Decode Obstructive Sleep Apnea: The Role Of The Nose

Keith Matheny, MD

Thank you so much, Dr. Wells. I am glad to be here.

Audrey Wells, MD

I want to point out to everybody that the nose is critical to breathing. To note, the floor of the nose is the same as the roof of the mouth. that is important because of tongue posture and promoting nasal breathing. I will start by saying that in my world, breathing through the mouth is a problem. Not only is it a problem during sleep, but it is a problem during wakefulness as well. It influences what type of CPAP mask a person may be using. A lot of what I get in terms of questions about nasal breathing is along the lines of, well, I have always been a mouth breather. Now I am curious to know how you, as an ENT surgeon, would respond to that question.

Keith Matheny, MD

Yes, thank you. This is one of my passions as well, which is to bring attention to the nose. I get asked that question all the time, and I hear that comment all the time. Well, I have always been a mouth-breather. My parents told me I was a mouth-breather when I was a baby. Well, just because it has been your whole life, that does not mean it is okay. So I am thankful at that moment that those patients found themselves in my office with a chance for me to evaluate and perhaps intervene. 

Yes, the nose is central, not only in our face, but it is central in our breathing, and it is central in sleep apnea. When we talk about this disease state that this entire summit is focusing on it. Almost always, there is some constriction or obstruction in the nose that is contributing to the poor sleep, the drops in oxygen levels, and perhaps the stoppages in breathing. It is very important for us as physicians for patients to recognize this and seek help if they suspect nasal obstruction.

Audrey Wells, MD

I could not agree more with you, and I know that there is a landscape of treatment options available. But why do we not start with an evaluation of the nose in your office and what kinds of things you are looking for?

Keith Matheny, MD

Absolutely. We, as ear, nose, and throat physicians, have recently expanded our physical examination. Let me explain what I mean by that. I have been doing this for probably 30 years or 30-plus years. Many times over my career, patients have come in and said, I cannot breathe through my nose, but if I just pull my cheek and pull my nostril open, it is so much better. Or perhaps they even talk about using some of the over-the-counter pieces of tape that have springs. That flares the nostrils open, and how that improves their athletic performance, or maybe it improves their sleep. 

For the most part, until about five or six years ago, which we will talk about, the ENT physician doctors did not have much to do to help those patients. It required a pretty elaborate nose job, a rhinoplasty, where we were transferring cartilage from either behind the ear or perhaps in between the ribs to try to strengthen the nostrils. Suffice it to say, that was a big deal, and typically it was a cash payment procedure for patients. I think as physicians, we often just overlooked that part of the physical exam because we could not offer much to help patients. That is different, and we will talk more about that over the next few minutes. 

But it all starts with looking at the nostrils. What I will do is have the patient just breathe normally, close their mouth, and breathe in through their nose. What I am looking for is any collapse of the nostrils that are pinching in. Usually, there is just a little bit of movement. If the patient is breathing at a normal rate, Then I ask the patient to breathe in through their nose. It is very hard to be inspired deeply. That is typically when I see the nostrils completely pinching shut. That is when I know that that is probably happening at night, especially in deeper stages of sleep when the patient is breathing that deeply. Dr. Wells, we start with the nostril. There are many more parts to the physical exam, but that is probably the first place that we need to look. The next thing. Yes, go ahead.

Audrey Wells, MD

I would imagine, too, that looking at the nostrils gives you an idea of the symmetry of the nose, including the septum.

Keith Matheny, MD

Great point. Yes. Patients can often identify that in the mirror themselves if they lift their head and look and see any asymmetry where one nostril is a different shape or seems less open than the other side, which probably indicates a deviated septum. That is number two. What I do before we go on to the deviated septum is, if I do see the nostrils pinching in and I feel that cartilage is weak, which happens with age, injury, and maybe prior surgery, then I will use a small instrument, just a blunt needle-tipped instrument, and put it inside the nose and just gently support the nostril, and then have the patient breathe in. The fancy term for that is a modified cottle, or Dr. Cottle described this as a C-O-T-T-L-E maneuver. A modified Cottle Maneuver. If the patient says, Yes, doctor, that fixes the problem. I know I have some options to offer them, but that is just one of them. We talk about nasal obstruction as having three legs on a tripod on a camera or three legs on a bar, perhaps. The nasal valve is one leg. The second way is through the septum. The septum is now the structure that divides the nostrils in half. 

