Get The Facts On Sleep Apnea Surgery

Steven Park, MD

Thank you for inviting me. As you said, I’m an EMT surgeon. Later on, I became certified as well. When I first started practicing about 23 years ago, I was a general EMT doctor in Manhattan. I was seeing typical L.A. patients. But the bulk of it was nasal congestion and ear problems—the typical problems that you see in general practice. However, I started to see a lot of sinus surgery patients who needed surgery because they didn’t respond to medical therapy. I realized that most of the people had severe snoring problems, so they didn’t sleep well. I did a prospective study informally, and it’s six studies on every one of my patients who needed sinus surgery. Surprisingly, we found that 80% had obstructive sleep apnea based on the sit test. That was a little bit surprising. But then, in the third piece, all these other studies documented studies showing that, for example, acid reflux is linked to chronic sinusitis. Just look at sleep apnea. Sleep apnea through acid reflux, all cut into intertwined together in one. The other one gets better in all directions. when somebody kind of hit me, that is, well, if you can treat the sleep apnea, because I thought that was the main source. When you stop breathing, you’re going to forcefully vacuum up your normal stomach juices into your throat. I think the main reason why people have reflux and like people have these issues and take medications is that yes, you can have stomach issues and indigestion. But for most people, the breathing problem is that you’re going to forcefully suction out now, and you just have stomach contents. But also, that includes not only acid but also bile digestive enzymes and bacteria. It’s a very irritating substance that comes out of the ears. It is not just the throat that gives you throat clearing, hoarseness, coughing, and lump sensations; these same juices can also go into your nose, sinuses, ears, and lungs. Therefore, we found pepsin and digestive enzymes in all these areas, which is.

Audrey Wells, MD

Fascinating. Yes, but not what you want. I mean, in my experience, having acid reflux at night as a component or even a red flag for obstructive sleep apnea is so common. I think it underscores the idea that when you look at a person’s sleep, you’re also looking at the whole person. You’re looking at a whole-body approach to help somebody not only optimize their sleep quality but also function better during the day.

Steven Park, MD

One of the things I’ve learned over the past decade, 15 years or so, is that this year, I was very focused on sleep apnea and breathing because that’s my specialty. I saw some incredible things happen when you can improve people with breathing problems from a surgical standpoint—not just sleep apnea, but other breathing issues that we see in our field. But I’ve had to kind of pull back and just look at the bigger picture, like what you’re saying. It’s not just the breathing but also the environment, your mindset, your emotions, your diet, your toxins— light therapy. It’s all just connected; like you said, as human beings, we’re part of our environment, and the environment affects us internally, and we also affect the environment. I had this holistic shift and the past couple of years, especially those past two or three years, where I’ve had to kind of open my mind to more holistic options of ways of treating sleep breathing, not as a breathing issue but as a bigger picture.

Audrey Wells, MD

Yes. It turns out that breathing is pretty central to being alive. Yes. I think that when you take a holistic approach, you’re taking a kind of common sense approach, isn’t it? It’s kind of going back and saying, What am I doing that’s healthy or not healthy? How can I identify factors that are interfering with my breathing or my sleep? One of the things that I enjoyed talking to you about before was your approach to surgery when it comes to treating sleep apnea. I loved the way that you weren’t so keen on taking out the scalpel or the carry wand and trying to address sleep apnea that way. Can you describe for our listeners and our viewers what your approach is when someone comes to you for a sleep apnea treatment evaluation?

Steven Park, MD

Or, as you can imagine, most people come to me expecting to undergo surgery because that’s why they found me on the Internet or were referred to me by someone else or even a sleep doctor because they couldn’t tolerate CPAP. But my priority is to try to avoid surgery. I go either way. I twist people’s arms to try to sleep if they’re reluctant and go to the dentist. We work on weight loss, nutrition, stress reduction, and light therapy using the sun to benefit these patients. That’s the priority. I take pride in the fact that I did get a lot of people to avoid surgery. But when it gets to the point of surgery, I’m much more aggressive than most surgeons.

