good evening and welcome to doctors on call I'm Dr Peter nalen professor and head of the Department of Family Medicine and biobehavioral health an associate Dean for Rural medicine at the University of Minnesota Medical School Duluth campus I'm your host for our program tonight on ENT problems including sleep apnea the success of this program is very dependent on you the viewer so please call in your questions or email them to ask at pbsnorth.org the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Andrew Davis an ENT specialist with St Luke's ENT Associates Dr Ryan Harden a family medicine physician with Gateway Family Health Clinic in sandstone and a faculty member with the University of Minnesota Medical School Duluth and Dr Mark Rhodes an ENT specialist with Essentia Health our medical students answering the phones tonight are Anna Shu from New Ulm Minnesota Tanner nordseth of Round Lake Minnesota and ludus rottermacher pardon me Lucas rydermacher from Battle Lake Minnesota and now on to tonight's program on ENT problems including sleep apnea and Dr Hardin the first question is for you what is sleep apnea so sleep apnea actually what apnea means is the absence of breathing so sleep apnea is a condition where when somebody's sleeping for short or more prolonged periods of time they'll actually stop breathing and when that happens the brain it signals the brain that there's not enough oxygen in their blood and their brain wakes the person up they change position and go back to sleep okay thank you and Dr Rhodes will having a tonsillectomy cure sleep apnea so uh sleep apnea is called obstructive sleep apnea because something is a blocking or obstructing the airway if your tonsils are big enough or primarily for children taking the tonsils out and often including the adenoids in fact we'll often cure sleep apnea so primarily children for the adult population if your tonsils are big enough they will cure sleep apnea Dr Davis how about the symptoms of sleep apnea well it can vary from Patient to Patient but usually you see daytime somnolence so you're tired throughout the day you can be more irritable but also you can have attention issues problems at work it also could be a significant psychological factor to it as well but daytime Salmons is the main one and Dr Rhodes what are some leading surgical procedures to treat sleep apnea so as I said sleep apnea is obstructed meaning the airway is getting blocked off and actually I want to mention before we talk about surgical options the biggest and best treatment for sleep apnea is actually what's called CPAP which is continuous positive airway pressure um I tell patients that you know our number one goal is Do no harm as Physicians CPAP is maybe one of the only treatments I know in medicine that really doesn't have any significant side effects to it and works really really well so I always recommend to patients they start off with CPAP as far as surgical options as surgeons what we try to do historically is try to remove stuff doctors our surgeons are pretty good at cutting things out so we would cut the tonsils out sometimes remove part of the pallet and the uvula those are primary surgical treatment for sleep apnea for many many years um it doesn't it works but not great and it's pretty hard uh pretty painful more recently we have something called the hypoglossal nerve stimulator implant this is something that we attach an electrode to one of the nerves that controls your tongue and it what it does is it tightens up your tongue throughout the night so that's our newer surgical treatment that's working great for us thank you Dr Harden what can patients expect if they're recommended to have a sleep study so we use sleep studies to diagnose sleep apnea a lot of times patients will come into the clinic with symptoms consistent with sleep apnea daytime sleepiness snoring high blood pressure that's refractory to treatment with medicines and in order to confirm a diagnosis of sleep apnea we typically recommend that patients have a sleep study sleep studies can be done in the hospital also less probably less commonly sleep studies can be done at home but when somebody's in the hospital they're monitored with a video and their respiratory rate is monitored their blood oxygenation is monitored and their heart rate's monitored and based on a combination of all those parameters and apneic events where patients actually stop breathing I think you know more than five times an hour that's consistent with a diagnosis of sleep apnea so generally speaking I think the best way to diagnose sleep apnea is an in-hospital sleep study Dr Rhodes you mentioned obstructive sleep apnea earlier what about Central sleep apnea a caller from Duluth wants to know can one outgrow Central sleep apnea so Central sleep apnea refers to sleep disturbance and apnea that's modulated or controlled through the brain so those that's a much different disease than obstructive sleep apnea and so I'll be honest I'm going to say I'm a surgeon I do really well of obstructive sleep apnea Central sleep apnea I kind of lead to or leave to our sleep colleagues so I really can't answer that one typically anything else to add on that one Central sleep apnea