Many people are familiar with the term deviated septum. What we mean by that is that the wall between the right and left sides is deviated or bent off of the midline. That is more common than not. Certainly, more than 50% of patients have a deviated septum, even from minor nose trauma throughout their lives that can cause some cracks and bends in the cartilage and bone that make up the septum. That is very easy for me as a physician to look at by just shining a light into the nostril using a nasal speculum, a small instrument to spread the nostril open so I can look inside. Then I look at the symmetry of the nostrils. You can see bone spurs. If the cartilage is bent, then I know that is another potential opportunity for me to help the patient. 

The third leg of the tripod for nasal obstruction is the turbinates. That word sounds very much like a wind turbine. If you think about those large windmills that are used as an alternative energy source, the same root word. What turbinates in the nose are little hook bones. Hook-shaped bones on the sidewall. The septums are in the middle and the turbinates are on the side, and they are covered in spongy tissue. When you have allergies, a cold, or any sinus infection, those turbinates, those sponge fills up with blood in response to histamine, leukotrienes, and other chemicals, That is why you feel congested. Well, many patients just have large turbinates for no good reason, or they have year-round allergies or other causes. But those turbinates hang out into the airway and can block the airway. 

You might think, well, why do we have turbinates to begin with? Well, they do a lot of great things for us. The turbinates, first of all, sense the airflow. If we just went in and, as a specialty, ear, nose, and throat doctors 40 or 50 years ago did just go in there and cut them off, well, I am going to give this patient a lot more room. But that made them numb. The patients cannot sense the airflow. It is the same frustrating, maddening, even sensation of being blocked that you cannot breathe through your nose. The other big things that turbinates do. One would be the humidification of the air. Microscopically, as the air flows across the service surface of the turbinate, there are these little hairs that look like hairs under the microscope, but they are not hairs. They are called cilia, and they filter out debris that we are breathing in. Plus, they are humidifying the air as it passes into your throat and then down into your lungs. 

Turbinates are a good thing, but if they are too large, they can cause obstruction, too. Then to review my physical exam, which takes much longer to describe out loud than to do it; it just takes a second or two. To do it in the clinic is to look at how the nostrils are performing. Is the cartilage around the curve strong or weak and prone to collapse? Then I looked at the septum. Is it bent one way or the other, or perhaps both ways, at different depths inside the nose? Then what do the turbinates look like? That tells me if nasal obstruction is a contributory factor to the patient’s sleep-disordered breathing. But it also tells me how I can help them.

Audrey Wells, MD

That is such a comprehensive and fascinating answer because it helps people appreciate the nuance of a nasal exam. That is certainly something I started doing in my practice with a disposable nasal speculum to just get a better look inside. Thank you for that.

Keith Matheny, MD

Yes, you must. Because you are the person who troubleshoots people who are struggling to receive it. Dr. Wells may be the first person to ever look inside a patient’s nose. Maybe they have a hugely deviated septum. One thing I did not mention is that maybe they have large nasal polyps, and that is why they are not tolerating their CPAP machine. If we could give them some nasal airflow, perhaps they would do well on their mission.

Audrey Wells, MD

I agree. One thing I tell people is that nasal breathing is important, whether or not you have sleep apnea. Fixing the nose and breathing through the nose is critical. But also for those people who do have sleep apnea. Nasal breathing opens up all of the nasal masks, nasal pillows, or nasal cradle options that not only make CPAP more comfortable but also increase adherence and use of the treatment. One thing I do is try to differentiate whether a person could go see a surgeon or an allergist for medical treatment and evaluation of allergies that may be adding to the congestion. Can you share any insights about what the difference between the two specialties is?