Audrey Wells, MD

Tell me about it.

Steven Park, MD

The problem is that surgery is minimally invasive because we have this minimally invasive mindset in our field like these things are done in the office, for example, for snoring. But what I’m finding is that of all these options that we have, most of them are too conservative or they’re not in the right area. Most people will have not just one level of obstruction but multiple levels of obstruction.

Audrey Wells, MD

I think that’s a piece that is oftentimes missing. When someone is educated about their sleep apnea, they think it’s all related to their tongue or their weight, when in fact there are multiple levels of potential airway obstruction, and defining that can help predict treatment response.

Steven Park, MD

One important concept that I’ve integrated into my practice is what I wrote about in my box of sleep interrupted: that all modern humans have some degree of dental crowding because their faces are getting narrower. If you look at modern humans and compare that to now, say, 50 or 70 years ago, they had much wider faces back then and higher cheekbones. If you look at some of these celebrities in their thirties or fifties, they’re like aliens because they’re these white faces where you get your grandparent’s pictures, for example. What that means is that as our faces are shrinking due to several different factors or airways, two or more of us are going to be susceptible to breathing problems to various degrees. We’re all on a continuum. So that’s why I kind of treat patients as if modern people have a sleep-breathing problem. Now you’ll have to have sleep apnea. This is one area that I’m involved in. It’s just in this concept that all of us are on a continuum, and sleep apnea is only the end of that continuum. Even if you’re normal or thin, you can still have breathing problems. For example, I’ve always had major sleep problems in my life. I always fell asleep in classes. I slept in most of my medical school classes. But the only thing that kept me awake and alive was surgery. I was rocking, walking around, and running around all day long, but it was only later in my career that I realized that this was a problem. I asked you to take the initiative to treat myself. I underwent the expansion. I changed my diet completely. I have healthy habits. Now. I feel better now than I did 20 or 30 years ago.

Audrey Wells, MD

I think that makes a huge difference when you experience something personally, and it kind of projects you to give better care to the patients that you see. I can certainly identify with that. Only recently did I capture the beginning of my sleep apnea. I want to point out to anybody watching that I would be considered an atypical sleep apnea patient. I’m a woman. Oftentimes, this is attributed to males only. But it turns out women probably look different with their sleep apnea. My body mass index is in the normal range, and I don’t have the sort of oral anatomy that’s typically associated with What I do have is a very strong family history of obstructive sleep apnea, and multiple factors play into someone’s risk. I define nine of them in the courses that I teach. Now for you, Dr. Park, I wonder: when you’re looking at someone who wants to treat their sleep apnea and maybe they’ve gone through the non-surgical modalities, how do you filter out what surgical treatments may be applicable for each person?

Steven Park, MD

My priority for anybody is to make sure that they’re breathing through the nose. The reason is that number one, it’s important to breathe through your nose because the nose has the important function of filtering, humidifying, warming the airflow, and smoothing the flow of air. But also, the nose makes a gas called nitric oxide that kills bacteria, viruses, and fungi. Also, if you breathe you inflate your lungs, that nitric oxide increases oxygen uptake by 10 to 20%. It’s important to presume that it’s not your mouth, but people think that if you breathe in your mouth, you can breathe easier.  But it’s wrong. When you open your mouth, the tongue goes back, so you get more obstructed. The priority is to help you breathe through your nose, and what I find is that it helps people tolerate or benefit from CPAP or dental classes to a much greater degree. I remember one study looking at people who couldn’t tolerate CPAP. They use it on average for about 30 minutes per night after a study went up to over five hours of CPAP. That’s a big difference. I see this happening all the time.

Audrey Wells, MD

I agree. I beat my drum about nasal breathing to the point where I feel like, there’s only so much you can communicate in one of those short medical visits. However, any time I see somebody wearing a full-face mask, I try to circle back and ask him, Why are you wearing a full-face mask? Because nasal masks, nasal pillows, or cradle masks are associated with more comfort, Longer use, and nightly use of CPAP compared to a full face on top of that. You get all the benefits of nasal breathing. Whatever people can do to breathe better through the nose is going to be more effective.

