267: Dr. Keith Matheny, ENT Surgeon & Airway Expert Discusses How a 20-Minute Procedure for Nasal Airway Obstruction Improved My Breathing and Sleeping

 Welcome to the Sleep Is a Skill podcast. My name is Mollie Eastman. I am the founder of Sleep Is a Skill, a company that optimizes sleep through technology, accountability, and behavioral change. As an ex-sleep sufferer turned sleep course creator, I am on a mission to transform the way the world thinks about sleep.

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Each week, I'll be interviewing world-class experts ranging from researchers, doctors, innovators, and thought leaders to give actionable tips and strategies that you can implement to become a more skillful sleeper. Ultimately, I believe that living a circadian-aligned lifestyle is going to be one of the biggest trends in wellness, and I'm committed to keeping you up to date on all the things that you can do today to transform your circadian health and, by extension, allowing you to sleep and live better than ever before

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Welcome to the Sleep Is a Skill podcast. Today's episode is all about something that can completely change the way you sleep, recover, breathe, and feel throughout the day and night. So if you struggle with congestion, mouth breathing, snoring, poor sleep quality, sleep apnea, or feeling like you are just not getting enough air, this conversation may uncover a major missing piece.

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So joining us is Dr. Keith Matheny, ENT surgeon and airway expert for a fascinating deep dive into nasal airway obstruction and innovative, minimally invasive treatments like that from Aaron Medical, including VivAer and RinAir, designed to help people breathe better and sleep better without the downtime of invasive surgery.

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Now, for me, after personally experiencing VivAer myself, I noticed meaningful improvements in my breathing and sleep metrics. So I am incredibly excited to share this conversation with you. And in this episode, we discuss the hidden connection between breathing and sleep quality, why many people unknowingly struggle with airway issues, how mouth taping can backfire if your nose is not optimized, and why improving airflow can support better recovery, HRV and cognitive health, and overall performance.

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Now, Dr. Keith also explains who may be a good candidate for these treatments, what people can realistically expect from the experience, and why so many symptoms people normalize could actually be improved with the right support. Now, a little about Aaron Medical. Aaron Medical is a privately held, venture backed company headquartered in Mountain View, California.

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Aaron's mission is to help the millions of people living with chronic ENT conditions breathe better, sleep better, and get back to feeling like themselves. The company's two in-office treatments, VivAer for nasal airway obstruction and RinAir for chronic rhinitis, use Aaron's proprietary temperature-controlled technology to deliver lasting symptom relief without the downtime of invasive surgery.

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Now, more than two hundred thousand patients have been treated with Aaron Medical's products to date. So if this episode resonates with you, please be sure to subscribe, leave a review, and share it with someone who struggles with poor sleep, chronic congestion, or mouth breathing, because this information can truly be life-changing.

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And if you want to learn more about VivAer, RinAir, or find a provider near you, check out the links in the show notes. So we're gonna jump right into this episode without further ado And welcome to the Sleep is a Skill podcast. This is a bit almost of a part two with one of my favorite guests. So, Dr.

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Keith, is that okay to call you Dr. Keith? Yes, but you said I was your favorite guest. That's what you told me. I know. We gotta backtrack on that, man. I know. It's just, you are one of my favorite guests. It's just, I can't even... Even before we hit record, I was just laughing to myself about how multi-passionate and creative and just your interest and knowledge in so many spaces.

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So I feel very honored to get to talk about this really life-changing topic for me. I've, and I've wanted an opportunity to talk about this exact topic because many times I had a real get mini viral for my account. You know, I don't have a big account, but a, a mini viral, and it was literally with the hook, how I fixed my deviated septum in 20 minutes.

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And people are like, "What? Tell me more." And so this whole topic of Vivair and how we can maybe improve our breathing and how that can support our sleep, we're gonna get all into it. But before we do, maybe just a little bit about how you came to be such a respected expert in this area. Thank you. I, I, I don't know if I am, but thank you.

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And I'm so glad to be back talking about these topics again for part two. Yes. And yeah, I'm glad we finally hit record, 'cause we've already been talking for about 30 minutes probably. Exactly. Um, but that's, that's a good thing. So yeah, I am still in practice. Uh, my partners sometimes question that 'cause I have a lot of other things that I'm juggling in my, my business life.

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But I'm an ear, nose, and throat physician surgeon in North Dallas. And over the 25 years that I've been in my practice, I've been with the same practice, same wonderful group for that whole time, my career has evolved into one where I'm really focused on the nasal airway. Mm-hmm. And we talked about it three years ago when we recorded and how important the nasal airway is in sleep, and we'll probably touch on a lot of that today.

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Uh, but the, the more I practice, the more I find, uh, the patients that I see and, and are helping have issues with nasal airway obstruction. So we'll talk a lot about that. Um, from all angles, you know, from daytime breathing, from exercise and performance, and certainly in sleep quality. So it's something that I'm very passionate about and happy to talk about.

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Ah, well, I am excited because so many people are struggling with different forms of breathing through the night, and they might come to... At least w- in the conversations I have with people, they might say things like, "Oh, I've got, you know, this really high respiratory rate on my Oura or Whoop." Maybe they already have been diagnosed with sleep apnea, and they're looking to kind of support, but they're just still not feeling like things are being, uh, fully addressed or their current treatment plan isn't- Common.

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Common, yeah. Right? All these things. And I know you, you can just speak to this to ad nauseam. And so we just see all these problems which can point to many aspects of how we can support people's sleep. But certainly I've found that it feels like a lot of people aren't aware of some of these procedures that maybe could almost act like a Venn diagram as compared to more kind of invasive surgeries or treatments that just would really be beneficial for people to know about, and maybe quite a few candidates for it, it sounds like, right?

