good evening and welcome to doctors on call I'm Dr Peter nen professor and head of the Department of Family Medicine and biobehavioral health and Associate Dean for Rural medicine at the University of Minnesota medical school duth campus I am 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 tonight or send them to our email address the telephone numbers can be found at the bottom of your screen our panelists this evening include Dr Todd Freeman an ENT specialist with St Luke's Ear Nose and Throat Associates Dr Robert gr an ENT specialist with Essentia Health and Dr Thomas gustaffson a family physician specializing in sleep medicine at both the grand itasa clinic and Hospital in Grand Rapids and Fairview range in Hibbing our medical students answering the phones tonight are Hannah Str from bigstone City South Dakota Becca floden from new pra Minnesota and Elsie Johnson from St Francis Minnesota and now on to tonight's program on ENT problems including sleep apnea and Dr Freeman the first question is for you where on the tongue do cancers arise and how do they get noticed uh well they can arise from anywhere on the tongue um uh anterior tongue where you can see them in your mouth those are typically in smokers and Drinkers and they present as a sore spot or a lump or a bump that either bleeds or is uncomfortable um more more in the last 15 years we' though we've had this really blossoming of viral induced cancers and they tend to occur on the posterior tongue uh below where you can see and they'll present as often times as a sense of a foreign body uh or a sore spot back there or many times has a lump in the neck thank you and Dr gr um what are treatment choices before getting ear tubes that's a good question question you know um a lot of times ear tubes are done for fluid to help clear fluid in the ear that won't clear on its own so we can try to use anti-inflammatory sprays to help clear the fluid there are different devices that help release the pressure and in the last decade or so we've begun dilating the ustation tube that's supposed to drain that fluid from the inside through the nose so those are a few different options before helping ventilate the ear uh through a different hole which is the uh which is what an ear tube is thank you and Dr gustaffson could you describe for us please what is the physical setup of a sleep apnea study for a child for a child uh it's a common question from parents so as we were talking about backstages I describe it as coming to a hotel for the night so I call it painless but Annoying so for parents it's just we're playing little stickers up on the scalp uh no shaving kind of in the hair like the old days some stickers on the face stickers on the chin couple stickers on the chest red light on the finger there's this little stretchy band that goes around your chest and belly and then one sticker goes right by your shin bone I'm not tied to the bed they all go into a little box that we around my neck and otherwise we try to have you sleep as normal as you can that night so it's usually not bad and uh the parents stay in the room yeah we usually try to have have a a fairly decent sleeper couch for the parent so if it's a young child we can have the parent be in bed while they're getting set up and kind of getting comfortable but once the child falls asleep we do try to get the parent into that little sleeper couch in the room otherwise sometimes we're picking up the sleep apnea or issues from the parent sometimes on the kid study but you can be there with the child the whole night if you need to but we do try to have a couch there thank you and Dr Freeman what are surgical treatments for sleep apnea um there's been a whole uh development of different things over over the years um the one guaranteed thing that can fix them in very severe sleep apnea patients are tracheotomies we simply put it bypass the obstructed Airway and put a tube in um there there have been various things tried with different fenal surgeries and tonsil removals with with just a few exceptions not very good results um uh which has pushed us more into medical management management with with the most common thing CPAP the most recent development has been the Inspire device which is essentially a a Pacer it senses you're starting to take a breath off a lead that goes to intercostal muscles and then has a stimulating lead that goes to your tongue based musketeer and it um kind of pushes your tongue forward as you take a breath and physically opens your Airway as you're sleeping it has a little wand that you can start the device turn it on and it usually has delay an onset so it gives you a chance to fall asleep before uh before it starts working and you got to remember to turn it off after you wake up very uh interesting and uh for how long has that technology been available uh probably the research has been going on for this and a lot of it was done through metatronics in the cities u in the N early 90s late 80s um the devices have been developed and really gone into practical use in the last 5 to 10 years thank you uh Dr Grill um after trauma what are common findings of a broken nose that's a good question the most obvious I suppose would be that your nose looks different you know it could be pushed off to one side either on top or on bottom a common find like if you feel your nose it's really sore and it feels like there's you know like a step off there like you're falling off and also when you break the bone the outer layer that supplies the blood can break so you can get a bloody nose those are the most common signs thank you and uh a viewer would like to know how does the CPAP work dror Freeman um you can kind of think of it as