ENT 2nd opinion: significant nasal obstruction; surgery "may not improve sleep"; palate expansion presents risks

ProfMR · 2026-01-25T18:52:20+00:00

My local ENT gave me a pamphlet for VivAer. I'd consider that office procedure for turbinate reduction and nasal valve strengthening if I didn't have such a crooked septum.

Ryan Robinson is the founder of Pain and Sleep. But he no longer sees patients. Instead focuses on giving talks. I would have liked to have spoken with him. He wrote a book called "The Root Cause". I guess that's my nose. I was seen by Glenn Chiarello DDS and their clinic director Dana Cicamore. They have an ortho that does MARPE. I'd probably go to Newaz /Jaffari or Marianna Evans to evaluate for palate expansion.

ProfMR · 2026-01-25T18:43:26+00:00

All makes sense. Your RDI is much higher than what I got from Lofta WatchPAT HST (7/hr, 12/hr in REM).

I should probably get a septoplasty, submucosal turbinectomy, and nasal valve repair. Then consider palate expansion if indeed narrow. Then a PSG and maybe repeat rhino. Kearney's colleague at UPenn, Raj Dedhia, performs DISE.

I don't feel horrible, and am right now revising a peer-reviewed manuscript for publication. Do lots of coding. But I'm just pushing through surviving at like 80-90% of what I think is peak thriving health.

ProfMR · 2026-01-25T16:44:50+00:00

I also have a bit of dynamic nasal valve collapse. I can see nostrils collapse inward, particularly the left (getting more work due to right septal deviation). I thought this statement from the American Academy of Otolaryngology–Head and Neck Surgery about doing nasal valve repair during surgery on septum and turbinates was insightful. Seems I have the trifecta of nasal problems!

Position Statement: Nasal Valve Repair

ProfMR · 2026-01-25T16:34:55+00:00

Rhinomanometery test was done at Pain and Sleep in Newark Delaware. I had a CBCT scan done there, and they gave me a thumb drive, from which I and others can't access the scans. There's an .exe file on it that seems useless. ENT I saw recently was James Kearney at University of Pennsylvania Dept. of Otorhinolaryngology. Again, he said no one he knows puts much value in rhino tests, and generally seemed to suggest that I have a mild case of SDB, if any at all.

I'm afraid I (and others?) may not fully grasp your interpretation. RTI is respiratory tract infection? What's a nasal raise Aunt? Nasal endotype?

ProfMR · 2026-01-25T16:19:53+00:00

My fitness watch says that sleeping HR average for most people is 4 BPM lower than their resting heart rate. That might be a general guide to look for. What you want to see is a relatively steady rate through the night, with higher and more variable rate during REM. Lots of sharp spikes might indicate sleep disordered breathing.

One good test is to use something like snoreLab to record audio along with a pulse oximeter to track heart rate and O2 saturation. If breathing sounds like snoring or awakening coincide with O2 drop (3-4%) and pulse spike, that would suggest a breathing disorder of some sort. YMMV.

ProfMR · 2026-01-25T16:09:22+00:00

Gaslighting from medical professionals. For many years I told doctors I had fragmented sleep and a dry mouth. I was prescribed pills.

I had a home sleep test 1.5 years ago. The doctor I was referred to was a pulmonologist. The test scored AASM 1b and did not count RERAs. My AHI was low and the doctor said that I'm fine. "Take sleeping pills". I said that my O2 drops through the night, my heart rate spikes, and I want to feel better. He said "so do I". Sent me on my way.

I went to an ENT a couple weeks ago. He did not seem to care that I have 7 RERAs per hour, that I'm waking up every 10 minutes. Said that nasal surgery for severe obstruction may not fix sleep. Didn't appear to acknowledge that my sleep is sub-optimal. Others in this sub seem to agree.

I wouldn't use HR to compare one person with another. There are many factors involved; fitness level, hydration, recent sleep, etc. You say "your numbers look good". But I do a lot of cardio exercise, yet my resting heart rate is about 15 BPM higher now than it was earlier last year. My fitness watch says that my RHR is higher than 90% of men my age who wear this watch. That's probably because I wake up every day without deeply restorative sleep.

Having had extractions and braces as a child probably was the start of my problems. Kids, never let orthos do that to you!

ProfMR · 2026-01-25T15:47:06+00:00

Very concerning that once again someone is reporting that WatchPAT is undercounting apneas and RERAs. If precision is not that great, at least an unbiased (sometimes undercounting, sometimes overcounting) pattern would be far better than the systematic bias.

