Ear, Nose, Throat, OtoRhinoLaryngologist, Aaron Pearlman, M.D.

0:00 Hi, it's Doctor Robert Seichert with episode #17 of The Doctor Podcast Show where I interview Doctors in all different specialties and relay their wisdom and knowledge and experience to you out in the audience. Thanks for tuning in today. I'm really pleased to have as my guest Doctor Aaron Perlman. Dr. Perlman is a ENT Doctor. He's a Clinical Associate Professor of ENT or Otorhino Laryngology at the Cornell Medical Center here in New York City, which is one of the top medical centers in the country.

0:35 He's also a clinical associate professor of head and neck surgery there as well. Thanks very much for coming today, Aaron. I really appreciate it. Thanks for taking the time. You're welcome. Really happy to be here. It should be interesting. Right. So otorhinolaryngology is very long thing to say. So we often say ENT or or ear, nose and throat. I know you specialize especially in sinus disease and in nasal disease and do a lot of surgery in those areas. So everybody knows where their nose is, but I see and many patients who don't know where their sinuses are or how many sinuses are there.

1:15 Can you tell us about where the sinuses are, why they're there, what they do? Yeah, I mean that's a great question. You know, people often come in and they'll say oh I have something's wrong with my sinuses or I have sinus or my, you know, I have sinus headache. And that's just is a very like sort of general way of describing something going on sort of with your nose and or face. Your sinuses are these air filled cavities that sort of sit around your eyes and between your eyes and in your cheeks.

1:44 And the sinuses are the reason why we have sinuses isn't really clear frankly. What sinuses do is they do make mucus and generate mucus that's drained into the nose and into the back of the nose. But why we have sinuses is sort of a mystery. There are some theories as to why we have sinuses. One theory is it lightens our head because our skull needs these air pockets in it, which makes our head lighter. But I think perhaps this is just my own feeling about the situation is that sinuses are maybe more like an airbag system for our brain.

2:18 So if we have trauma to our face, our sinuses will sort of be the first cushion that crack and protect the brain from getting a sort of significant traumatic. Career. That's an interesting idea. I never thought of that. In case you get hit in the head, the sinuses protect the brain. It does to some degree because they're, you know, they're the things that will crack 1st and then there's this air pocket behind it, you know? So it's built in airbags in your head? To some degree very clear, so it probably also does lighten your head up, your skull up a little bit so you can walk around with this.

2:47 Right. I think the head weighs about £20, right? I mean something to that effect. Yeah. Yeah. So if it was all bone it would probably be 25 or 35. Yeah. And fluids, right. All bone and fluid, right. So it's pretty heavy. And and so the sinuses you have are are the on top, they're called the, the, the frontal. Sinus, right? So essentially, there's four sets of sinuses. There's your frontal sinuses, which sit above your eyes, right? Or between, you know, sort of in the middle of your brow region. There's the ethmoid sinuses which sit between your eyes.

3:19 There's the maxillary sinuses which are in your cheeks and then deep sort of within your skull there at the end of the nose or the back of the nose, there's your sphenoid sinuses and your sphenoids, yeah, sort of are the most posterior, most sinus that sits most in the back, sort of at the end of the nose. We also have our ears, and within our ears, ears have airspace too. And so ears are kind of like another sinus. They're not the nasal sinuses, but it's another air filled space where things can occur that affect the patient negatively.

3:53 Right, so sinuses aren't empty, they're filled with air. It's not a vacuum, right? Yeah, sinuses are complicated structures. They're Bony structures that have a mucosal layer around there. Mucosa. Mucosa is any sort of tissue within the body is considered mucosa. Right. Like inside your mouth. Yeah, exactly. Inside the back of your. Mouth like mucosal membranes and sinuses have what's called respiratory epithelium on them. And so respiratory epithelium is different than like say your skin, right, just made-up of different stuff.

4:23 And you know that mucosa is has a really important function. It makes the mucus, it moves the mucus. You know if we get infections, it helps rid us of that infection. But some people's mucosa doesn't work properly and those people are set up for problems. And you know, over time those, you know, if you have dysfunctional mucosa, you may go on to develop what we call chronic rhino sinusitis, which is a chronic inflammatory condition of your sinuses. Right. So the word sinusitis. A lot of my patients tell me they have sinusitis.

4:52 That means they have an inflammation inside their sinus. Yeah, It's really depends, you know, So we sort of split this up into categories we call we, there's people who have acute sinusitis. So what is acute sinusitis? These are people who have a cold, right? They have a cold, and a cold is almost typically viral. And a viral infection should be improving around days five, maybe peaking at days 5. And by days seven through 10, they should be getting better, right. So say a person has a cold and it's day seven and they're in it one week and not, they're not getting better.

5:26 In fact, they're getting worse. That person and and their complaint, you know, are sinus in nature, meaning that they're complaining of congestion, mucus obstruction, facial pressure, maybe tooth pain. That's a sign of an acute sinusitis or a bacterial infection. You may also have somebody who is getting better and all of a sudden it's getting worse. We call that double worsening. And that person also may have what's called acute sinusitis. And the thing about acute sinusitis is it's thought to be an infectious process and those people need antibiotics and typically they'll improve with antibiotics.

5:56 Actually, if you didn't give them any antibiotics in about six weeks, they'd probably improve anyways, but in antibiotics might hasten their improvement. Now we have a group, we call it subacute rhinosinusitis. These are people who have had the symptoms that have been persistent for between 4:00 and 12:00 weeks. So they're congested, they may have mucus obstruction, facial pressure and it's persistent, but it hasn't been going on more than 12 weeks. And then we have patients who we call chronic and those are patients whose symptoms go on for greater than 12 weeks.

6:26 When you sort of have fallen into the chronic category, you are having an more likely having an inflammatory condition of your sinuses, something more similar to to asthma for instance, rather than an actual infection. Now bacteria may be playing a role in that, driving that inflammatory response, but we don't necessarily know that in that bacteria are the progenitor or the purpose or the reason why you're having that inflammatory response. The dysfunction in your sinus mucosa it the reason for that is at this point somewhat unclear.

7:02 And so those people with chronic sinusitis, they're the people whose symptoms are persistent, you know, and need long term care and some of those patients may end up going on for surgery. I see. So their sinuses are inflamed. They fill with fluid. Lots of different things. They can have fluid in them. The tissue itself can be inflamed. If they have severe inflammation. There's tissue can change into what's called polyp tissue. Polyps are sort of the sinus lining is so swollen it it, it changes into a different type of tissue and it may leave the actual sinus and fall into the nose like a teardrop.

7:42 And when it and then when it's in the nose, it causes obstruction, right? You feel like you can't breathe because you have these polyps that are sitting in your nose, right? And that's really polyp disease is really the end point of really severe inflammation. I see. So those patients are sort of chronically stuffed up and very uncomfortable. I see patients as an ophthalmologist who come in complaining of eye pain and then I do a thorough eye exam. They have nothing wrong with their eyes but on further questioning that they're complaining of pain in their cheek area or in their forehead and I tell them to see an an ENT doctor so sometimes it can present as eye.

