talking that way here at ADVENT, and I was on the other side of that too, and dismissing some of those issues, honestly, because it's just the way I thought about things. "Hey, it's not that big a deal. "Your COPD is the bigger issue."

- Yeah, to me, it's just wrong-headed thinking. Like I said, it's wrong-headed and so that's wrong, but on the flip side, we know, with thousands of patients that we treat, when you get somebody's nose working, it's powerful, powerful, and if they've got sleep apnea or whatever other issues they've got going on, basically, both ways. If nobody's perfect, I don't think, are you perfect today?

- No.

- No, you're not perfect. I'm not perfect.

- Some days.

- So whatever other medical issues you have going on, if you combine that with a nose that's not working, you're going to just add, you're going to accentuate the negative. If you get the nose working, it doesn't make everything else go away magically, but sometimes, sometimes we've seen folks and it happens frequently, certainly for folks who have allergies and asthma issues, is you get the start of the airway working and magically the downstream issues, they tend to hover towards better. Not perfect, but better, and even if they're going to be horrific, and there are folks that we treat, who've had horrific other medical issues, and because we can do office-based treatments for them, we can get their nose working, if that's what they need. Can't fix their horrendous other medical issues, but it's a massive quality of life boost to have a nose that's working.

- And we removed a barrier that people would use or doctors would use as a, "Hey, your co-morbidities, "your other medical problems, are too much of a risk "for us to put you under general anesthesia." To do this, so, "Hey, let's get these other things "under control first and then let's back into your nose." Whereas now, it's like, well, let's put that on its head. Let's say, "Okay, great, stay awake. "It's like going to the dentist," and I've been using that thought process a little more with patients like, "Hey, you go to get a cavity. "That's your experience. "That's what you should expect," and then you can get this thing taken care of.

- Well, I think that right there, honestly, it's complicated, but the reality is the fact that we can get folks up and running and breathing properly without having to go to surgery and go to sleep, it allows us to make the very simple statement that if your nose isn't working and you've got downstream issues that you probably ought to get that, or you ought to have the option to get your nose taken care of, but when we say that, we typically mean in an office based approach and we can certainly do surgery if necessary, so it's not like we can't, but I think if all you could do is surgery on somebody's nose, to get it working better, then you certainly aren't, I wouldn't, and I can't, and you can't operate on somebody, who's really, really sick medically otherwise, because it's too dangerous, and so I think that's probably at the heart of why some of this thought got put into our heads and, unfortunately, most ENTs aren't able to offer the same services, that we can offer, from an office based approach. So if you were trained not to be able to think this way and you can't offer the same options we can offer, then you just revert back to, "I guess we just have to leave this thing alone," kind of a thing, so I kind of get it. I mean I don't get it. I'm not excusing anything, because it's not the reality of the world. The reality of the world today is that we can do simple things in the office that make massive changes to people's airways, and because we can do that, in that more simplified manner, more folks can take advantage of it, and that's a good thing.

- This came up today, because I was in the operating room this morning and just thinking through, we were using some, it was an implant thing that releases steroid, but it was like the idea that like, why is something like that, not covered in a surgery center, but it is in a hospital? And so I started thinking. I was just talking with some of the other staff there. So I ask you this question. What percentage of sinus surgery or nose stuff that we do needs to be done in a hospital center, and even an ASC setting, to be honest with you?

- Yeah, I mean, low. I guess the question, so I guess what percentage needs to be done, not in our office? Let's flip it and make a double negative and it's pretty rare, and we can do pretty extensive work in the office, so I think for when do we have to go to the OR? Only when push comes to shove. I think it's less than 5%. It's low single digits. It's probably even lower than that. When you say needs, because there are times where we're talking with patients about office options and OR options, and some folks will choose to do OR. Maybe it's a need. Maybe it's just because, there's various reasons of why somebody might choose that, but even there, I don't know if I would say it's because we couldn't do it in the office. It's more of a personal preference kind of a thing.

- Sure, let's say 10%, but then what percentage of that do you think should be done in a hospital setting?

- None, really. Well, not none.

- Small.

- Almost none because I think, when it comes down to it, if somebody is sick enough that they have to have their surgery, their ENT surgery, done in a hospital, which it should be the barometer. The barometer for having an ENT surgery in a hospital is because you need a hospital, and the only reason you need a hospital is because if you're sickly, other than an ENT kind of sickly. The reality though is 99.99% of all ENT procedures are done in a hospital setting, which ain't right.

- No.

- Basically, to recap, 99.9% of ENT procedures don't need a hospital or OR, yet 99.9% of hospital procedures happen in an OR. It's really messed up. It just is. But I think that the challenge is, it's problematic for a couple of different reasons. One is cost. The second is that it raises the bar for folks to want to get something done, and it raises the bar, meaning decreasing and diminishing the ability of folks to seek out treatment or surgeons to offer treatment, because, "Gosh, is this real? "Is your nose blockage problem really so problematic "that I have to take you to this hospital "to get you to sleep, to do this." And that's a pretty high bar.