Steven Park, MD

Also, they’ve shown that when you switch the nasal mask after surgery, the pressure can be lower, too. It becomes much more comfortable.

Audrey Wells, MD

Yes, I’m sure people will love to hear that because it’s reassuring. You were meant to breathe through your nose. Let’s try to get back to that. How do you decide which operations to offer? With the nose, I know that there’s the turbinectomy to where you’re kind of debulking in the inside of the nose; there’s a septodiviation correction. What else?

Steven Park, MD

Well, so that’s an interesting history behind the nasal operations. In our field, when I first trained, we were very aggressive. We did a set of plastic, which is just threading the crooked septum from crooked to straight in the middle of the nose and then the terminus, these wings, in the side of the nose. That’s what swells up when we have turbinology. In the old days, we used to take out a quarter, a half, or even the whole thing. But that caused long-term problems—something called empty nose syndrome. Over the past couple of decades, the pendulum has swung in the other direction toward very minimally invasive procedures. These are what they call: mucosa or minimally invasive mucosal therapy, and mucosal sperm therapy, so these procedures can be done in the office using a few radiofrequency probes to kind of burn the tissues on the inside. The problem is that, yes, they do work, but now we’ve gone too conservative. What I see a lot of times is that these patients undergo these nasal terminal procedures, but they still have this congestion because, over time, the swelling and the inflammation cause the terminus to fill up again. After all, they didn’t address the source of the inflammation. That’s one area. Number two is that a lot of surgeons don’t address the nostrils. This is a major issue for many people. My theory is that if the face doesn’t expand, like this, the nasal cavity is also more narrower. Your septum is crooked. This way, the ends are more towards the middle here, and the nasal angle, and you’re being like, is more like this. It tends to cave in a lot easier. One of my colleagues at Einstein Maritime said that ten years ago, he did a study on whether a plastic surgeon is a plastic surgeon, and he did a pre- and post-sleep apnea study after nasal surgery. In most cases, we’ve shown in our field that if you do nasal surgery, for the most part, it doesn’t cause sleep apnea. maybe about 10% of patients with mousy brown; it does help, but overall, it doesn’t help this development in the previous analysis. But what he did was, in addition to the septum and the terminus, he also addressed the nostrils. This success rate was much, much higher—I think like 40 or 50% as opposed to 10%.

Audrey Wells, MD

Oh, that’s remarkable.

Steven Park, MD

I was very aggressive about addressing the nasal nostrils and using different techniques you can use. The most traditional operation is something called an open rhinoplasty approach with other band grafts. You take cartilage from the air and put it like a stent here, but these are more aggressive operations, and then you kind of squish some more conservative options. There’s a suture suspension option. You kind of bury a screw right under the eyelid, and you go on this skin and grab this nostril looped back up. then there are other ways of going inside the nose and kind of overlapping ecologies. There are different variations. But when you do something for different nostrils, you get much higher success rates.

Audrey Wells, MD

That makes sense. You know, kind of analogous to sleep apnea, it seems that there are multiple levels of surgical approach there. You mentioned that you’re a surgeon who doesn’t necessarily recommend surgery, which makes me think of my grandpa, who I always used to say, If you take a cow to a butcher, you’re not expecting a haircut. It’s a little refreshing to hear from a surgeon who would recommend going back to CPAP therapy if a person hasn’t given it their all. I know this is something that you address on your website and in your coaching and teachings. Can you give me an example of some of the techniques that you use to recruit people back to the idea of using their CPAP better?