8:24 Pain. It can and but I would say pain is a really complicated complaint because not all facial pain is sinus in origin. And so we as sinus specialists are always trying to determine whether we think this patient's pain is related to their sinuses, may be related to their sinuses or not related to their sinuses, right. And so we do get that consultation quite a bit from ophthalmology of the patient complain of eye pain and we examine them and they're normal. The, the ophthalmologist said to go to ENT.

8:57 So what I do is, of course, I do an exam, I take a history, right. And I say, you know, I look for symptoms of sinus disease, congestion, mucus obstruction and pressure, right. Those are the four hallmark symptoms of a sinus disorder. Then I do an exam and that exam will consist of a nasal endoscopy, which means I take an endoscope and I feed it through the nose and I look for areas of inflammation. So you're putting a tube into the nose and it has sort of a camera at the end of it, yeah. So essentially it's a flexible fiber optic scope or a rigid fiber optic scope.

9:30 There are different ways of doing this. So it's a camera and a light and you can actually see inside the scope. Yeah. So we can actually see inside, Well, we cannot see inside the sinuses unless the patients had sinus surgery. What we see is inside the nose and we can see the areas where the nose joins the sinus. I see. And so we look for evidence of inflammation, infection, mucus, what have you anatomic abnormality in those areas that we think could maybe be participating in sinus disease. So once we've sort of done that exam, if you see evidence of sinus inflammation or what you think might be sinus evolution, you can go ahead and treat that patient, right.

10:06 And you can say, OK, this patient's eye complaint may be related to their sinuses. But if you don't see anything, I think it's more complicated, right, because the exam is normal and the patient has pain. So what do you do then? This is practitioner specific, and I think some people call it. You might call this the art of medicine because you have to make a decision, you know, how are you gonna determine whether this patient's eye complaint, eye pain, is related to their sinuses? For me, I typically would move on to a CAT scan at that point.

10:34 Cat scan. Because, yeah. And there you can see some. Imaging this is a is interpretation of future humans. Right, right. Not to. Yeah. This is not what my CAT scans would look like, but but it isn't. It is impressive. So I would get a CAT scan and I would look into their sinuses with that CAT scan and I would look for evidence of sinus inflammation. And if they have it, maybe their pain is related, and if they don't, then maybe their pain is not related. Right. How about just doing an X-ray of the skull as opposed to a CAT scan?

11:05 Do you get as much information from that or no? CAT scan is better? CAT scan is better. What about an MRI? What's Yeah, so MRI's are good. They're MRI's are looking for something different, right? Right. CAT scans are looking for bone, air and everything else, right? That's what they tell us. Whereas MRI's can tell us the difference between tissue and tissue density, fluids, things like that. When it comes to and MRI's take a lot longer, right? Right. They're much more expensive, but the benefit is they're not.

11:35 They don't use radiation, whereas CAT scans do use radiation. Now, maxillofacial CTS or CTS of your sinuses, depending on the institution that you're having it done, they can be lower in radiation than an average CT because we're not looking for all of the typical soft tissue issues. So we may not, you know, they may the patient, the radiologist or they may not have to have so much radiation to get the CAT scan. But in with the original question, can you get a plain film? Plain film's also a radiation for sure, and they do not give you as much information.

12:08 They don't tell you nearly as much. And so in this day and age, we are societies. We recommended a CT. Right. It just doesn't pay to get the X-ray and then not know and then you have to order CT on top of. It yeah. Now, if I'm suspicious of some other pathology, right? Or I see something on my exam that might push me to get an MRI, that could be done right, Right. But the gold standard test is a CT. Going back to this tube in the nose, how how uncomfortable is that? I I sort of think of that and.

12:38 Well, it's not, that's. Gonna make me tear a lot. Yes, it is definitely gonna make you tear. I mean, it's not the best thing, but we do often use topical anesthetic though. Some people don't need topical anesthetic, You know, they can do it. We. Use a lidocaine gel. It's a numbing. No, typically use a lidocaine spray spray and we might use a decongestant like Afrin or Oxymetazoline in there to sort of open the nose up a little bit to make and you put. It in each nostril. And you wanna look at each nostril because you wanna see what's going on on each side, if you think there.

13:06 And you can use that same endoscope to move through the nose into the back of the throat. So you can examine their larynx or their throat, their orpharynx, their epiglottis, the base of tongue. You can do all those things with that same scope. And you do that in the office, right, It doesn't require going to operating room or surgery or anything like that and it takes just a few minutes to do. Yeah, even less sometimes. But it gives you so much information and it really lets you helps you with crafting A diagnosis.

13:36 I always say to patients, the endoscopy is to some degree what separates me from other physicians because that lets me look inside and lets me sort of have more information. If we don't do the endoscopy, then it's kind of I can get your history, but I'm missing some. Right then you have to go by history and symptoms alone, and that's what a primary care doctor would do. To some degree, but. Then you have more sophisticated testing. I just thought of another reason why sinuses exist. I think this is it.

14:08 It allows us to swim because if there were no sinuses, the head would be very heavy and very possible sink in the water, right? Absolutely. So we your guess. Is as good as mine. We evolved in such a way so we can escape sharks and stuff by by swimming. Just a thought. So let's say you do find somebody with with acute sinusitis. How do you treat that? So if you think they have acute sinusitis, you give them antibiotics. Typically we'll give it a amoxicillin based antibiotic unless they're allergic, and if they're allergic you could to a sulfa or Clindamycin, something like that.

14:41 A lot of patients get Z Paks. My patients. Does that work as well? Yeah, we don't think it works as well, not as well no Z Pak, those Z Pak azithromycin does cover the classic organisms Haemophilus, Miraxella and Strep pneumococcus are strep pneumonia. They it's probably not as great penetrance into the sinuses as some of these other medications. So it's not really my first choice. Amoxicillin is really our recommended first line treatment for uncomplicated sinusitis. And yeah, so we move on from there.

15:15 All right, now, what if they have this sinus problem at last? You mentioned like 12 weeks. They're pretty uncomfortable. They don't want to wait 12 weeks. What happens at six and eight weeks? How do you treat that? Yeah, I mean some acute sinusitis are are you know sinusitis have been persistent for a few months but not like you know isn't really approached at chronic time. You know there's there's no real hard and fast recommendation what to do. Antibiotics are not the only thing in our armamentarium was certainly you know if you if you examine that patient they have evidence of you know what you think is infection, you're certainly gonna choose an antibiotic for them.