an airway splint first of all it's the first choice for treatment with this condition It's very effective if you can wear it for almost everybody with um obstructive sleep apne it's effective and whether you wear it over your nose or your mouth it it it provides positive pressure when you breathe in so it essentially uh helps open your Airway so it can't collapse and they're very they're extremely effective thank you Dr Grill another viewer would like to know if uh tenidis gets louder and impacts one's hearing what else could be done that's a great question and people ask that a lot about the ringing is so loud that I can't here and if we take a step back it's you usually the ringing is from hearing so it's a it's a kind of a a chicken or egg situation you know um a lot of people I would say a majority of people who have ringing they have hearing loss so when when the the brain's not hearing because the ear is damaged from the hearing loss there it kind of fills in that sound so by amplifying or like if people get hearing aids they kind of replace that sound they kind of tune it up so that their brain is getting stimulation and hopefully it kind of turns down that ring ringing so um it seems kind of backwards um that the ringing makes it feel like you can't hear but if you amplify the sound a little bit you can hear better and hear less ringing often times okay thank you and H Dr gustaffson when uh you're describing the sleep apnea study to adults um how do you describe it and do they ask you about testing at home yet we get a lot of questions about sleep tests at home and that's become a pretty big percentage of what we do and the home test can be very straightforward there's even one that can come through the mail that really is just on the finger and wrist of one hand so there's nothing on your face or body with that one but otherwise an adult sleep test would be almost the exact same as what I describe for a child where again just you know small sticker sensors kind of head face uh chest you're not tied to the bed you can get to use the bathroom and most most nights we're just getting information it's rare that we're going to come Ambush you in the middle of the night and put a caap on you though that can come up during a sleep test and uh What uh clinical information is being gathered from the finger and the wrist uh so uh actually a lot so we're uh on this one when you put the it looks like a large finger cop to me gets snug on your finger and actually measures these very minor changes in the uh muscles in your vessels of your blood vessels of your finger um and when also collecting oxygen I used to be a computer scientist so we actually run this through a machine learning algorithm and it did a very good job of identifying obstructive sleep app thank you and uh Dr Freeman following up on one of your prior answers a viewer would like to know what is causing the increase in cancers of the tongue it's a it's a viral induced tumor it's the human papiloma virus and actually the vast majority of the new tumors we see these days are these human papiloma induced viruses that um that start in either the tonsil or the tongue base um that's the bad news that we're seeing lots more of them the good news is they're very minimal to treatment um tumors that formerly you would have very low cure rates we're having cure rates 80s 90s percentile um um we know we're overtreating them now and a lot of the focus and research for these tumors is trying to deescalate therapy to try to find the right doses of of chemotherapy and radiation therapy with or without accompanying surgery to to effectively treat them but we're in the process of trying to figure that all out now kind of Nationwide Dr GRL if a if a patient is recommended to have a tongue biopsy um what are some uh special considerations and any special care the patient needs to do afterward um I guess it sort of depends how big the the thing is that we're dealing with but us usually a tongue biopsy is not too much noticeable for the person um afterwards for example if somebody has an ulcer or those can be really painful and if it doesn't go away sometimes we'll biopsy it and the biopsy will remove most if not all of it so a lot of people feel better after they get a biopsy because the irritated tissue is removed and if it's really large or something we may have them use some mouthwash to help any kind of stitches that are there dissolve or help things kind of heal but it's generally not too bothersome for people thank you Dr Freeman what are tonsil stones and how might they safely be treated or prevented well um as people if people if they have their tonsils and then they get older the tonsils will tend to get cryptic and pitted and in the depths of those pits you collect Foods food particles and bacteria and cells that SL off the lining of your throat and form these little white to yellow concretions and they um create irritation in those tonsor pits and eventually kind of get expressed out um they can um cause or help they can be part of chronic tonsilitis they can contribute to bad breath um as far as treatment it's just a hygiene issue um gargles rinses water picks can be real effective in cleaning them out um if people develop pain with them and actually chronic inflammation and discomfort and that's more than three months in duration um then people can be a candidate to have them surgically removed but that's pretty rugged in adults thank you Dr gustaffson um are there other good options for sleep apnea treatment Beyond The Sleep pardon me CPAP machine or uh the implant device yeah yeah I mean Dr frean did a good job of that CPAP is usually be our gold standard but if the sleep apnea is not