I I think central sleep apnea is primarily neurological in origin where the brain just loses its ability to tell the body to breathe in a regular pattern so I would say that it's typically not something that people would outgrow but can be treated with CPAP with seatbelt and can you for our viewers just say a little more about what is actually happening when the CPAP apparatus is being worn yeah so what the what CPAP does is it forces air into the throat that actually opens up the the back of the tongue region and also wherever the level your obstruction is or whatever reason why you're having the uh the obstructive event the air kind of just forces the airway open so you can actually breathe you can put oxygen to it too if your oxygen is too low throughout the night but it's just basically a method to force Arrowhead thank you Dr Rhodes what is a deviated septum and why might it matter so the septum refers to the structure inside your nose that's basically a wall that divides it into a left side and a right side so it's supposed to go right down the middle uh but majority of us or almost all of us do something over our lifetime we fall off the swing or get hit by a baseball or we do something to hit our nose and it pushes that wall off to the side we refer that to as a deviated septum so what it tends to do is block one nostril or the other and depending on the degree of severity sometimes it's completely occluding that nostril and so surgery can help fix it move it back into place Dr Hardin a caller asks not having a cold or allergies but might be leading to a constantly runny nose well that's a good question and one I get a lot in the clinic there's something called basal motor rhinitis where for reasons that we don't entirely understand the nerves and the nose cause the nose to secrete more secretions then we would typically expect and that can cause kind of a you know constantly runny or drippy nose it can also go back down the back of the throat and that can cause a chronic cough typically as we age that has a tendency to get a little bit worse vasomotor rhinitis there's treatments for it but um medications that other things certain of our especially blood pressure medications can cause a runny nose drippy nose or congested nose so it's the other thing to look at you know it's a great one with your primary care provider to review some of your medications sometimes for side effects of the current meds sorry right Dr Davis a caller from Two Harbors has had sleep apnea and CPAP use for 40 years with recently started snoring What might explain that a number of things could explain it it could just be that the mask isn't fitting as well it could be the the you're not getting as good of a seal on the mask it also could be that you just might need some more pressure from the CPAP itself to kind of keep the airway a little bit more stunted open said advise you to review with your be their sleep doctor your primary doctor about potential reasons why that could be happening also if you had increased weight gain or some other lifestyle changes that could also increase your chance of it but a caller asks why are they more tired after using the CPAP anyone want to answer that probably because the cpap's probably not working that great for them so once again that's in those type of situations you want to whoever prescribed to the CPAP you'll want to spend some time with them trying to figure out better ways to use it but if you're feeling more tired after using a sleep app I would question without the CPAP is being properly used cards CPAP is a great treatment but it can be hard to get used to and sometimes if it's causing you more annoyance then benefit it could be that it's keeping you awake more but there's lots of ways to modify that multiple different types of masks to help you get more acclimated to your CPAP about 50 percent of people cannot tolerate a CPAP so it's a very common thing not to be able to tolerate a CPAP and sometimes it's you need to go through a bunch of different uh masks before you actually get a good seal I'll just add to that if um it's one of the rewarding things in medicine to have somebody who has sleep apnea if you treat it appropriately and effectively and the CPAP works or surgical options work for them it's really life-changing and it's there's a dramatic Improvement in people's lives who have sleep apnea once it's appropriately treated they have a lot more energy you know and it decreases their risk for some long-term complications associated with sleep apneal in this way like Dr Davis and I keep talking about keep trying it keep push that CPAP right to work with your sleep medicine doctor to see if you can get it to work this can make all the difference in the world while continuing with our ENT topics a caller asks about chronic ear running after an acoustic neuroma resection and removal of part of the hearing nerve can anything be done to fix this okay so that that's referring to a very very complicated specific situation acoustic neuroma involves a benign tumor that's growing on the nerve between the ear and the brain so an individual who's gone through that operative procedure has gone through a really complicated surgery