Steven Park, MD

Number one, we adjusted the nasal congestion issue that’s important. The second is dietary habits. The most important tip that I recommend is to accept that it’s an absolute must to stop eating close to bedtime because that is also what can aggravate acid reflux. Even if you have a low level of sleep apnea, having these apnea events can suction up the normal sound, which is in your throat, that causes more inflammation in thought than your nose. You have to take these other conservative adjunctive measures to improve sleep apnea therapy, whether it’s a CPAP device or a dental appliance. Also,  professional therapy is very important. A lot of people get confused about what the best position is, but I tell patients, that they’re going to normally sleep in their favorite position anyway. Like people these days, they can sleep on their backs. If you realize this, most people like to go in this size of the stomach because they can’t breathe properly, but this happens when they get injured or undergo an operation, and suddenly they have to sleep on their backs. Now their sleep apnea goes up, the roof just goes straight up, and they can’t breathe or sleep at all. and then also a neck position is another issue where, as you may know, when you tilt the head forward, the area gets more narrower. This is why some of these contour pillows make a little bit of a difference they allow you to sleep more, like this neck pillow, which can open up your airway. These are all factors to kind of address in a very cohesive way to not only previously but also allow this CPAP therapy to work much better.

Audrey Wells, MD

I want to spend a minute talking about body position because it’s something that I get asked about a lot, and it seems that we might have a similar philosophy. I tell people that there’s no one superior body position. Certainly, if you’re sleeping on your back, your air pressure from the CPAP machine should be high enough to help keep your airway open. I like that position being available because it’s not going to place pressure or metal alignment on the neck, the back, the shoulders, the hips, the knees, or all of these major joints. Your spine can develop issues if you’re limited to sleeping on your side. Having the back position available is a positive thing. My least favorite position is stomach sleeping. A lot of that is because of the talk on your neck. Your back is not in alignment. Also, for CPAP users, it does tend to produce more mass movement that leads to air leaks. Do you agree?

Steven Park, MD

Yes, in most cases, I do agree. But some people, even with CPAP and CPR on their backs, aren’t comfortable. I realize in the lab we titrate for that in the REM sleep on your back.  But what happens in the sleep lab doesn’t always correlate to what happened in your life. Now, when you think about the stomach position, you realize that when you’re on your stomach, you’re always going to turn your head right. Most people don’t sit face-down on the bed. But what happens to the airways when you turn your head to one side? It opens up the airway. It’s similar to when you move your jaw forward.

Audrey Wells, MD

Oh, interesting.

Steven Park, MD

They’re kind of naturally doing that on their own. But I tell them to sit and use a simple machine in the position they normally sleep in, which is their favorite position. Like I said, most of them are going to be on their sides. But I agree. For example, I don’t like sleeping on my side because of pain and numbness, and I just like to signal my back. But the way I sit on my back is to use a contour panel, or I kind of make my custom pillow.

Audrey Wells, MD

Oh, interesting.

Steven Park, MD

Using a dowel and a husky Philip pillow. My wife laughed at me because I had to go through so many iterations of pillows and custom-fit different options. I squeeze and breathe Whitestrips every night and also tape my lips. Yes, I know all these things when I go to sleep, and that’s how I get good-quality sleep.

Audrey Wells, MD

That’s one thing that kind of highlights how important sleep is to you and should be to everyone because it’s such a component of health; it’s a biological need, and oftentimes the impact of a little lower sleep quality or a little less total sleep time has subtle effects on your life. But when you consider that it’s night after night after night, those add up.

Steven Park, MD

Up. Yes, it’s very cumulative. We can handle short-term sip deprivation very well. It’s cumulative long-term prevention, not just quantity over quality, that affects your quality of life and other health effects.

Audrey Wells, MD

I have a similar pillow. I travel with it. That’s how particular I am, and it goes behind my neck to give me that little lift. I also find that doing some pillow prepping, like putting pillows stacked up under my knees, helps flatten out my spine in a way that allows me to sleep on my back, which is my favorite position. Head turn to the side.

Steven Park, MD

Is this another tip for travelers? Oftentimes, I forget I take my pillow too, but sometimes it’s what I do: I roll up the large hotel towels, neck and neck, and long roll, and that works pretty well.