15:50 But there's we also have steroids, oral steroids, which help decrease inflammation, nasal steroids, which should be started in both acute and subacute sinusitis. Nasal steroids are topical sprays that treat locally the inflammatory condition, saline irrigations, very very important saline spray and saline irrigations. Saline helps to rinse out this mucus out of your nose and by clearing this mucus over and over again by rinsing you know you rinse today, it rinse tomorrow, you hope to lower that that persistent inflammation because that by moving the mucus out so it's not sitting there and stuck the inflammation system sort of lowers down, tammers down.

16:32 The other thing that saline has been shown to do in both really specifically in chronic sinusitis but probably works similarly in all patients is it helps to reestablish normal ciliary beat function. So what does that mean? So on this respiratory mucosa that we talked about, there are cilia which are these little fine like finger projections that all need to beat together in the same direction like. Little hairs. That's right. Move things around. Microscopic, but they move that mucus and they all need to move together to move the mucus to the back of your nose, out of the sinus, and into the back of your nose.

17:04 When you're inflamed, whether it's infectious or non infectious, the cilia stop beating together and so then your mucus just doesn't move, It stits, it sits. So some of them are pushing in one way and the other is pushing it back it kind. Of doesn't so we use the word stasis. The music, the the the the mucus is static, it's not moving. So saline rinsing has been shown to re establish normal ciliary B function and so thus that's another reason to do it. And you mentioned surgery, you do a lot of sinus surgery.

17:34 When is surgery indicated and what what things you operate on in sinus? Yeah, I mean surgery is definitely in the armamentarium of a otolaryngologist for treating chronic sinusitis. You know, it's really the data for for traditional endoscopic sinus surgery comes from the, for the chronic patients. The patients who had symptoms, excuse me, for greater than three months, you know they have to have to be considered chronic. You have to have two symptoms of congestion, pressure, mucus or obstruction.

18:06 Plus you have to have this evidence of inflammation where they're on your endoscopy or CAT scan. So if you have that evidence of inflammation plus persistent symptoms, you are in that category of chronic sinusitis. If that patient doesn't respond to what we consider maximal medical management, which we haven't discussed in chronic, those patients can proceed on to sinus surgery. And what we do in sinus surgery is we are taking down the Bony separations or Bony septations that make up the sinuses to create one confluence space with the nasal cavity.

18:40 So the way I always describe it, because I work in a big office space, is they'll tell the patient, think about the hallway as the nose. And all these exam rooms are the sinuses. What I'm doing in sinus surgery is I'm taking down all the drywall because I'm connecting the hallway back to the rooms or the nose back to the sinuses. And the reason, you know, the reason why we wanna do that is because if I'm in the hallway and I have a hose and I'm spraying it around to try to rinse everything, I'm gonna get a little water under the door here in the exam room, but I'm not gonna wet the walls.

19:07 But if I take the drywall down, I can wet everything, right? I can rinse everything. That's a great explanation. Right. So I can rinse everything with saline. I can put topical medicines on those. That tissue that's dysfunctional, That's what sinus surgery lets us do for those chronic patients. And that doesn't close up with scar tissue later. On I mean, anything's possible, you know, these are the negative. Stays open. Yeah, I mean we have tricks and that try to keep these things open, but scarring of course is an issue in the post operative setting that we were, you know, that we're all, you know, diligently trying to fight against scarring recurrence.

19:41 You know, the disease is a chronic disease. Surgery is a treatment for the disease. This is another thing that I say all the time, I'm not doing surgery to cure you, I'm doing surgery to treat you right because the disease is chronic. We're looking for improvement of those four symptoms, congestion, mucus obstruction and pressure. But we're not looking for resolution because that we don't know if that's going to happen. We in fact, the data shows this is probably not going to happen. So some people are just prone to this and you can help them and manage it and make them feel better.

20:13 Because. Because the people who have chronic sinusitis have an inflammatory condition. And just like, you know, in the inflammatory condition of asthma, which is an, you know, a persistent inflammation of your lungs, there's no surgery that cures asthma, right? But in sinus surgery, it is a surgery that helps it, right? In sinus disease, there is a surgery that helps it. The sinus surgery, is that done under local anesthesia or the patient's completely asleep? I mean general or there are different ways to do?

20:39 It yeah, there. There are certainly different ways to do it. This practitioner specific, you know, preference. Most people I think do sinus surgery under general anesthesia. I do use general anesthesia for my patients, but there are certainly doctors out there who do it under local. There are positives and negatives to, you know, using local anesthesia. I think one of the positives is the patient wait is not asleep, right. So they don't have all the risk factors of general anesthesia. They some people suggest there could be less bleeding from the surgery with an awake patient as opposed to an asleep patient.

21:13 So there are pros and cons depending. On, but you know, I think in the types of cases that I do which are you know, pretty sick people, pretty advanced disease, that this surgery takes a fair amount of time. I think it's more comfortable for the patient to be asleep. It's it's safer. Or yeah, I think I'd wanna be asleep for. This I think most people would too and so would I. And so that's kind of how would I say to the patients, but you know patients are really adamant about being awake. I know some people who do surgery that way and I can help them find them.

21:42 And you do this with an endoscope also, right? So it's a tube with with special instruments at the tip that allow you to do the. Surgery, Yeah. So as a general role, endoscopic sinus surgery is done through your nose. There's typically no cutting on the face. Now there's always caveats because there are sometimes still need to go through, you know, the facial anatomy to get to the sinus. But for, I would say the vast majority of procedures are all done through the nose. There's no bruising, There's no swelling.

22:14 Yeah. So it's pretty much that's how we do it. Wanna go back for a minute to the nasal irrigation I see on TV these ads for various products that are basically a nasal irrigation. There are like 3-4 different companies now that advertises and it's it's advertised a lot. Are these effective? Are they safe? Is it the same thing that you're prescribing for patients or or is it different? Can you tell me why there's so many commercials about this? Well, there's so many commercials because so many people have sinus, feel as if they have sinus disease.

22:49 Whether they actually do or don't, that's a different question. But I see you know there's a plenty of people out there who are stuffy or congested or mucus what what have you. In general, if you're just using saline, properly prepared saline and no matter how you get that saline in your nose, it's good, right? Whether you're using irrigating machine of one of those machines that gives you pulsation of the irrigation or just the squeeze bottle. I think that for my patience, I generally just recommend the squeeze bottle because I think it gives a fair amount of force and they rinse the nose and they're done.

23:26 They don't necessarily need a fancy contraption to catch the secretions that are coming out. There's. I don't see it as needed, but I don't necessarily think it's bad either. I see. So I don't discourage it either. If that's what the patient feels comfortable using, I'm fine with using that. Now there are some fancy preparations that people can buy over the counter and put in their own rinse. These things I'm not as excited about. I really like straightforward saline preparations. Or sometimes we'll direct them to use medicated rinses and things like that, but that's under our direction, right?