Keith Matheny, MD

Yes, great question. I am often told to. In general, an allergist is an internal medicine physician. After medical school, they have done their special training, their internship, and their residency in internal medicine. They have learned about cardiology, gastroenterology, and all those things. They approach the patient holistically, but from a medical perspective, as a gross generalization, an ear, nose, and throat physician is a surgeon. After medical school, we first train in general surgery and all kinds of things. I did cardiac surgery, orthopedic surgery, urology, and all those things in addition to ear, nose, and throat. 

Then I did four more years of just the head and neck. I think the easiest jumping-off point between the two is identifying if a patient can be managed medically, meaning they can manage their allergies either with medications proper or perhaps with allergy shots or allergy drops under the tongue, which is commonly done but is still not an FDA-approved treatment, I might add. Allergy shot injections are FDA-approved, or is the patient in need of some structural work? Meaning, do they need their septum fixed? Do they need their nostril cartilage strengthened? Do they need nasal polyps or inflammatory polyps removed? Do they need their turbinates reduced in size? Those would be done by an ear, nose, and throat physician by and large, not at all by an allergist.

Audrey Wells, MD

Yes, that is helpful. A question that comes to mind from some people who are trying to use nasal CPAP is about the experience of being able to breathe through the nose when you are upright, and then when you lie down to sleep, all of a sudden you are experiencing nasal congestion.

Keith Matheny, MD

Common problem.

Audrey Wells, MD

Yes. Sometimes I entertain the idea that is just my allergen, might be in the pillows or things like that. But this also seems to be a component of vascular congestion of the nose. I wonder if you can give me your take on this issue.

Keith Matheny, MD

You are exactly right. It is often both. I mentioned a moment ago that the turbinates are just big sponges. It is erectile tissue. When people take medications for erectile dysfunction most of us are familiar since they advertise those on TV seemingly every commercial break. One of the side effects is nasal congestion, too. If you think of the turbinates as a big sponge, there is a vascular component. The reason that the turbinates become more swollen when you are lying down, is that gravity does not help to drain it when you are sitting up. This is a common issue for patients of all types. Certainly, for those who are trying to use CPAP with a nasal delivery component, we must address the size of the turbinates. Sometimes or oftentimes we can prevent that congestion by using a nasal spray before bedtime. I am not talking about an over-the-counter decongestant that is addictive, one of the brand names for that would be Afrin. But I am talking more specifically about a nasal steroid spray. There are many available nasal antihistamine sprays. There are even two combinations of those: nasal steroid spray, nasal antihistamine spray, or both in the same bottle. Those can be quite helpful in improving comfort and, therefore, compliance with CPAP at night due to congestion.

Audrey Wells, MD

Are there, and you said those are available by prescription only?

Keith Matheny, MD

Several of those are over-the-counter. A couple of the nasal steroid sprays are available right on the same countertop or cabinet as the allergy medicine antihistamines or those types of things would be available, nasal saline spray. There will be some nasal steroid sprays available in one of the nasal antihistamine sprays are also available there too. Patients do not necessarily need to use prescriptions to help with this. It would be helpful to most physicians if the patients tried some of these things first, to help speed up their treatment once they get to the provider.

Audrey Wells, MD

I was happy when Flonase and Rhinocort went over the counter. The generic name is Fluticasone Nasal Spray. What is the antihistamine spray that you are talking about?

Keith Matheny, MD

Azelastine.

Audrey Wells, MD

Yes.

Keith Matheny, MD

Yes. It is very good because it decongests, but it also dries up some of the mucus. This is a funny thing: patients sometimes, when they come into an ENT office and talk about congestion, though they mean mucus. They mean this drainage that is coming out the front and the back of their nose. Sometimes, some patients come in and say they are congested. They just mean they are physically blocked and they cannot breathe in or breathe out, and in many people’s minds, that is the same thing. But it is quite different. When the patient is blocked, that means the turbinates. If it is temporary, that means the turbinate is swollen. If it is permanent, then it could be anything that we talked about earlier—the deviated septum or nasal polyps. But if it is mucus, then that often indicates either an allergic process or an infection of some sort. Not always. There are other diagnoses, too, so that is an important thing to tell your providers. Which congested are you? Are you snotty congested, or just physically obstructed type of congested?