highly severe there are some mouth guard type devices that we can use I bring my jaw forward to help keep my airway open some of us have a very positional sleep apne where if I'm on my back it's really severe if I'm on my side it's a lot better so we have these devices called positional therapy looks like a fanny pack you're wearing backwards helps keep you on your side um going to mention ccal options can be the right choice in some cases and in very mild sleep apnea occasion even use some kind of anti- decongestion type medications have been helpful thank you and following up another viewer question Dr gustaffson what is the difference between CPAP and BiPAP so uh as Dr Freeman explained you all these machines are using positive air pressure so I describe them as blower fans in a box a CPAP is continuous or constant just like Dr Freeman said a BiPAP or a B level still constant pressure but it can we can change the the amount of air pressure when I'm breathing in versus breathing out so that can treat sleep apne but we can also help people with things like COPD or other breathing problems with the machines with a bipad thank you Dr gr uh a caller wants to know would spy Rea be helpful with sleep apnea um I suppose you know inhalers for the lungs if they had and maybe if you had anything else to say about it I wouldn't say directly for Sleep apia usually not much the the best success we've had and this is with kids is things like uh flones uh nasal saline and uh singular we've had some success okay very well and um another caller asked for just a little more explanation about the mouth guards for sleep apnea yeah so they come in two flavors I call the professional model and the selfish fit model so you can find these online they're usually sold as anti- snoring mouth guards but the professional version is actually fit and made by a dentist but hopefully coved under medical insurance even though it's made by a dentist to me it looks like I don't say a brand name invisaline the little Trace people wear instead of braces I say Envision those but we're attaching the top piece of the bottom piece so it's a single unit and now we can bring your jaw forward and keep it there while you sleep so worn just at night time thank you and Dr Freeman do your patients ask about any natural remedies for ringing in the ears yeah I mean and there's been tons of things studied for tenus everything from Brew yeast to acupuncture and the results are dismal um avoiding caffeine is really important staying well rested because fatigue really contributes to it um if you have anxiety or depression issues get those addressed with your primary doctor doctor because managing those can dramatically reduce at least how much tinitus is bothering people um but otherwise if your hearing isn't bad enough that hearing aid won't help you just kind of strategic use of masking sounds uh every I think people are pretty familiar with these sound devices people use for kids for sleep that make like running water sound or gentle wave action sound um even or just even a fan in the background but some low-level sound input um because anything external to your body seems seems to be much more well tolerated than the t just generated inside your body interesting thank you Dr Grill uh a caller asks about um ear impactions that actually cause pain and what might be a strategy for addressing that um yes so you can definitely get ear wax that ear wax is normal you know it's it's kind it's made by the sweat glands in the ear and it serves to kind of hydrate the skin of your ear canal so people try and clean it out it's kind of like washing your hands too much it can get dry and itchy you know but um on the other side of it you can get so much wax buil up and it can get hard and uncomfortable so in that case you should have it removed which is sometimes done by means of irrigation kind of squeezing it out or the use of hydrogen peroxide or we use a little microscope to pull it out gently um sometimes though people who have discomfort they C they can have other things going on like eczema in the ear canal and um there are different ways that we can help deal with that or um sometimes people have like a little piece of lead or a little piece of a twig that H that came off during yard work and it's stuck in their ear so if the ears uncomfortable you should definitely have somebody look at them thank you and Dr gustaffson how might you uh advise a patient who reports food getting stuck in the upper part of the throat while eating um just like uh that might be best I mean we can talk about maybe do you guys have a better answer for it for dysphasia yeah when you're dysphasia is the medical term for swallowing difficulties and it can be it can occur at various levels in your swallowing mechanism it can be an oral Preparatory problem um with like a neuromuscular disorder it can be a fair Andel problem an upper throat problem and probably the most common one of the more common things we see causing that is um a spasm of the upper sofil sphincter behind the voice box from acid reflux and often times people who have that are unaware uh they don't have classic gird symptoms of heartburn or or sub sternal pain or epigastric pain they just have their throat symptom um but it's pretty important to have a look at those I mean me I think it's reasonable if you start having a sensation of food in your throat to try an over-the-counter acid suppression medicine but if you AR pretty promptly getting better within a few weeks it's something that should be looked at thank you Dr Grill a viewer asks from two harbers how serious is a perforated septum um well in terms of it affecting your everyday life usually it's not