24:01 So this is a sterile saline that you can purchase. Well, you can purchase sterile saline, but most people make it themselves. So you get you buy these packets of salt, you put it in the bottle. I usually recommend using distilled water or boiled water so that the water is sterile and then they fill up the bottle and they rinse and then they should follow the package inserts on how to clean the bottle. Usually every week you put it in your dishwasher or something along those lines. Every six to eight weeks you get a new bottle because bottles can become colonized with.

24:29 Bacteria, right? So it's not sterile, but it's very clean. Yeah, I mean, the nose is open to the world, right? Right. Like our nose is exposed. So it's not a sterile necessarily a sterile environment. That being said, you don't wanna put dirty water in your nose, right? Right. You know, there are some concerns, right? There are some concerns. You know, we don't know exactly what's in the tap water that's coming out. You know, in some municipalities the tap water is cleaner than in others. And so, as a general rule, if you're buying sterile, if you're boiling your water by or buying distilled water, it.

24:59 And then you let it cool, by the way. You don't. Yeah, right. I would not put the boiling water in your nose. That would. Not just wanna clarify. That yeah, but you do let it cool and then you can use that, I think. Much safer. All right. Well, that that's interesting. So those ads are reasonable if you want some kind of a device to help you do this. Yeah, I think so. I mean good. What about nasal surgery? What? What type of nose or nasal surgery do you do and for what conditions? Yeah. So this is always something that I'm always talking with patients.

25:30 There's your nose and there's your sinuses. And sometimes they're related and sometimes they're not related, right. Sometimes your sinuses may not be doing anything and the problem may be coming from your nose. So like you know, chronic congestion, nasal obstruction, these can be nasal issues. So for instance the diagnosis of chronic rhinitis which means chronic inflammation of the nose. Chronic rhinitis can be both allergic or non allergic right? So people with allergies may have chronic inflammation of the nose that makes them feel stuffy and mucusy and congested, but they may not have allergies and they still may feel stuffy mucusy and congested that would be non allergic rhinitis.

26:07 So initially for those patients we'll treat them with medicine, right. We try to get them better. Again, nasal steroids, topical nasal antihistamines, saline of course sometimes oral medicines, oral antihistamines, leukotriene inhibitors, when you know, managing those types of issues. Now, if you cannot get that patient improved and you examine them and let's say they have a deviated nasal septum, So what does that mean? The nasal septum is the center of your nose, right? It's what separates the left from the right, and in the front it's made of cartilage and in the back it's made of bone.

26:42 Everyone has some element of deviation to their septum, but not everybody feels blocked, right? OK, so if you feel blocked and you have a deviated nasal septum, and when we examine you, if our exam cooperates the way you feel, then you may be a candidate for what we call septoplasty. And that means trying to take out the crookedness of the septum. So it better approaches the midline. So again, not everybody needs a septoplasty. I often will see patients and say somebody told me how to deviate septum.

27:13 So then I ask them, can you breathe your nose like yeah, I breathe fine. So that's no problem. Right. Need to do anything. Exactly. Now on the side of our nose we have these structures called turbinates. Turbinates are kind of, they kind of have the length of your finger and they help humidify air and catch pollutants. And but what's also interesting about turbinates is they also help you with the sensation of breathing. So you really rely on your turbinates to feel the air movement. So you have to be careful with operating on the turbinates.

27:44 But we often do, we do something called a turbinate reduction if the turbinates are kind of big and bulky and there's different ways of doing that. But ultimately the goal is to shrink the turbinates slightly without but not remove the turbinate because you want that function to to continue. If you remove the turbinate, you may set the patient up for not feeling like they can breathe. But if you shrink the turbinate with these various safer methods, patients can feel improvement from that too. So those are example of two like nasal procedures.

28:13 Right. And you, you brought up topic of allergies. I'm sensing, and I see from my patients everybody's more allergic now than they were years ago. Kids are allergic to all sorts of things like peanut butter that in the old days they weren't. And adults have numerous allergies that they didn't have before. I became allergic to Kiwis a few years ago after eating Kiwis for many years. What? What do you think the role of allergy is to all this that you've described? And do you see also an increased incidence of allergic rhinitis and allergic sinusitis?

28:53 Well, I I don't necessarily see an increased incidence of allergies. I mean, I think when you're in an otolaryngology practice, you see a lot of allergic patients. So it's kind of hard to see an increase in the incidence of that, right, because a lot of people have allergies. That being said, what's interesting about allergy is, though allergy, allergic rhinitis, allergy specifically. It makes you feel stuffy, it makes you feel congested, it makes you feel sneezy, Watery eyes, right? These are classic allergy symptoms.

29:23 But allergy doesn't usually make you feel blocked. It doesn't necessarily make you feel like significant pressure on your face. It can, but not significantly, you know. So there is a little bit of a difference in the symptomatology. Now when you look at allergy and chronic rhinosinusitis, what's interesting is that patients who are allergic are just as likely to have chronic sinusitis as patients who aren't allergic. So it's they sort of split right down the middle. So within allergy or within chronic sinusitis, it's not really clear of allergy driving anything.

29:56 Now we can get even more granular about this. There is some data that shows that dust allergy may be playing a higher role in chronic sinusitis than other allergens. For instance, there's a sort of a newer topic in rhinology or in sinus disease called central compartment syndrome. And what is central compartment syndrome? The central compartment is the middle vault of the nasal cavity and consists of the middle turbinate and the sort of entryway to the sinuses. We call it the middle miatus. And so sometimes you'll look at this area and it's just super swollen.

30:30 It almost looks like there's polyp, but it's really the middle turbinate that's like totally inflamed and degenerated and those patients actually. And then you and to to clarify and you look further into their sinuses say with a CT scan and the sinus is beyond the middle mediatus look pretty normal. Those patients have a high rate of allergy. So the theory is that they're breathing in these allergens and they're the allergen is moving over this area and causing this robust inflammatory reaction.

30:57 And in those patients it's actually they get a lot better with surgery in just that area. If you just resect a lot of the inflammatory tissue, that's sort of exacerbated there. You can get some control with allergy maintenance. But so that's an instance, I guess, of allergy playing a role in sort of limited sinus disease. Right. So there are different types of patients with different. Issues. And that's like, what's hard and interesting is that you're always trying to parse that out. And brings us back to your original point is when the patient comes in and says I have a problem with my sinuses, you know, that's why we're, you know, there's all this other stuff that's could be going on in there.

31:33 Right. What role does air quality have with sinus disease and and nasal disease rhinitis is? Is it related to poor air quality or air pollution? I mean, probably, probably right. The answer is again unknown. I mean I think when it comes to chronic sinusitis, there's a whole host of in theories as to what could be driving that problem. And in some patients maybe pollutants in the air are their trigger for their inflammatory condition, not all patients, I'm sure you know unfortunately it's not a one-size-fits-all disorder.