- Well, it diminishes it in the patient's mind about how important it really could be or should be, because most people struggle with this issue. "Wow, I have to do all this, just to get this addressed, "then maybe this isn't that big a deal "and I should just live with it." But the reality is shouldn't live with it. It's not the way you should live. We can take care of it.

- Right, which is profound. It really is profound. Back to this airway thing, and back to this ABCs that we were talking about before, airway is fundamental, and if your airway is compromised--

- B and C don't matter.

- No, and though the challenge is before we were able to do some of these office based procedures, the bar towards getting something done, to get something corrected was, to I, in most places, even today, it still is, unfortunately. It's too bad, but back to the truth though, the heart works for the nose, right?

- I mean, essentially, yes.

- When you go home today, you need to be pounding the table with that message.

- Heart could be in the C suite, but the nose is the CEO.

- Exactly.

- It's no question. It's important. It's upper level management.

- We don't have a problem with the heart.

- But it's a big muscle and muscle wants to can work aerobically.

- Correct.

- Not anaerobically, and the only way to provide that is airway.

- Airway, through the intelligent, functioning nose. Correct.

- Yes, 100%, yes.

- Noses are profound.

- Noses are profound.

- Yeah, they are. That's good. That's good. All right, well, I think our time is getting short here. I think that, today, I'm not sure when you guys are listening or watching this segment, but today we're opening a new office. Where's that at?

- Oak Park.

- Good answer. Yes, that's true. Oak Park is where? What state?

- I believe the great state of Illinois.

- I don't know, what's their motto? Illinois?

- Don't know. I have no idea.

- I don't know either. Illinois--

- We have Chicago. I don't know.

- Illinois, what's Wisconsin's motto?

- It's a huge state. What is Wisconsin, like we're badgers? I don't know. I'm not from here. I don't even know what California's motto is. The 49ers? Gold miners?

- I'm just trying to think which Illinois is.

- What's the state flower in Illinois or Wisconsin? Do you know?

- Oh, I don't know. We're the dairy land. Wisconsin, if I'd say--

- Dairyer.

- America's dairy land would be Wisconsin's motto. What is Illinois's motto? I don't know. We have Chicago?

- We have Chicago, yes. We have the .

- I mean, it's a good state. I'm not knocking. I'm not, it's not pejorative. The land of Lincoln.

- The land of Lincoln.

- That's solid.

- That sounded familiar to me. I was thinking that.

- That's solid. But I was like--

- That's solid. Oh, you were thinking it.

- The land of Lincoln.

- I like that. Yeah, that's a good one.

- Who does Wisconsin have that is Lincoln to Illinois? Don't say McCarthy.

- No, we have a run of really good quarterbacks, between Rodgers and Favre.

- Is that better than California's run of quarterbacks with Montana?

- No, I'm just saying, between Abraham Lincoln is to American presidents as Aaron Rodgers and Brett Favre are to American quarterbacks. They'd be on the Mount Rushmore of, so I'd say it's probably a tie between Lincoln and Aaron Rodgers, tie.

- Tie. Shorter facial hair.

- Maybe give the edge to Rodgers, because I think he's got, well, at least back in the day, he had better legs. He could run around a lot better than Lincoln, I think.

- I can see that. Yeah.

- Are you going to say anything bad about Abraham Lincoln?

- No, no, no. No, just listening a little bit more about the history. He was an incredible time, for him to do what he did and live in that time.

- This is Aaron Rodgers or Abraham Lincoln?

- Definitely Aaron Rodgers, yeah. I mean, man, what he has to deal with on Twitter. I don't even know how he .

- Yes, it rises to the level of Abraham Lincoln.

- Did he break up with Danica? Did that happen?

- Yes, it's over. It's done.

- Oh, God, it's just super.

- She's from Illinois. No, she's from Wisconsin too.

- Well, that's why, oh.

- But she's a bears fan, so there's that.

- Yeah, that's a problem. It was never meant to be.

- Yeah, doomed from the start, but Oak Park, we love you, Oak Park. Do you know where Oak Park is?

- It's outside of Chicago.

- It's right there.

- It's west, isn't it?

- Just barely west of the loop.

- Very good, some trendy restaurants, when they open again, finally. I'm sure in the area.

- I think they're open on the street, at this point, Vernon Hills, that's our first Illinois location, Northbrook, Oak park, Financial District is coming, so we've got Chicago covered pretty well.

- Yeah, pedal the metal.

- Yeah, we're rolling. You've got any shout-outs?

- No, I think that's a pretty good shout-out, right there. Let me shout out, no, sports are back. I'm excited. PGA next week, for all those golfers out there. I'm pretty excited about that actually.

- And with that one, they say, no. Nobody cares. Does anybody care about golf? I don't know.

- It's going to be at Harding park, which is an amazing course actually. It's a beautiful course, along the coast in San Francisco, kind of that area, so lots of big Cypress trees and good track.

- I'll take your word for it. You'll have to tell me all about the details of that event. So if you're watching us, give us a like, give us some comments. If you're listening to us, same thing. We will be back with more captivating content.

- Next week?

- In the near future. Next week, hopefully.

- Thank you everybody.

- All right, take care. Bye bye.

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