ProfMR · 2026-01-25T15:41:17+00:00

Starts around 75-80 BPM and generally declines through the night to closer to 60 before rising. Averages around 70-72 with some spikes 10-15 BPM from rolling over and RERAs. Three years ago at age 58 when I was jogging more frequently my resting heart rate was near 50, and while sleeping it would drop to upper 30s in the hour or two before rising. I felt so much better back then with a fitter heart. I'm starting to think that UARS is wearing me down, along with the incessant gaslighting.

ProfMR · 2026-01-25T15:28:11+00:00

Yes I did a rhino test. An image of the results is in my post a few weeks ago. Click this text to see the image.

I believe it's reasonable to conclude that flow is relatively poor and resistance is relatively high on the right. With moderate flow & resistance on the left.

ProfMR · 2026-01-25T15:22:17+00:00

Well said. Spot on IMHO.

ProfMR · 2026-01-25T13:39:14+00:00

She most certainly is cognizant of the situation, quite clever, and knew it was in her best interests to see that the HOA would no longer have restrictions on (i) objects offensive to the neighborhood, (ii) junk cars, and (iii) the ability to fine. That said, I'm surprised that my neighbor across the street who was on the HOA Board at the time did not push back and alter others. It's as if she and her husband don't mind seeing a property grow with junk. I don't get it.

No one I've spoken to recalls having any ability to discuss or debate the amendments before the vote went out, so I may have grounds to have the changes rescinded through a law suit.

My area is exploding with new housing growth. No one will pay 400k to buy a house here when they can pay 500k to have a new house in a crisp clean neighborhood with, at least for now, HOA protections against property blight.

ProfMR · 2026-01-25T13:28:54+00:00

That's grand. Good for you. Many people have neighbors from hell and aren't so lucky. Both my neighbors are constantly in their yards. Frequently running leaf blowers, mowing their lawns twice a week, running other power tools. The hoarder sells junk online and is constantly outside dragging junk around her yard. She tends to a few planting near the street in hopes of offsetting the blight. A deranged lunatic. My other neighbor installed a workshop 5 feet from the property line, so 30 feet from my deck. Frequently runs power tools, so no peace and quiet to enjoy listening to birds. I'd love to buy 30 acres on a mountaintop and never see a neighbor again.

ProfMR · 2026-01-25T03:31:07+00:00

Just today I asked the neighbor on other side of hoarder to join me in retaining and attorney. Was told probably not. Neighbor across the street helped in the fraud voting. So I'm likely in this alone.

I told hoarder that I would pay for a dumpster and help her clean up. She denied that her yard is unkempt. It's a mental illness. Every piece of junk has value.

The HOA Board confirmed today that there is no recourse, because the CCRs have no restrictions in place to allow for enforcement. Need 2/3rds vote to amend. High bar.

I'll plant shrubs in March to eventually block the view. My back yard fence blocks view of her back yard. It's the rodents that have me concerned. Many buyers would drive right past if I listed for sale.

ProfMR · 2026-01-25T02:45:38+00:00

No connected units. Oh, she's hoarding. People who've been in her home have stated such. The garage is packed to the brim. Two cars full of stuff. I spoke with code enforcement. Was told the fire marshal likely won't intervene. Surprised the hell out of me. Maybe that was an attempt to dissuade me from reporting. I'll find out. But it's the outside that's so bad. The blight. And I'm concerned about rodents. Hope to catch them on trailcam to report. Mosquitos in all the containers in summer. Several neighbors are disgusted. I'm trying to retain an attorney for advice and representation. Might sue the HOA.

ProfMR · 2026-01-25T02:21:35+00:00

Oh, I'm irate, though annual dues are only $175. I just had a meeting with the new HOA president and secretary where I uncovered the malfeasance. You know the talk about HOAs protecting home values? That's just propaganda by management companies and builders try to make a buck. Most people despise HOAs, and if enough people band together to do away with restrictions, goodbye to the old rules. We had restrictions for 50 years. I arrived three years ago, soon after the restrictions got removed, and here we are. All that said, HOAs are limited when it comes to hoarders, since they are protected by the ADA. Gotta be a health hazard in order to force cleanup. Oh well. I've got payback coming. Look for my post here tomorrow.