Audrey Wells, MD

That’s a good tip. Okay, Dr. Park, I have a question to pass on to you from all of the people who asked me. You know, truly, I feel like it takes maybe 30 or 40 minutes to explain the ins and outs of an inspired surgery. But that seems to be on people’s minds, and I wonder if you can explain more about their criteria and the expected outcomes.

Steven Park, MD

Yes, well, I have the privilege of having been involved in the early phases of the development of this technology with a company called AppNexus in 1919, 2010, and so I was involved with the feasibility studies and then the phase two FDA studies. Unfortunately, the company didn’t survive for a lot of technical reasons, maybe even financial reasons. We don’t know why. But ARPANET, so inspired, was a competitor with AppNexus, and eventually Inspire got FDA approval in 2014. Now the technology is pretty neat. It’s very high-tech. What it involves is that there’s a pacemaker, just like a heart pacemaker, implanted under the skin on top of the ribs up here in the chest cavity, and a wire lead is tunneled under the neck, shoulder to shoulder. You make a little incision under the neck, and you find a nerve that goes through your tongue, called the hypoglycemic nerve. Then you connect a cuff around a nerve. So there’s another sensor that goes through the rib cage. When it senses that you’re breathing in, it stimulates the nerve to activate the tongue muscle to move forward. It’s a very neat idea. It was first developed at Johns Hopkins. That meant that around 2000, the idea got shelved, and then, I guess, the companies took it off the shelves and started to develop it because the technology was much more advanced now. It’s a great idea. The criteria are to inspire two, four, or five criteria. Number one, you have to have tried, failed, or refused CPAP, since that’s a given. But number two is that your body mass index has to be less than 32. That’s a major issue because the higher the layer’s body mass index, the more audible the results. We saw that with our study as well. You can have more than, I think, 25% central apnea as well.

Audrey Wells, MD

That’s right. 25.

Steven Park, MD

It has to be within, like, one or two years. It’s just different criteria. But a recent sleep study and I think now their velocity in-home studies as opposed to just lab studies. The last one is that you have to undergo what’s called a drug-induced sleep endoscopy. This is where they put you under anesthesia, like a colonoscopy. You take a look with a camera to see how the airway collapses. There are certain criteria, what they’re looking for, that make you a candidate or not. The biggest factor is: in what direction does a soft power collapse? If there’s a collapsing front to back like this or like a person, so if you like a purse string, that means you’re not a candidate is too floppy. Now, the way this works is that when you simulate the tongue and the tongue base moves forward, there’s a lot of tissue from the side of the tongue that causes the soft palate. It’s called the palatoglossus muscle. When you put it down for that, the soft, plastic, flimsy, weak, and floppy moving.

Audrey Wells, MD

I wonder if you can say to start with the palatoglossus muscle fold.

Steven Park, MD

Yes. The reason why the simulation works is that when you push your tongue forward using the simulator, it tugs on a muscle called the palatoglossus muscle that comes into the side muscle and connects the tongue based on a soft palate. When you pull the tongue forward, it’s kind of a soft palate. That’s what opens at this soft palate. But if the soft palate class is like a purse string, that means the tissue is just too floppy. So we train the palate, so we tend that the tongue base is not protecting the palate, but if the pipe collapses from the back, that means it’s tight enough to respond to tongue stimulation. It’s a very simplistic way of explaining why the words inspire dogs. You’re not touching it. You’re not operating on the soft palate.

Audrey Wells, MD

What do you feel like? Patients experience? I’ve been told that it feels like the tongue is crunching forward or scrunching forward when they breathe. Is that consistent with what you see?

Steven Park, MD

After everything feels, what you’re going to feel is just as if you’re voluntarily pushing your tongue forward. Initially, because of the surgical effects, you’re going to feel more irritation and swelling, and you may feel either numbness, pain, or something. But after everything heals and slows down in uncomplicated situations, it’s as if you’re taught to stick your tongue forward. That’s what happens. But involuntarily now, this operation does work very well if you choose a patient very carefully. I think the success rates of a company are think the 90% range in terms of patient satisfaction. But objectively, if you look at the official FDA study, if you look at what surgical success means in the anti, that is defined as a 50% drop in the original HIV or the severity, and the final AHI has to be under 20. This is a very technical term, and it’s not even a very good definition because you just need to have a 50% improvement to say you’re successful. But you could still have severe sleep apnea with a 50% drop.