32:05 But those patients, let's say you know a patient has severe rhinitis and you test them and they don't have allergy. So you say what is driving this patient's, you know, chronic rhinitis In some of those patients it may be environmental pollutants, but ultimately we don't have a way to test for that and our treatments are the same. So we sort of treat them in the same way. What about comparing different countries? We have relatively better air quality than places like in India or China where air quality is very poor all the time.

32:40 Is there increased incidence of sinus and nose disease and those areas that you know? No. It's pretty, it's pretty conserved. You know what is different, I'm not, I'm not sure about India, but what what is different amongst different ethnicities is the type of inflammatory reaction that's occurring within chronic rhinosinusitis. So this is a sort of more newer part of our field looking at what we call endotypes. And endotypes are of endotypes and chronic sinusitis and endotypes are essentially breaking people down into what the actual inflammatory response what is going on.

33:21 So on a immunologic level, there's AT helper 2 cell, there's AT helper one cell and there's T regulatory cells. There's a lot of other TT cells too and I'm not. These are all immune. Cells. That's right. And I'm not an immunologist, so I'm not gonna go, you know, pretend that I am. That being said, when it comes to chronic sinusitis, it's important to understand these guys. And so most people in the western world have a TH2 mediated process when they have certainly when they have polyps and often even when they don't have polyps.

33:51 Now some people have a TH1 mediated process and then some people have a mixture process. So they've basically broken it down into these three endotypes, 1-2 and three. One it would be TH, 1-2 would be TH. Two and three would be a separate group. But most people are sort of a can be a mixture of these endotypes or some people are a mixture. And the reason why this matters is because certain drugs work for certain types types and this is all sort of experimental. At this point we don't have any clinical way of testing for these things, but but in the lab you can look at tissue and sort of these are.

34:33 Research tools, right? Right. But one day we will probably be treating based on this. Right. We'll probably be able to do a genetic test and say you're TH one, so we're gonna. Try. I don't know if we'll have to do a genetic test as much as just get a sample of their tissue and do spin the cells down and see what the most cell is there, but. Customized medicine. Yeah, absolutely. And so then you'll know with these newer medicines that we're starting to use such as monoclonal antibodies, who we would expect them to actually work on because right now we have an idea of who they might work on when we use them.

35:07 But there are some people who they don't work. And you say, OK, well the reason why this might not be working is that this person actually isn't the proper in the proper group, the proper category cuz. These monoclonal antibodies are designed for a TH two group, and that's most people, but not all people, especially not all people without polyps. Right. So we're still on process of learning. Going back to nose for a minute, a lot of my patients tell me they get recurrent nosebleeds and they have to go in and get it cauterized or have.

35:37 What is that about? Why does that happen? Well, nose bleeding is very annoying, right? Patients hate it, the doctors hate it. Everybody hates it. Doctors. Hate it too. Well, it's not fun to have a patient who's bleeding and you wanna get it stopped for them. And it can be somewhat stressful sometimes in the office, right? But typically the vast majority of nosebleeds are coming from the front part of the nasal septum cuz that's where there's this big plexus of blood vessels that sort of meet there.

36:04 And you know again your nose is open to the world. It dries out in that location, You can touch it in that location, right, can blow your nose and wipe really hard and so you can thin out that mucosa and expose, expose those blood vessels and then they're like. Thin, fragile blood vessels. Yeah, absolutely. And the mucosa is thin and fragile there I see. So most people who have epistaxis or nose bleeding, it's self limited. It'll get, but you know they stops with pressure. Maybe they'll use some saline gels in their nose and it will improve.

36:32 But if it doesn't, they might need what we call cauterization. And cauterization is where we actually, depending on the method we use, we burn the tissue that's bleeding to try to get it to heal. Now that's those are the more straightforward nose bleeds now and today is day and age. So we have so many older patients who are on anticoagulation, right? Right aspirin, Eliquis. Plavix exactly for all these heart conditions and whatnot that need it and that makes it much more complicated because those patients are not going to form a clot.

37:04 And so they may have what might be a simple bleed without that medication is now a very severe bleed. And so you have to manage that and sometimes that management needs nasal packing or something along those lines that you know may be more semi permanent until to try to. Yeah. A lot of my patients, the nosebleeds are on aspirin or Plavix or sometimes both. So yeah, that's a problem I wanna get into. Recently the FDA came out with information that a lot of the over the counter products that are sold for colds and sinuses and congestion really don't do anything and they said don't use them can you?

37:41 Yeah, I mean, I thought this was an interesting development. Basically, it's about phenylephrine and phenylephrine is was marketed as a decongestant. Right. For decades, right? And it's not pseudephedrine, right? Pseudephedrine is Sudafed by brand name. Pseudephedrine is still available and is behind the counter. You don't need a prescription, but you have to ask the pharmacist for it. Sudafed or sudafedrine works, and apparently phenylephrine doesn't seem to work. And what was interesting about it is it's in so many different medications, preparations, cold and sinus preparations, right.

38:23 And you know, I guess it's not as helpful as it seemed to be. But So what was interesting though what I what I think people need to remember though a little bit about that is a lot of people are not just taking straight phenylephrine, they're taking let's say Tylenol with phenylephrine or or ibuprofen with phenylephrine. So they're getting some benefit from probably the Tylenol or the ibuprofen for their upper, you know, for their cold symptoms. You know, when you have a cold, you feel, you know, muscle, achy and chivalry and you have congestion, so you have facial pressure.

38:54 So those things may be actually improved with that. So I think maybe we don't need the phenylephrine part, but maybe we never did, right? Maybe we just needed the ibuprofen or the Tylenol just to sort of manage the sort of discomfort system, right, and move through it. Now. Topical phenylephrine. Still my understanding is topical phenylephrine still works. So a spray, Yeah. Do they sell I? Believe they do Ucinephrine. I don't know if that's exactly. I use phenylephrine eye drops to dilate the pupils.

39:28 Works very well. Right, so right. So there are some uses. But I think. Why did it take them decades to figure this out? Cuz Phenylephrine's been sold over the counter. Yeah, well, I know they started using it because it was a easier, it was a less risky medicine to have in the community in terms of making illicit drugs like pseudoephedrine, I think can be made into right as an illicit drug. That's why you have to ask the pharmacy. That's why they sell it to kids. And you can only maybe have a certain amount of pills per month or something along those lines.

40:00 But and then. I'm not an expert on this, but I read that there's some sort of metabolism like the phenylephrine's already metabolized and it doesn't work when it goes to GI absorption, but long and short of it is less medicine is. Better, right? I tell patients this all the time, when you have a cold you feel miserable. But most viruses are gonna improve within 5 seven days. And when I get a cold I have to tell myself that same thing cuz when I'm sick I wanna take anything that will make me better.