Audrey Wells, MD

That is an important distinction and one that helps determine whether the response is medical with medications or saline rinses versus surgical options.

Keith Matheny, MD

Right.

Audrey Wells, MD

It sounds like if the problem is structural, you would be looking at a nasal septum deviation repair; you might be looking at a partial turbinectomy or procedure to restore insufficiency to a nasal valve; or the ala, that curve of the nose. Have I missed anything?

Keith Matheny, MD

Or all of the above? There are a couple of other things that we have not touched on. I have mentioned the phrase nasal polyps a few times. If you Google an image of what nasal polyps look like, it looks like a cluster of red grapes inside the nose. Those are inflammatory. They are in response to the patient’s allergies; about 20 to 25% of patients with chronic sinusitis infections, form nasal polyps. 75 to 80% do not. But they physically obstruct the nose. In my practice now, where I am. with all of my gray hair, other people will even send me these patients. Sometimes the polyps are hanging out of the patient’s nose. They are so out of control. That is something to look for that is related more to chronic sinus infections, but because it physically obstructs, the nose can lead to sleep-disordered breathing.

 The next thing behind that would be adenoids. Most people are familiar with phrasing about tonsils and adenoids, and you have your tonsils out and you have your adenoids out. Tonsils in adenoids: which adenoids are tonsils. They are just located at the very back of the nose. If you are going all the way from the tip, you have the nasal valve, or ala, as you said, Dr. Wells and you have the septum and the turbinates, then you have nasal polyps or not, and then you have your adenoids. Those are two other things that an ENT physician has to look for, and we have not even gotten to the mouth yet. We are still talking about the nose.

Audrey Wells, MD

Yes. I think the adenoids are typically associated with problems breathing as a child, but they can also affect an adult’s breathing.

Keith Matheny, MD

It can be. Now, your point is well taken. Many adenoids, or most adenoids, shrink down to a pretty small size, even by adolescence. Whereas the tonsils do not necessarily do that. If you have big tonsils at age 14, you may still have big tonsils at age 54. But adenoids. Even though they are tonsils, they tend to shrink down, but not always. In the past couple of weeks, I have operated on an 18-year-old kid and a 22-year-old kid. To me, as an adult, they are kids who still have large adenoids. Going into the back of the nostril. They benefited from having those removed. Of course, in adults, we are a little more concerned when the patient does have large adenoids that there could be something going on, namely, cancer. There can be lymphomas; there can be a tumor or a cancer called a nasopharyngeal carcinoma. Sometimes it is more than we bargained for. It is more than just a nasal obstruction and sleep problems. Unfortunately, we find that the patient has a cancer-causing obstruction. All of these things are on our minds. When a patient is on our schedule, we look at our calendar and say, Okay, they are coming in for nasal obstruction. Well, it could be a lot of different things. We have to think of all of the above.

Audrey Wells, MD

Continuing our tour of the nasal cavity, in the retro nasopharyngeal space, we have the soft palate and uvula. Tell me about your approach to evaluating that and then deciding if a person is a good surgical candidate, especially if they have sleep apnea.

Keith Matheny, MD

Absolutely. It is the nose and the nostril, a pretty easy physical exam. When we have the patient, usually they are sitting in our exam chair upright, like you and I are sitting here now. That is not how we sleep. When we are sleeping, especially on our backs, but even on our sides and, to some extent, on our stomachs, that changes the relationship and where all this soft tissue in our throats is. Those listening can do this now. Just look in the mirror, and then stick your tongue straight out. Say, Ahh. That action of saying ahh elevates the roof of your mouth and elevates the soft palate. If you cannot see the back wall of your throat as all you see is your tongue, maybe you can see the top part of your uvula. It utilizes a little punching bag that hangs in the back of your throat off of the soft palate, and you are sitting upright and awake. 