Audrey Wells, MD

But, you know, I think that’s worth repeating. Sometimes surgical success is different from not having sleep apnea or having a surgical cure for sleep apnea. You might see a reduction in the AHI by 50% or that plus a high of less than 20, which does not mean sleep apnea is absent. It means it could be labeled as a surgical success.

Steven Park, MD

Because you can still have 19 as a result and still have minor sleep apnea.

Audrey Wells, MD

Yes, exactly.

Steven Park, MD

Now, that’s a very old definition. It’s called the CHER criteria. We’ve modified that to say surgical success. There’s a different threshold for success. under 20, under ten, and then the five under five, it’s considered a surgical cure. the idea that the dentist, for example, uses these definitions, especially for jaw surgery, so you have to kind of look at not just a funny number but how the patient feels because sometimes you can have very low numbers. The patient doesn’t feel any better, or vice versa. You can have very low responses in terms of the numbers, but they feel much better. That’s one of the paradoxes of surgeons.

Audrey Wells, MD

Yes. a paradox of sleep, too. You can have very severe sleep apnea but not be bothered too much by daytime sleepiness. Then, kind of, the reverse is true. I’ve seen some people who have relatively mild sleep apnea by our current measurement standards but feel almost debilitated by their sleep and their daytime alertness.

Steven Park, MD

Well, one that brings up a very interesting point is that one area that I had this fascination with is what’s called upper airway resistance syndrome. These are more subtle partial obstructions that disrupt sleep that don’t show up or get scored on a sleep study. It’s somewhat controversial in our field of sleep medicine as to how significant that is. You have people on both sides of the argument, but I see it happening in people. We did a study looking at people with UARS less than five who were very symptomatic. We took a look at a sleep endoscopy. We found that 83% had significant multilevel obstruction.

Audrey Wells, MD

Yes, it’s remarkable. I think one thing we can all agree on is that the AHI, or apnea-hypopnea index, is a relatively limited measure of what’s happening. I’m glad that there’s been some attention to that recently. Getting back to the Inspire surgery, one thing that’s changed is the criteria that you have to have less than 65 for an AHI. Now that’s gone up to 100. I’m a little tentative to see that as a big advance because, to your point, the patient selection for Inspire is important. I think, you know, on one hand, 100 sounds are quite severe sleep apnea, but some people have very long airway obstructions, and as a result, they have a relatively low AHI can tell you that with an age of 100, I would know that person has relatively short airway obstruction. Sit still for more than 10 seconds, but not for 45 seconds to a minute. What do you think the difference in the AHI threshold is going to mean for the outcomes in Inspire?

Steven Park, MD

I haven’t seen any other studies regarding this criteria. I’m sure they justify that based on their studies, but I guess what they’re doing is they’re kind of trying to expand the indications for the Inspire. For example, if they recently lowered the age in children to 13 for kids with Down syndrome, they’re going in the other direction and then trying to raise the threshold for adults as well to make this much higher, but in general, with any kind of sleep apnea surgery, the higher the second you score, the greater the success rate in terms of satisfaction. Yes, in a sense now, but I guess you argue that if you go from 100 to 40, it should be considered so you can get well; there’s a successful 60% reduction. They’ll feel better. .  maybe the best risk factors if we drop significantly, but they’re still not going to be normal. But if they can’t tolerate anything else, then they have no other choice. But going back to this exacerbated issue, If you apply the surgical criteria, the sure criteria on the Inspire in the 2014 FDA study in the New England Journal, their success rate was like 60%, just on par with the best UAP operations. The more modern update apnea-powered operations are in the 67% range.