40:32 But sometimes you really just have to sit on your hands to some degree. Right. So all these products that they sell. I mean, there's limited improvement. Some of them, they're. Basically antihistamines, right? No, I mean antihistamines, incongestants, well, phenylephrine was considered a decongestant, but I mean antihistamines would be like Zyrtec Allegra. But I personally don't feel that antihistamines have a big role in acute viral infection because it's not a histamine response, right. Histamine response is an allergic response.

41:03 So I don't typically prescribe those types of things for acute, viral, upper respiratory. You know, it just depends what the patient's really complaining of. If they're in pain, then Tylenol and Advil, right? If they can't cough up their mucus, they could think of a mucolytic, something like a brand name Mucinex, right? If they need cough suppressant, right? Right. So it just depends what the issues are that they. What? Their symptoms are all right. You mentioned you do nasal surgery, sinus surgery.

41:37 I know in lots of other medical specialties robotics is becoming very popular where the surgeon basically operates a robot surgeon through a computer or other devices. Is that also being used in your specialty in ENT and? So robotics is definitely being used in ENT, mostly in the for cancer resection, for tonsil cancer, base of tongue cancer. Those are, I think, primary robotic cases. I don't work with the robot, so I'm not really an expert on that. People are trying to sort of come up with these novel approaches to try to use the robot in Transnasal.

42:21 The issues with the robot right now, my understanding is it's too big for the nose, but like with all technology, I'm sure it'll shrink. And then there may be a role for this. There's some, the people who use the robot, they really think that it is helpful. They get they're right up on the disease process, they're right where they need to be to work. They have really good visualization with the cameras, so there's some really good positives for using it. I don't know what it's gonna do for Endonasal sinus surgery, but there's probably a role for it.

42:56 Yeah. Seems like it's evolving still in in most other specialties because surgeons I speak to some of them say, yeah, it's great, you know, but you have to do a lot of cases to really get the benefit and know how it benefits. And then other surgeons say it's it's not much better than my own hands. So it sounds like it's still evolving? Yeah, I mean I would think that's probably accurate. You know, I don't know the data on that, like what the, you know, the risk, the outcomes data on robot versus traditional surgery for various procedures.

43:27 But I do know a lot of people have converted to using the robot for various procedures that they used to do open. You mentioned cancer and tumors, that you can have cancers or tumors in the sinuses. Or in the Yeah, you can. And those are not always that great, unfortunately. One of the more common things we see in the sinuses is something like lymphoma. We might diagnose that, but you certainly can have other cancers. And you would pick that up on a CAT scan on. A Yeah, you might pick it up in various ways.

43:59 The patient could be symptomatic, right, with maybe they're having nose bleeding or something like that. And then you examine them and then ultimately get them a scan, some sort of imaging and then need a biopsy. But there's certainly other cancers. There's cancers that come down from the olfactory epithelium like neuro aesthesioblastoma. You can have like mucosal cancers, You can have nasopharyngeal, carcinoma, squamous cell cancers, you know, So there's various, you know, the list goes on. At all, and those are treated with surgery, radiation, chemo.

44:31 Depends. Yeah, it just depends on cancer. Cancer for sure, like lymphoma, is not a surgical disease. For the most part, that's treated with chemo. Now I know you also deal with patients who have sleep apnea, and one of the questions I I want to ask him don't ask you is snoring. Because, you know, I see patients, occasionally couples come in and somehow the topic of snoring comes up and it's usually men who are snoring and the women are complaining about it. And then it comes out they have sleep apnea as well.

45:08 So tell me about sleep apnea. Well, what I would say is usually women who are complaining about it and then the men complaining about the women, but right, complaining. You know that she snores too. I hear that all the time. But what? You know the thing about snoring is snoring is a is a noise generated by the airway, right? Typically we think of the palate as being the uvula, vibrating as a source of that noise. But the noise but snoring noise could also come from the lateral walls of the throat, the back of the nose.

45:34 It's been, you know, when they people have studied this, have been found to make a noise, you know, with vigorous airway, vigorous movement. The way I sort of describe snoring is anything that increases airway resistance increases the work of breathing, and that and that work of breathing causes snoring. Not everybody who snores has sleep apnea, but most people with sleep apnea are snoring. So what is sleep apnea? Well, we're really talking about obstructive sleep apnea. And obstructive sleep apnea is when the soft tissue of the back of the throat is collapsing, when you're taking a breath in.

46:07 And so when you try to breathe in, you can't. And so you increase the the intrathoracic pressure, so your your pulmonary pressure goes up. And then if you do that over and over and over again for years and years and years, you could lead to right heart failure. So it could ultimately lead to heart disease. In the short term, though, if you think about it, every time you're trying to breathe, you're not breathing, right? So this could be, you know, maybe you do it for 20 seconds, but maybe you do it for 2 minutes.

46:33 You hold your breath. And so while you're holding your breath, your oxygen saturation is going down, right? So we want your oxygen to stay 9192 or above, right percent. But you know, your oxygen may be 80, it may be 70, it may be 60, depending on the duration. And that hypoxia over and over and over again each night causes you not to have restful sleep, right? Because every time you're hypoxic, your brain rouses itself 'cause it recognizes that it's not getting oxygen, wakes you up, wakes you up, wakes you up.

47:04 Even if you don't know you're waking up. And then you're, you know, ultimately you're not rested. And so that lack of rest can, you know, leads to daytime tiredness, lack of, you know, difficulty mentating or, you know, paying attention. So there's a lot of like, you know, immediate effects of obstructive sleep apnea too. So when I have patients who come in and they say they're snoring, you know, I'm always concerned with or do you have obstructive sleep apnea 'cause this is the thing that puts, you know, has a long term medical risk to it, right it.

47:33 Also increases the risk of stroke and we think it may increase the risk of glaucoma in the eye as well. So it has numerous adverse effects. Yeah, so snoring is annoying, right? It has psychosocial implications. It's a real thing and it's a real issue. But obstructive sleep apnea is the thing that has the long term medical risk now. So if they don't have obstructive sleep apnea, great. Now we can just talk about snoring and methods to sort of mitigate snoring if possible. The other thing I always think that's hard about a patient who's come for snoring is snoring is isolated.

48:05 Snoring without obstructive sleep apnea is kind of somebody else's problem, right? The bed partner's problem. Because the person who's snoring doesn't really notice it for the most part. Good point. And so, you know, some people can't have any sound in the room when they're sleeping. Some people can have some sound, right? Right. And it's hard to know what how much reduction in sound that bed partner needs to sleep soundly. And so it's really tricky because you're it's very unlikely you're gonna make someone completely silent, right?

48:34 That just doesn't seem possible. So you know, is it 20% reduction in the sound enough or is it 30% or do they need 100% and so? They need another room. Or the Yeah, exactly. And a lot of people. Don't if they don't have obstructive apnea. That's right, another room might be. But in New York, you know, another room is hard to find. So. That's tough to find. Now, what kind of surgeries can you do if somebody has, let's say obstructive sleep apnea and or their snoring is so horrible that they need something?