Then imagine how all of that soft tissue is collapsing when you are in the deepest stages of sleep, especially on your back. It is as simple as looking in there for five or 10 seconds, just shining a flashlight, and looking on either side of the uvula, are the tonsils. We were talking about the tonsils a moment ago. The tonsils themselves are major contributors to sleep-disordered breathing in kids, for sure, but even sometimes in adults, just because of the physical amount of space they take up. Those are, again, other opportunities for improvement. I will talk a little bit about some of the historical surgeries that were done, and they are still done on occasion today. then some newer treatments we have for these things.

Audrey Wells, MD

I think that what you are describing is often a debulking procedure, as tissues are being removed from the airspace to help with breathing. There is also an element of support, holding the airway open, which is one way that the surgery like a uvulopalatopharyngoplasty or UP3, also called a U triple P, has been modified over time to be more effective.

Keith Matheny, MD

Correct. Those types of surgeries were exactly as you said: the soft tissues in the throat are trimmed to create more space and to prevent the collapse of the airway. If you think about a carpet, when you are laying carpet on a floor and a new carpet is rolled out, you pull it very tight, cut it there, and staple it down. You do not want any extra fabric or material. Well, when you look in your throat, all you see is your tongue and your soft palate. You can barely see your uvula or tonsils. You have got too much soft tissue. It stands to reason. It has helped many patients over the last four decades—five decades or so—to trim some of that tissue and create a little bit of space.

 Now, there are a lot of downsides to that procedure, and that is why it is not done all the time. Number one, it is a very painful recovery. As most people know, recovering from tonsils, especially as an adult, is 17–14 days of extremely sore throat with a slight risk of some bleeding. It is a tough recovery. It is hard to swallow, and it is hard to stay hydrated. That is the initial problem. But over time, just like everything else, gravity works. That tissue that you trimmed within a period taking five, 10, or 15 years can also relax back to where it was when the surgery was not that effective long term. I think that is why a lot of us have gotten away from doing that procedure because we have a lot of other things to consider for patients with that problem.

Audrey Wells, MD

I know you are on the cutting edge for surgical procedures and to think outside the box and even layer procedures, as you alluded to earlier. What is new in the world of ENT when it comes to sleep apnea?

Keith Matheny, MD

Yes, lots of things. There are lots of things. We are still working on proving, even though we know from a common sense standpoint from what we see in our patients that the procedures we do to improve nasal airflow dramatically help patients sleep. I have patients every week that come in and I just strengthen their nostrils. We will talk about how we can do that or fix their deviated septum. Oftentimes, we do all three things at the same time: reduce the turbinate, straighten the septum, and strengthen the nasal valves in the nostrils. But the first thing they do is come in and say, Yes, my spouse says I am snoring a lot less, so thanks, doctor. We know that. We are working to create the actual scientific data proving that streamlining the nose improves sleep-disordered breathing.

 We will talk about those procedures in a second. But even for the mouth, in situations where the tongue is relatively too big for the mouth or the soft palate is long and floppy. We have various methods where we can tighten up the soft palate so it is not as floppy during deep sleep stages. In my practice, I refer a lot of patients to my sleep dentist, who works inside my office, to fashion dental appliances and what they do. They are very similar to bite guards that many patients have, but they stabilize specifically the lower jaw. The tongue is not falling back against the roof of the mouth or the back wall of the throat. Patients with mild and even moderate sleep apnea do well with dental appliances. 

Of course, we have the CPAP option, but we are trying to focus during this time on surgical options. Many of my patients are managed with CPAP. Of course, that is the gold standard. Let us talk a little bit more about what I have to offer nasally, and then maybe some things in the mouth if we have time. The nostrils are made up of two cartilages nearly roughly rectangular. Even though this lower one is curved like a scroll to form the familiar nostril that we are used to looking at when looking at what we do to help patients with nostril collapse, which we call nasal valve collapse or one of two techniques,

 One, the less invasive of the two, we use heat. Specifically radio waves or radiofrequency inside the nostril, and several three or four spots. It is like ironing a shirt—ironing a wrinkle out of a shirt. We are using the heat. Of course, the patients are numb. They are usually awake for this procedure, although we do it in the operating room sometimes. They are numb, but they are awake. We are pushing out, pushing the soft tissue away from the center while we are heating the tissue. What that is doing is injuring the cartilage. As it heals, it scars and the scars are stiffer. We take advantage of the body’s natural scar formation to strengthen the nostril. It is remarkable. Even within about two weeks, using that radiofrequency treatment around the nostril can make a difference for patients who are off those strips of tape in springs, and it takes maximum effect within 2 to 3 months. The effects are also very durable. We typically see these results lasting 5 to 7 years or even longer. 