Audrey Wells, MD

You’re talking about the Uvulopalatopharyngoplasty, where the back of the soft palate and the end, oftentimes the uvula, is removed.

Steven Park, MD

Why not the traditional one? You just cut out the whole thing where they move the muscles around the movement as opposed to coming out.

Audrey Wells, MD

Yes. In my experience, the Inspire treatment is viable, and I don’t have the opinion that sleep apnea necessitates CPAP treatment for everybody. But the folks who are overweight and have a higher BMI tend to do less well than those with a lower BMI. For me, people who have significant co-morbid insomnia also tend to not get the satisfaction and relief for their sleep apnea.

Steven Park, MD

Yes, that’s a very good point. That’s why you have to have a good sleep medicine team and work together with a surgeon. But I believe the sleep lab has to be kind of hands-on with the patient in terms of follow-up because ultimately, that follow-up and care and just setting adjustments and the counseling is what’s so important for success because I’ve seen this happen when it was Inspired many years ago, which says I would say about 30 patients well from the start. Third, they have some issues. You have to keep bringing them back and changing the settings and trying different things, and about a third are not as happy, or it takes a lot longer for them to get to a point where they’re happy. but your point about does come over sleep apnea with insomnia. That’s why you also need a sleep doctor to kind of address that from an insomnia standpoint. But I’ve also been interested in a doctor’s very close work.

Audrey Wells, MD

I have practiced in Albuquerque for about eight years or so. That’s where he’s located.

Steven Park, MD

He’s doing a lot of work on comorbid insomnia, complex sleep apnea, and PTSD nightmare therapies. He brought up a lot of interesting points about how insomnia and sleep apnea are interrelated.

Audrey Wells, MD

Yes, they overlap, sort of.

Steven Park, MD

Yes, yes, I think if paraphilia with the studies where people with complex apnea have that severe insomnia, they are not responding to any kind of medical therapy, and when they treat sleep apnea, most of the insomnia goes away.

Audrey Wells, MD

Yes, it’s so interesting. At that transition from wake to sleep, it is a rather fragile time for the brain and breathing. I think that the person who experiences a hiccup in going from wakefulness to sleep and having their breathing kind of go on autopilot if there is some friction will experience insomnia, not a breathing problem. It’s so fascinating. There’s a new surgery that’s becoming more available: an abscess or cervical stimulation. What are your thoughts on that?

Steven Park, MD

Well, you know, you’re going to have new technologies coming and going. I’ve seen it all coming, and it’s never going to end. What technology is going to come out of the problem is that fundamentally, I believe, sleep apnea at this stage of the game. Yes, obesity is a major factor, but fundamentally, it’s a jaw structure problem. The more aggressively you can make the jaws wider, the better the results are going to be in the long term. That’s why I think the surgeons are much more aware of the power expansion and the surgically assisted power expansion options. I think double jaw surgery, which is mostly a medical advancement, is much more popular these days because of increased awareness. Since more of these things are being done, they’re getting better results. I think there’s a role for all these different options, and start with the most conservative first, but some people kind of move up that ladder to get the more aggressive options. So the answer is, I don’t know; I haven’t seen the long-term studies yet, but it sounds promising. But just like the Inspire with these nerve stimulation options, you’re only going to get to a certain point where there’s a plateau.

Audrey Wells, MD

I think there might be an opportunity for these procedures to be layered, and that could create the desired effect. But I also want to say that there’s a role for prevention here. even starting to look at kids and seeing how wide the palate is, so the roof of the mouth is the floor of the nose and the room for the tongue. The openness of the nose is something that can be addressed much more easily in the pediatric population. So for those of you watching, look around at the kids. Make sure that you breathe through your nose.

Steven Park, MD

Absolutely. It’s an important point. I would argue that you should start even before they’re born.

Audrey Wells, MD

Tell me.