49:04 Right. Well, the gold standard treatment for obstructive sleep apnea is something called CPAP, which is a machine called. It stands for continuous positive airway pressure. And this is just like a little box that sits by your bed and you has a hose and that little tube and a mask, some sort of mask device that goes over your nose or nose and mouth. And what this is doing is giving you a continuous airway extending your airway open with continuous positive airway pressure. And so they when you breathe in, instead of collapsing, you stay open.

49:32 And by staying open, you can exchange carbon dioxide and oxygen and you don't have that breath holding, right. Right. So this is the gold standard and if people can use CPAP, that's probably the best thing because it's not invasive, it's not invasive, it's not surgery. You put it on every night. It doesn't really low risk and it works. Now say you have a patient who can't use CPAP. You have to figure out, you know, you wanna try to figure out why they're not using it. Are they just like frustrated and they just don't wanna deal with it or do they feel like they can't breathe through it?

50:01 So there are different reasons why people might tell you that they don't like it. So if I have a patient who comes in and says every time I have it on, I have it on for an hour or two and I tear it off cuz I can't breathe through my nose, that patient, I might examine their nose and if they have like a deviated septum or large turbinates, by optimizing their nasal airway with a surgery with a septoplasty or term reduction, I might be able to get them to use their CPAP more effectively. I see I'm not trying to cure their sleep apnea by doing nasal surgery.

50:29 The data shows us that's not gonna happen. But the data does show us that you can improve CPAP compliance or the ability to use the machine by optimizing someone's nose. OK, so that's a nasal surgery. There are some surgeries that are directed towards the oral cavity, right? So one if the patient's big tonsils, removing the tonsils, trimming the palate, that procedure when you do those two things together, it's called a uvulopalatopharyngoplasty or a UP 3. Some people resect the tongue base, some people suture the hyoid bone which sits right here to the chin.

51:01 It's called a hyoid suspension. All of these surgeries are have limited effectiveness. You know it depends on the patient. There are some patients who have amazing results from a surgery and there are some patients who have no result from a surgery and for that reason you. Sometimes you can't tell in advance. That's right. And so for that reason, you know you wanna use surgery as a last resort because it it it'd be it's horrible that if a patient goes through a surgery that's very painful, has risk of significant morbidity and then ultimately needs CPAP, right.

51:34 And now maybe they'll turn to tolerate their CPAP better after surgery. It's true. You know they may do better with their CPAP, maybe more effective. So maybe there is a role for surgery in that case, but these people need to understand that they may still need CPAP. Last thing is there are some newer a novel treatment, something called the hypoglossal nerve stimulator. What the hypoglossal nerve stimulator is, it is like sort of like a pacemaker for your tongue base. And So what it does, it's an implant that goes under your skin, under your chest wall or under your clavicle region.

52:06 And then there's a little electrode that goes to your hypoglossal nerve, which is the nerve that controls tongue movement, right. So you turn it on before you go to bed and as you inspire, it pushes your tongue forward. So for people who are having what are what's what we call tongue based collapse, sometimes the hypoglossal nerve stimulator is a good modality. For them, they don't feel anything. It doesn't wake them up. No, they like it because they're sleeping better. Really. But it's for people with, you know, base of tongue collapse and so you know you really have to analyze the patient to make sure that that's what's that is their issue.

52:44 Right, you you mentioned tonsils a few minutes ago. I remember the old days, kids used to always have their tonsils out. Every kid had their tonsils out by the time they were 10 or so. And then for years. No, you shouldn't have your tonsils out cuz we it's part of your immune system. Now I'm seeing patients who tell me they're kids. Some of them are having tonsils removed, some not. What? What's the story with tonsillectomies or tonsil removed? There's tonsillectomy in kids and tonsillectomy in adults, and it's not necessarily the same thing in kids.

53:18 One of the most common reasons children are getting their tonsils and adenoids. Adenoid is kind of like your tonsil tissue, but in the back of your nose removed is for obstructive sleep apnea. Kids often have big tonsils, big bulky adenoid tissue, and that's because that's just part of development in kids. It's a lot more enlarged than in adults and because they're small, their Airways are small, it takes up a lot of space and so they may be having some of these obstructive sleep apnea issues. And snoring.

53:47 Snoring, but but more so, disordered sleep. You know, they're tired during the day. They're falling asleep when they get to school. So those kids are having typically a partial tonsillectomy and a adenoidectomy. And So what they're doing is they're shaving the tonsils away but leaving a small rim of tonsil behind. And by doing that, it's a less painful procedure for the kids and it's less likely to have post operative bleeding and you're creating space to allow the kid to grow and giving them time essentially.

54:15 Now there are some kids who are getting recurrent tonsillitis, right, tonsil infections, right. And if you get a certain amount of tonsil infections per year, you become a candidate for a total tonsillectomy, which is essentially removing the whole tonsil in a more traditional fashion. So not leaving, trying not to leave any tonsil tissue behind. And there's various requirements that how many infections you need per year, per two years, but there is still a role for that. Now when you look at adults, adults, there aren't really the no real requirement of when a patient needs what they need to satisfy to have their tonsils removed.

54:49 But most people will wanna see some strep positivity if a patient is complaining of recurrent tonsillitis because we think that strep is kind of living in the tonsil and coming out every once in a while and causing them to have tonsillitis. So by removing the tonsil, you're sort of taking away that nitis of infection. But adults, they've lived longer. They've had more infections, the tissue's more scarred and it's harder to get out. And it hurts. Right. I've heard though tonsils are part of your immune system in that area that it might not be great removing.

55:24 I mean they are part of your immune system in that area, but you have plenty of other immune tissue I see. So at the back of your tongue, you have the whole back of your tongue is inflammatory tissue. The back of your throat has little bits of inflammatory tissue. So you really can live just fine without your tonsils. You can do you still give ice cream after removing. Tonsils, you know, patients can have whatever they want, but I think that most patients actually don't like ice cream cuz ice cream is very cold and it causes the muscles to contract and that's, you know, you're taking the tonsil out of a muscular area, so the muscle might be a little bit exposed.

55:53 People most likely most like room temperature food. Another myth destroyed on Doctor podcast. That's, that's I mean they can have ice cream. Who doesn't want it? But. Right. What about acid reflux? A lot of my patients have that seems to be more common again over the years and many of them see ENT doctors for that. What's your role with acid reflux? Yeah, it's interesting. We do see a a fair amount of acid reflux. Are people who think they have acid reflux or people who've been diagnosed with acid reflux anecdotally?

56:25 So acid reflux, by the way, is is stomach acid coming up your esophagus. And that's right, get into your throat. So so. Acid, you know there's gastroesophageal reflux disease, GERD and that's when you're having symptoms in your, you know, chest or abdomen related to the to acid moving through your esophagus. And then there's what we call laryngopharyngeal reflux or reflux that's makes it all the way up in through through your esophagus into the back of your throat, so affecting your larynx and your pharynx.