The next option I have is to strengthen the valve is a little more invasive, but still a very simple procedure that we can do while the patient waits in the office. What we do there is inject a dissolvable rod. It is about an inch long, about two centimeters long. After numbing the patient up, we use a needle to inject that rod into the skin on the outside of the nose. I am not superficial. You cannot see these implants, but they are above the bone and the cartilage of the nose. The best description I give patients is that it is a diving board in the swimming pool. If you have the diving board jutting out over the pool and you lay a sheet on that or a shower curtain or something, it just prevents it from falling into the pool. That is what this rod does. It is not anything that lifts it out. It is not an active implant. It is just something to provide a little more stability so it does not collapse. With that procedure, as soon as you place it, the problem is fixed. It is very gratifying to do that procedure, especially in a waiting patient, because they can instantly tell the difference before they get up and out of the chair. 

That implant does dissolve over time, over about 18 months, but it leaves some of that stiff scar behind. That procedure also tends to last 5 to 7 years or longer. It was both of these, and we can just do the procedure again. We have not burned any bridges, but we have given that patient a long time of better breathing. Now, what I have learned is, and I mentioned this a moment ago, that we often do multiple procedures at one time for 150 years or longer. Surgeons have been straightening the septum. It used to be a very barbaric procedure. People are very familiar with all the horrible packing that ENT doctors used to do. Of course, you typically had the black eyes or the raccoon eyes after surgery. That is not true at all now. It is so much less invasive and so much more effective in our modern techniques, a lot of times we use balloons to remodel the septum, the crooked cartilage, and the crooked bone. Sometimes you do not even have to make any cuts at all. There is essentially no bleeding. It is dramatically less invasive and more effective. 

But what I have learned is that sometimes in improving the internal airflow, if you do not address the nostrils out here and there collapsing, that can make the external problem worse. We can unmask more collapsing of the nostrils by removing more airflow on the inside. If you think about it, we took a patient who could barely breathe into their nose, and now they can breathe in very hard. Well, of course, the nostrils are going to collapse. I try to anticipate that ahead of time when I fix both at the same time. Then almost always in that patient, there is a component of terminated enlargement. It is very common that, 60–70% of the time, they will treat at least two, if not all three, of these problems together.

Audrey Wells, MD

Hearing about this experience is so valuable because I think it helps to manage the expectations of the patient. A question that I get a lot is, Okay, I understand that nasal breathing is important, but I want to fix or cure my sleep apnea. In my experience, having a nasal procedure does not fix moderate-to-severe obstructive sleep apnea. Do you concur?

Keith Matheny, MD

Agree. Sleep apnea, especially moderate or severe, is often on multiple levels, and we have to address multiple levels. The CPAP machine does, especially when we are delivering positive airway pressure nasally. We are addressing the nose potentially; we are addressing the throat; we are addressing anything lower down in the airway. Surgical procedures are no different. If a patient has moderate or severe sleep apnea, almost for sure, they have a component of nasal obstruction but a significant component in their throat where the tongue is too big, the palate is floppy, there are big tonsils, or obesity is a significant component too just the sheer weight of the soft tissue under the chin. All of those things need to be addressed. I concur.

Audrey Wells, MD

Yes. Breathing through your nose has lots of benefits. Better sleep. You get the nitric oxide release for vasodilation. It is more comfortable because the air is nicely warmed and humidified, as opposed to the mouth, which does not have that type of tissue able to humidify the air. I think the big message is that it is worth it to get your nose open no matter what it takes because it helps you to live better.