they've had a significant amount of surgery done on the ear it's changed it quite drastically so if we're seeing drainage we want to know what's the nature of that drainage often drainage can represent infection and we've got to treat the infection rarely drainage after that kind of operation can be what's called CSF cerebral spinal fluid would want to know that too so you should get evaluated he or she should get evaluated and yeah there's probably his treatment very good Dr Hardin is there a relationship between sleep apnea and the arrhythmia atrial fibrillation um absolutely you want to treat sleep apnea for on one part to improve people's symptoms during the day but more importantly probably you want to treat sleep apnea because untreated sleep apnea increases risk for um something called pulmonary hypertension which is a cardiac problem and it also untreated sleep apnea definitely increases the risk of cardiac arrhythmias probably most commonly atrial fibrillation and it also increases your risk for stroke and there's been some association with untreated sleep apnea and dementia actually thank you Dr Davis what could be the cause of periodic sharp spasmodic ear pain there could be a number of causes for it it could be actually year itself where you have uh ear infection or you know some type of actual primary ear problem but it could also be related to the jaw joint too which is just sitting right in front of the ear which is probably which is a very common reason why people do get ear pain when they have temperamentibular joint disorder which is usually a muscular issue or an actual issue with the jaw joint itself Dr Hardin what are the side effects of flutozone for treating eustachian tube dysfunction fluticasone I think is that's a it's a nasal steroid um so I think a steroid decreases inflammation so if somebody uses fluticasone for a short period of time to treat eustachian tube dysfunction it's pretty effective and I prescribe it regularly if somebody uses fluticasone chronically for months or years it can decrease the thickness of the lining in the sinuses and it can increase the likelihood that somebody's going to have chronic runny nose from that so generally what I do is recommend people if they're going to use a nasal steroid that they you for eustachian tube dysfunction they use it just when they need it for a short periods of time Dr Rhodes this caller wants to know regarding uh permission or or eligibility for an MRI the patient has had metal stapes implant can they still get an MRI the answer is depends exactly what kind of what we call prosthesis but the vast majority of those prostheses are compatible with an MRI machine most of them are titanium they're non-uh ferrous metals so the vast majority can go through MRIs okay thank you here's a caller who's been admitted through the ER with vertigo still having bouts of poor balance Dr Harden could this be related to the history of vertigo a year earlier so if somebody had vertical vertigo a year ago and then they had a asymptomatic period and then they developed a vertigo again it's probably something called beef ppv which is benign positional proximal vertical which is a temporary disorder in the balance Center in the inner ear that can cause really profound sensation of spinning nausea um which patients will commonly describe this sensation of spinning as a dizziness there's medications that can be used to treat it but I would say if somebody had an episode of vertigo years ago and then or a year ago in a period of with that where they didn't have any symptoms and then they developed again I'd say it's a recurrence of benign positional vertigo thank you this question is about ringing in the ears Dr Davis what are some evaluations or treatments of ringing in the ears it's probably one of the most common problems we see as ents it's called tinnitus is the medical term for it it's usually not always but the vast majority cases are related to hearing loss so it's kind of a symptom of hearing loss I always tell patients it's kind of the brain's interpretation of the hearing loss so the in terms of evaluations everyone should get a hearing test to determine whether or not there's actually true hearing loss or not and what that degree of hearing loss is and treatments are tough you know if you Google treatments of tinnitus you'll hear you'll see lots of different things a lot of it's not necessarily uh uh FDA approved or recommended but the best way I find people to treat it is use background noise so have some type of white noise in the background or else have the radio on the background or something like that otherwise hearing aids there's a tenderness mode on hearing aids if you're hearing a candidate and that'll help bring down the ring interesting Dr Harden what are some common risk factors for sleep apnea and does weight loss help um so for obstructive sleep apnea some risk factors are being overweight um and having large tonsils and definitely you know Lifestyle Changes which can lead to weight loss can sometimes effectively treat sleep apnea so weight loss can decrease your symptoms of sleep apnea but generally if somebody has diagnosed sleep apnea I would like to treat it with CPAP