Steven Park, MD

Even before you’re pregnant, get pregnant because the health of the mother affects how the baby grows. Yes. One of the other things that I learned this past couple of years is how the environment affects fetal and child development. This is a whole other discussion. All the toxins, the fluoride, and the pesticides. Yes, the endocrine disruptors. There are so many different insults to our health, not just our bodies but also children’s bodies. I can have a lot of different theories as to why things our jaws are not widening. We did a study; we didn’t publish it yet, but we had a manuscript. We looked at college yearbooks from the 19th century—the thirties compared to now. We measured the height with Michaud.

Audrey Wells, MD

Of the palette?

Steven Park, MD

No, the facial profiles.

Audrey Wells, MD

The facial profiles.

Steven Park, MD

Is to this dimension, and modern faces are much more narrow and taller than expected.

Audrey Wells, MD

Oh, fascinating.

Steven Park, MD

But that means our jaws are getting more narrow as a result of whatever is happening. They talk about soft diets, lack of breastfeeding, congestion, and all these other factors. But there’s another component, which is that some of the toxins, the chemicals, and this is kind of going a little bit off. But even glyphosate, I can argue, has effects on biochemical processes that prevent bone, jaw, and cartilage development.

Audrey Wells, MD

Interesting. Well, you know, I think we’ve circled back to kind of the whole body approach to sleep. I love that philosophy because it helps physicians like you and me treat people in a personalized,  tailored way to help a person actualize not only their health but their sleep quality from one night to the next. For decades ends as we close. Dr. Park, I wonder if there’s anything you’d like to add. Also, where can people find you?

Steven Park, MD

Well, going back to what we talked about earlier, if you’re starting to breathe better and sleep better, focus on those first, because most people have nasal congestion issues in this day and age. So do everything you can to improve their breathing. I have a free resource called 7 Natural Ways to Unstuff Your Stuffy Nose. You can find that DOCTORSTEVENPARK dot com, doctorstevenpark.com/7.

Audrey Wells, MD

That’s fantastic. Thank you. 

Steven Park, MD

So if you start with a nose, I would say about 10, 20, or even 30% of people will succeed better automatically. Then, if you have weight to lose, that’s always a factor. A major factor for people who have weight issues now is that it will also lower their severe sleep apnea in general. But for people who are about to be skinny and who have no way to lose, there are lots of these natural options available, but I think the biggest bang for the buck I’m seeing is suppression. children are to talk to an airway specialist or a dentist. It’s very paradoxical. It is very big these days in orthodontics, and we’re seeing fantastic results from powder expression, and kids and even adults can benefit to some degree. I did it myself. I did a palate expander, and I feel so much better afterward.

Audrey Wells, MD

Oh, that’s great. Yes. As an adult, it’s a little more difficult because the bony sutures have formed. But for kids, that rapid palate expansion, you know, I can attest to that being very effective, not only for breathing and sleep but also to, again, widen out the nasal cavity and nasal breathing. Yes, you know, we’ve talked about it a lot today. I think one of the main messages is the value of breathing through the nose and preserving that nasal breathing even during sleep. We talked about stopping eating before bedtime for at least three hours to not only give your body’s rhythm a chance to optimize the digestion of food but also to prevent acid reflux that happens during the night especially when someone is lying flat. We also address body position and neck position as potential ways that one might breathe better or worse during sleep. It was interesting to find out that, as a surgeon, your approach is rather conservative in directing people back to treatments like CPAP and helping them through that. But if surgery is needed, you’re willing to roll your sleeves up and get in there to make sure it’s an effective surgery. That may mean a multi-level surgery because sleep apnea is a multi-level condition. Finally, we talked about the Inspire treatment as a relevant and successful treatment for many people, but patient selection is key to making sure the patient’s expectations match the results. That’s the valuable content here today. Dr. Park, thank you so much.

Steven Park, MD

It’s my pleasure.

Audrey Wells, MD

People can find you on your website. That’s doctorstevenpark.com. That’s all spelled out. That’s fantastic. Thank you for talking with us today. I’m sure people got a lot of value out of this discussion.

Steven Park, MD

Thanks again. I enjoyed it.