Keith Matheny, MD

Agree.

Audrey Wells, MD

I want to change and do a little pivot here because you have an interesting company called Sleep Vigil, which is a type of remote patient monitoring company that is looking at patients with sleep apnea and other conditions. Can you tell us about it?

Keith Matheny, MD

Sure. Very briefly, I am very excited about that. What my partners in that company and I have built is a software platform that can take data from your fitness tracker. I am trying to be very inclusive here. As I mentioned, brands, but I wear an Apple Watch, and I wear it during the day mostly most of the time. But I wear it every night because I monitor my sleep. specifically, how do I look at my oxygen levels? Yes, there are other sleep monitoring functions on an Apple Watch, but there are many fitness trackers, probably 30 or 40, that can monitor a patient’s oxygen level, respiratory rate, and perhaps sleep staging, perhaps if there is a microphone that can listen for snoring. 

What sleep visual software does is take that data in packages to send either to the patient, the consumer, or to the physician, the person who is managing the patient’s sleep-disordered breathing. That gives us so much more ability to manage those patients. The best way to explain it is that way. I am sure this has been covered many other times during this summit, but just so I also say it, upwards of 20 to 25% of the people walking around on this planet have diagnosable sleep apnea, or a quarter of people. Yet even in the Western world, we have probably only diagnosed 10% of the people who have sleep apnea. That is not okay. It is terrible. Then of that 10% that have a diagnosis, probably only 10% of them are being treated beyond 90 days, no matter what, whether it is CPAP, a dental appliance, some surgery, or an implant. That is not okay. 

This is not just a disease that is a nuisance to our bed partners with snoring. This is a fatal disease. Before a patient dies from it, they have all kinds of medical problems neurologically. From head to toe, even cognitively, even driving a car or flying a plane. You are dangerous. That is not okay to be treating essentially 1% of a quarter of our planet’s population. Now, of that 1%, the way it works now, Dr. Wells and I do it because our hands are tied by the people who pay the bills, the insurance companies. We see these patients and diagnose them. We have someone who is motivated and compliant with their treatment. But more or less, we can only do a sleep study about once every three years to see how they are doing.

 One out of every 1000 nights. What Sleep Vigil does, is monitor them every night and give us an idea if whatever treatment we are using—CPAP, appliance-inspired therapy, surgery—is working or if we need to make some tweaks. Is that patient still at risk? That is why that company is so exciting to me because whether we just go straight to the consumer and the consumer realizes that there are some problems and they go discuss that with their physician, or whether we send the data to the physician and they proactively say, Hey, we need to make some tweaks in your treatment, Either way, we are at least optimizing the 1% of patients that we are treating, and hopefully we will grow that number.

Audrey Wells, MD

I am cheering you on, and I think we have parallel missions in this regard because there is new information coming out about how one single night of sleep data does not necessarily represent a person’s sleep quality or quantity.

Keith Matheny, MD

Not at all. Good or bad.

Audrey Wells, MD

Correct.

Keith Matheny, MD

It is just one point in time. We need to see the whole pattern.

Audrey Wells, MD

Yes. This is a way to leverage technology to do that. I think this is a fantastic way to end on a note of hope that things are going to improve in the future. We are going to get people the help that they need and be able to make adjustments based on data coming from the wearables that they are wearing anyway. I love that. Thank you so much, Dr. Matheny. As we close, I wonder if you can tell us how people can find you.

Keith Matheny, MD

Absolutely. You can tell I am as passionate as Dr. Wells about this and all of our fellow faculty at this whole summit. I am very active on social media specifically, LinkedIn. Seems to be a good platform where we can talk about these topics, sleep, and other things. The nasal airway, for sure. I talked about that a lot. Look for me there, and I am very active in checking my direct messages. That is probably the best way besides just contacting my practice here in Dallas.

Audrey Wells, MD

That is amazing. Thank you so much for joining me today on this informative topic, the nose, and remote monitoring.

Keith Matheny, MD

Absolutely. Thank you for this opportunity.

Audrey Wells, MD

Take care.