too big of a deal the question whenever look in the nose and see that there's a hole that um like people aren't born that way some something happened to make that hole and the usual caus is trauma like somebody broke their nose they didn't know it a blood collection formed and over time it kind of damaged the septum can also be from other things like drug use in the nose or even like really aggressive nasal spray use but there are other causes like autoimmune diseases that can cause a hole in the septum so if we can't find another good reason for the hole we just want to rule those things out and beyond that it can just be kind of dry and annoying and create crusting and bleeding and it honestly is also a really hard problem to fix thank you Dr Freeman why do wrestlers wear protection over their ears because if they don't they'll end up looking like Dan Gable if anybody's a wrestling fan you'll you'll see a condition called a cauliflower ear where the the ear gets really um swollen and hard and you can't fix it once it's formed so the the thing to do is to wear these protective coverings over your ears so you don't get this um hematoma or collection of fluid in the ear that can essentially solid solidify or calcify and cause a very distorted ear so it's it's trying to prevent that Dan Gable ear from occurring and the fluid can be uh bloody or cus fluid can be either okay usually the bloody the more acute ones are tend to be bloody and as they become more chronic you tend to see more of serus fluid in there Dr Grill um again about a idus ringing in the ears is the evaluation similar or different for ringing in one ear or both ears I think that's that's a great question and um you know everything in your body you kind of think should be pretty much the same on one side versus the other you know so um if you have something that's you know if you have blurry vision in one eye or if you have ringing in one ear you should have that def have that evaluated usually the first thing we do is get a hearing test and it could be that your hearing is different in that ear and in in that situation I mean there's a bunch of different qualities and we usually try to break it down does it sound like your heartbeat or does it sound not like your heartbeat and the evaluation kind of goes a little bit different direction from there in terms of what types of Imaging or other tests we should do Dr gustaffson for the patients who have sleep apnea are there medications that you either recommend adding or uh carefully removing say right now there's nothing specifically would recommend adding that might be changing in the near future with a lot of people have heard of some of these glp1 uh medicines are used for a lot of times for weight loss and diabetes there may be some benefits there that we're learning about uh usually we're more often watching or taking away medications there are usually pain medications so like classically opiates uh we're careful about things like alcohol um and some kind of anti-anxiety medicines we're also careful with but most were usually are not of a concern for it thank you and this question is about the description of good candidates for a clear implant Dr Freeman well it's really interesting when I was a resident in finishing only the most profoundly deaf people got got um clear implants and when they did a lot of times the most you could hope for was just some vague sound perception and now um people get uh can get dramatic um word understanding with clear implants and as a result of the improving technology uh uh we have a lower and lower threshold to send people on for them um I mean you can have hearing losses in the in the 60 dbel range which formerly which oftentimes you can treat with a with hearing hearing aids but particularly if their word understanding is going down uh then they can be considered candidates uh for for the colear implant so it depends on hearing levels but certainly the hearing levels uh that that we used to wait to see before we'd send them are nothing like the hearing levels now I mean devices are so much better and they can expect so much improvement from them thank you Dr Grill a uh viewer asks what would be recommended to uh prevent or reduce episodes of Miner's disease well somebody must have some experience with the disease to ask about it but um the number one treatment and there's a whole guideline set on it is um we think that it's related to a buildup of fluid in the inner ear the part that we can't see from the outside so we try to reduce the pressure primarily by really strict salt restriction in the diet and um we try to flush some more out with some or with some diuretics some water pills and then avoiding triggers a lot of the same triggers that Dr Freeman described for tenius like alcohol fatigue stress all those things can trigger maners flareups um caffeine so um salt restrictions the primary treatment and there are some medications and lifestyle things that can help as well and uh Dr Freeman we might have time for this question what are causes for the production of more saliva that is actually persisting yeah when people are drooling that's the question is it is it over production or ineffective clearing of the saliva and it it can be a frustrating problem to deal with can be um medication side effects but not terribly common um uh and yeah it's frustrating usually it's about dressing swallowing thank you and I do want to thank our panelists Dr Todd Freeman Dr Robert and Dr Thomas gustaffson and our medical student volunteers Hannah St Becca floden and ELC Johnson please join Dr Dena Claybon next week for a program on mental health for families and couples thank you for watching good night