56:55 So laryngopharyngeal reflux and the symptoms are different. You know people with laryngopharyngeal reflux, often some people call it silent reflux cuz they're not really getting heartburn. They're getting hoarseness, throat clearing, phlegm, feeling like they can't swallow properly. They need to swallow five times to get something down or feeling like something's in the back of their throat. We call that a globus sensation. Now not everything is reflux. So a lot of times we have a patient who comes with these symptoms.

57:22 We don't see anything. We think, OK, well this patient may have reflux and we may empirically treat them and if they're getting better then we think, OK, they did have reflux. But if they're not getting better, we might have to investigate that further. We may have to prove whether or not they have reflux right with pH probe manometry or something along those lines or do an endoscopy, have an endoscopy by one of our gastroenterology colleagues to look at their esophagus and stomach. So not everything is reflux, but it is common.

57:52 I mean, the reason why it's common is because of probably the way we eat. You know, there are a lot of things that promote reflux. Caffeine, coffee, tea, soda, chocolate, foods with acid, tomato, tomato sauce, citrus spice, eating before bed, alcohol before bed. These are all things that promote reflux. Right. Also, the gastroenterologist I interviewed recently told me that obesity increases. Yeah, of course, you know. As well. For sure. And you know, so I often tell patients, you know, we nothing is gonna improve.

58:25 There's no medicine that's gonna improve without diet restriction. You know, so initially I try to get people and sometimes I, I, I don't give a medicine at all. I say we know, let's look at your diet, let's, you know, really focus on that and then we'll see if you, you know, if you really cut out the caffeine, you really cut out the late nights eating the snack or whatever, and you're still symptomatic. Yeah. Then we move on to, you know, adding antacid. I see. What about ENT is ear, nose and throat?

58:54 What about hearing loss? Another question I have is a lot of my elderly patients have hearing problems. They need hearing aids and so on. In years past, you'd have to get a hearing aid from an ENT, doctor or audiologist. Now they're selling them on TV, all different companies, claiming they're just as good as the $5000 hearing aids. But now they're $300.00. What's the story with hearing? AIDS. Well, I mean, this is a whole other podcast, right? Entirely. But firstly. We can stay here till midnight.

59:29 I can't wait. So hearing aid, you know, hearing loss, we're really talking here about age-related hearing loss or the the medical term is prespicuousis, right. So as we age, most people are gonna have some hearing loss and typically it's our high frequency hearing which we lose 1st and then it may progress into more lower frequency hearing. Not everybody, Not everyone is the same. But as a general sort of understanding, most people who have age-related hearing loss have a higher frequency hearing loss.

1:00:00 And the reason why high frequency hearing loss is a problem, like you and I are, we're talking in low frequency hearing. So if you had high frequency hearing loss or if I had high frequency hearing loss, we probably wouldn't have too much trouble here. But if you add in a lot of background noise, we go to our restaurant, the music's playing. That's when we're gonna rely on those high frequencies to try to pick out the sound that we wanna hear. And so a lot of patients come in and that's what they say, you know, I'm in a meeting, everyone's talking.

1:00:23 I can't hear. You know, I can't figure out who's talking or what they're saying. You know, it's got the the the sound is garbled and you know what, not. So, you know, if we prove that they have significant enough hearing loss, they may be a candidate for a hearing aid. And a hearing aid is essentially A sophisticated amplifier. Right. Because hearing aids, what they are designed that they can amplify the frequencies that you need while letting the frequencies that you don't need amplify pass through.

1:00:49 That's kind of like The Dirty version of a hearing aid. Now you're right, in the recent past they have these over the counter hearing aids and for some patients with straightforward high frequency hearing loss or an easily programmable hearing aid loss, it might be a good option for them. But some people have really difficult types of hearing loss. Every frequency might be a different degree of loss. And so the audiologist measures that, that's right. Which frequencies are affected? Yeah. So the audiologist sits there with the patient and tunes each frequency to get the hearing aid exactly the way it should be.

1:01:30 I see and they're kind of missing that a little bit with I think the over the counters Now that it's pretty new and I think they're doing there is programming that is happening because that's how those even those hearing is having some program. But I don't think you're doing it with an audiologist. I see. And sometimes that and often times I think that technician, the audiologist, the technique is so important to making someone have a hearing aid that they like. Cuz I mean, I'm sure you know people who have hearing aids who say I hate my hearing, right?

1:01:57 Right. And that comes from probably maybe the type of hearing loss they have, the way in which they've lost their hearing, but also maybe an improperly fit hearing aid, an underpowered hearing aid. There's different reasons. Right. The commercial I saw just yesterday said we're not just an amplifier like other hearing aids, we're a true hearing aid. Well, back in the day, they used to sell the amplifiers, right? When RadioShack existed, you could just buy like a microphone, essentially, and it amplifies, It's louder.

1:02:25 Yeah, and it made it all louder. But you didn't need it all louder, right? You only needed some of it louder. And so these newer over the counter hearing aids are you know, they're trying to be you know they're more sophisticated. Some of them say you can tune it through the Internet. Yeah, I think that's how they're doing it. Right, pretty interesting. I mean it's if if it's works for some people, it's going to be great because it's going to save them so much money. Hearing aids are expensive. Right.

1:02:50 Yeah, very expensive, thousands of dollars, my patients tell me. Whereas these are now on TV for 300, but I'm not sure they're working as well and they're not as customized. Yeah, and you don't have an audiologist helping you fit it, but you may not need it depending on the type of your hearing loss. So sometimes when I look at people's hearing tests with them and they say, well, can I get an over the counter hearing aid? Sometimes I say, yeah, you should try it. Why not? Your hearing loss doesn't look that complicated, but sometimes I see people's hearing loss.

1:03:18 It looks really complicated. And I say, oh, I don't think that would be a good idea. Right, they need to customize, so they should be tested by a ENT Doctor. Or an. Audiologist and then figure out where they can buy right online or or have to go for the more expensive customize. Right. I mean, not every, you know, not all, just like not all Sinus disease is the same thing. Not all hearing loss is the same thing. Not all eye problems, that's. Right. It's just not the same. Well, this has been incredibly educational for me and I'm sure the audience as well.

1:03:46 I learned lots of things today. I really wanna thank you for taking the time to come here today and explain all these complicated issues that now seem a lot more simple and understandable. I was gonna say more complicated you've explained. Things very well. So I think the audience will appreciate that and understand it better. Or at least now when they go to their ENT Doctor, they'll have some background information and knowledge, which I think is very helpful when you go to the doctor. Thanks very much for coming today.

1:04:16 Really appreciate it. Thank you very much. Thank you. It was great being here.