while they're losing weight because I think treating their sleep apnea giving them more time more energy during the day is going to allow them to be more active and lose that weight so weight loss definitely helps to treat sleep apnea Dr Rhodes what's the relationship between nasal polyps and sinusitis um so nasal polyps referred very specifically to a structure in the nose where you've developed basically look like very congested and gorged mucosa uh and it's actually something that's genetic just some people have it and it really has surprisingly a little relationship to sinusitis other than if you do an x-ray of them their sinuses are full but what they are is full of polyps and many of those patients actually don't have infections they just have polyps and polyps polyps in themselves will cause pretty drastic symptoms so but not always related to infection okay thank you for that and Dr Hardin caller wants to know is the CPAP noisy uh the newer equipment is less noisy um I actually have a friend who has CPAP and I didn't even know he was using it and um so the older equipment tends to be noisier but the new CPAP equipment is almost noiseless okay and Dr Davis a patient has a deviated septum and uses a CPAP is a surgery needed only if you're having problems with the CPAP so some patients if their septum is deviated enough it makes it difficult or uncomfortable to have the pressure from the CPAP to go through the nose so in those patients we can do strain the septum to make this CPAP more functional for them but if you're tolerating your CPAP okay without any issues it's okay to have a DVA a septum and use your CPAP Dr Hardin this question is about how to manage oral lichen planus um oral lichen planus just I think needs to be monitored you know it's typically asymptomatic but I think it needs to be monitored to make sure that it doesn't become a like a cancerous lesion or something like that okay thank you and here's a question a caller is sneezing about 20 times a day with no known allergies or colds how might you begin that evaluation Dr Rhodes so sneezing usually is caused by some form of irritation in the nose you sneeze because something is triggering the nose even though they may not have allergies based on testing they're still reacting to something so I usually would treat them with a good what we call nasal hygiene meaning keeping your nose nice and clear saline is great either saline spray or saline irrigations use of a nasal steroid spray will often decrease some of that inflammation that might be triggering the sneezing Dr Davis regarding nosebleeds can you describe the indication for something called packing the nose so we try not to pack the nose unless we really have to so probably the main patient you see coming into the clinic who has their nose packed either by the emergency room or the family medicine doctor is usually somebody's uh who's had a significant nosebleed and usually they're on blood thinners now sometimes patients who you know whether there's a trauma or they have a significant nose bleed they get packed you there's a we try to get those packs out usually in the first three to five days and then after the pack comes out a really good nasal hygiene with lots of humidification and saline rinses to kind of prevent the reason why they're the nosebleed in the first place Dr Rhodes can you provide some thoughts on comparing the nerve stimulator procedure or treatment versus CPAP so the nerve stimulator treatment again we're talking about this structure our device called the hypoglossal nerve stimulator it's a relatively recent treatment it's working really well Dr Davis and I are both placing them in patients but it's an operation we're surgeons we like to do operations but every operation is going to carry with it potential for problems or complications we call them so if you can avoid having an operation you should always avoid having operation um so again CPAP should be your primary goal as Dr Davis said up to 50 percent of people can't use their CPAP though so for certain of those patients the the nerve stimulator is a really nice alternative Dr harden a brief question from Superior does sleep apnea have an effect on blood pressure definitely untreated sleep apnea causes high blood pressure in fact a lot of times people who have sleep apnea are are identified because we try to treat their blood pressure with medicines and they're ineffective and Dr Davis a brief question can the tubes that a patient had years ago in their ears impact their health later on no I mean as long as they're not uh they can be there for life and not have any significant impact if they're need to have your ENT check them out if they are cause you some pain or some discomfort but they can stay there for life well thank you for this very interesting question and answer with a very active audience tonight I want to thank our panelists Dr Andrew Davis Dr Ryan Harden and Dr Mark Rhodes and our medical student volunteers Anna Shu Tanner northsif and Lucas rottermacher please join Dr Mary Owen next week for a program on lower GI problems when her panelists will be Dr Joe Bianco Dr Jonathan Gap and Dr Paul Sanford thank you for watching good night foreign