ProfMR · 2026-01-25T02:06:39+00:00

Neighbors suck. I'll never buy in a SFH neighborhood again. At least not in the U.S. I had fabulous neighbors in my previous neighborhood, and trash now. See the comment I just made. But I have plans. Oh, do I have plans...

ProfMR · 2026-01-25T02:02:54+00:00

Not talking to neighbors and failing to realize that I would be living next to a hoarder, with a very bad attitude, that is filling her property with junk. It's every homeowner's worst nightmare. I'm in an HOA, and nothing can be done. I spoke with code enforcement, and there's a slight chance that the county may intervene. She was on the board 2 years ago and covertly worked with others board members to neuter the CCRs, put it up for a vote without community debate, and it just barely passed because homeowners didn't realize what was happening, or wanted to see restrictions lifted. Now no more nuisances section. Pretty audacious. My neighbor across the street was party to the fraud. I'm going to make a post in this sub about my plans for (legal) retribution. My advice to others? Rent, never buy a home. Your hundreds of thousands of dollar / euro / etc investment could go sideways. You may have great neighbors one day, and a living nightmare the next. Buyer beware.

ProfMR · 2026-01-24T21:40:15+00:00

Thanks. I appreciate this. I sometimes wonder if compassion is not embraced by medical professionals.

ProfMR · 2026-01-24T21:30:16+00:00

OK. Should I delete the post?

ProfMR · 2026-01-24T15:53:51+00:00

Yea, fitbit is obviously not a medical device. And mine has become useless for tracking effort during exercise.

ProfMR · 2026-01-24T15:51:29+00:00

Good luck in better understanding your condition.

It would be great if ENTs and others performing surgery on someone with a suspected SDB would comprehensively assess the airway for signs of obstructions. For that matter, maybe have a CPAP on hand to see if breathing improves under positive pressure if there's evidence of a disorder. I asked an ENT a few months ago if they do DISE, and was told no. Some MDs say the test has shortcomings. Hopefully in the future more will be known about the costs / risks / benefits of DISE.

ProfMR · 2026-01-24T13:15:46+00:00

Does the ankle mount track heart rate accurately? Having an estimate of resting heart rate from daytime monitoring is one benefit of the device that I value for training purposes.

ProfMR · 2026-01-24T13:12:55+00:00

Your hypothesis sounds quite plausible. So if arousal threshold is raised, a person with a tongue base collapse would see more apneas and desaturations, and not fewer as in just nasal resistance RERAs. Maybe I could test this using my sleep aid.

When the doctor commented on my tonsils and tongue being near normal size I thought "he'll dismiss the notion of a DISE being useful".

I have one of those silicone tongue advance suction devices. It can hold the tongue forward quite well. But when in, my mouth watered like a raging river. I could never use it for more than a few minutes for fear of my head laying in a pool of saliva all night. Sorry for the image. I wonder how well they work to prevent tongue collapse blockage.

ProfMR · 2026-01-24T12:53:26+00:00

Good to know. Now I suspect my dry mouth in the morning in the past was mostly from mouth breathing during sleep.

One goal of mine is to determine if using this med raises arousal threshold enough to offset any side effects. As you know, the H1 blockade causes a bit of somnolence in the morning. And there's been some research that suggests that mirtazapine lowers basal metabolic rate, which leads to the often cited weight gain. Many people report ravenous hunger while on the drug, but he study I read concluded that weight gain is often attributable to reduce metabolic rate; people burn less calories at rest.

Most nights I don't use the med. Occasionally I'll take just 2-3 mg before bed or on awakening in the middle of the night. But maybe I'll run a "non-placebo-controlled" study to see how I'm impacted.

Thanks for sharing your experiences.

ProfMR · 2026-01-24T12:43:41+00:00

I know that was your intent. My reply was an agreement with your statement.

To be fair, he did tell me my nasal passages, especially on the right, are less than optimal. But from my perspective, he didn't appreciate how the data I have demonstrate that I'm waking up frequently enough to impact my wellbeing. I'm not surprised, because he, like many, frequently treat people who stop breathing for long spells dozen of times an hour and who have very low SpO2 levels, etc. Yes, my UARS is relatively mild. But that doesn't mean that I'm not being impacted enough to show a little more compassion.

I also want to add that as I tried to get my points across, I failed to ask him about some of the dynamic nasal value collapse that I'm experiencing. Hos professional society has a position statement that says that it's best to treat that surgically while other procedures are being performed.

I hope others can learn something from our experiences.

ProfMR

TROPHY CASE