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Before we get into all that- Yeah ... maybe you could help define a little bit about this topic of kind of nasal airway obstruction, what this looks like, and maybe a little bit of the landscape of what people might do to support problems there. I think most of our audience is familiar with the, the term deviated septum, the septum being the dividing wall between the two nostrils, and it's almost the rule, not the exception, to have a bend off of the midline.

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That structure actually goes all the way back to about the depth of your throat. So the septum- Mm-hmm ... is a pretty big structure, uh, as is the nose in general. It's not just what's sticking out on your face. It's, it goes way into the, the middle of your head. So people are familiar with that. Maybe they have experienced and recognized the congestion you get with allergies or a cold or sinus infection, and that's usually turbinate swelling.

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But a lot of times, even as physicians, we forget the third leg of that tripod. I like to think of nasal airway obstruction as a, a tripod with three equal legs, and the third one is the nasal valve. So when we're talking about the nasal valve, and you may see references to the internal nasal valve, the external nasal valve, this, that, and the other, really all we're talking about is the strength of the nostril.

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Mm. And so perhaps, um, people have seen those that wear Breathe Right strips during athletic events or maybe people sleep with those. That's one of the many treatments we have. Those are springs that hold the nostrils open to help support the nostrils. So as we get older, things get floppier on our bodies.

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Our, our nostrils are not immune to that, uh, the cartilage part in particular. And so certainly with deep inspiration, breathing in really hard- Mm-hmm. The nostrils can collapse. So in that case, that would be more of an external nasal valve collapse when the, the nostril completely collapses. But further in, you can have blockage too that's dynamic, meaning when you're just sitting here at rest and breathing normally, there isn't really much of a blockage.

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But when you're really exerting yourself or you're in deep sleep and breathing deeply, then it can be a blockage. And so We even as ear, nose, and throat physicians often have underestimated how many people have nasal valve issues, nasal valve weakness. We often will do surgery to fix the septum, to fix the turbinates, to shrink them down.

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And sometimes not only does that not help the nasal valve at all, but it can even unmask and make the nasal valve collapse worse because we're moving more air inside the nostril, and it's pulling back on that soft tissue. I think maybe that's, that's what you were experiencing a little bit. Yes, exactly.

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Just for a little bit of context to share my own personal story. Leading up to this, first of all, I didn't even know that I had this, as they're kind of referring to as this slight deviated septum. And from this optimization perspective, then yes, I did some of the different strips and the... I was using the intake breathing with the magnets and, you know, just these different steps to try to support a more optimal breathing.

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Yeah, just hold it open, right? Just hold it open one way or another. Yeah. Exactly. Yeah. Exactly. What am I gonna do to hold it open? And so it took those, you know, the extra kind of added forethought every single night. And after a while you're like, "Is there a more kind of permanent way to make a difference here?"

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And- Right ... right, more meaningful of a difference. So then, yes, I got this Vivaer treatment, and then I did get to experience my respiratory rate going down since I've, you know, been tracking for so many years. So that was really neat to get to see a kind of cause and effect on the difference. And it was a real notable, especially when it first happened, to have life how it was to breathe and then this aftereffect.

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Right. Which you thought was normal, right? Yeah. Yes, exact- Like you don't know any different, so you just think that that's life. Right. And so that was fantastic. And one of the things that I like about this too, because sometimes we hear stories of people getting more in-depth surgeries and maybe new things are coming up, or new challenges, or maybe they overdid it on the surgery side of things or...

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So sometimes people are hesitant to take that leap to surgery. And so for me, it was just such a great option in literally 20 minutes, I recorded the whole thing, to have this whole process done and have such a lasting kind of shift. And for as far as a procedure is, you know, even the cost was more, I think, attainable f- than for a lot of people.

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Granted, it's not always exactly covered under insurance. We can talk about all the details, but- Yeah, it was still a heck of a lot cheaper than rhinoplasty, right? Exactly. 100%. So, yeah. 100%. Yeah. And so I really do think that this is kind of this exciting thing for people to know more about. So maybe how you think of it, how often are you seeing kind of candidates for this?

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The whole scope of it. Yeah. Right. Well, again, um, hopefully I'm, I'm painting an honest picture, which- Yeah ... isn't always the most, um, you know, rose-colored glasses for us. Sure. I think as a specialty We largely didn't look for nasal valve collapse until ten or fifteen years ago. And some people may take exception to that, and maybe in their practices they, they did.

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But even our electronic medical records, which most of us have been using since two thousand and ten, they didn't even have a line in the nasal exam template- Mm ... to evaluate the function of the valve. And so as technologies like Vivaer became more widely available, let's say in the mid-teens, two thousand and fifteen, two thousand and sixteen, my dates may be a little bit off- Sure

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and we actually started looking, we realized that what had been the, the board exam answer of how many people have nasal valve collapse, and it was estimated somewhere between like twelve to sixteen percent. But that's not what we were finding. Mm. Once we started looking in every patient, we realized it was much higher.

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And by looking, what we s- we did is called the modified Cottle maneuver. So Dr. Cottle, uh, esteemed facial plastic surgeon, described this. There were many instruments that we used are named after him. And what it is, is you simply put a, a rigid instrument, like something that we would clean earwax with, for example- Uh-huh

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inside the nostril. I'm not gonna pick my nose on video here. Yes. But inside the nostril, and then just have the patient breathe in through their nose at first, just normally, maybe a little bit harder, and see if just supporting it, not torquing, not pulling the skin out and the cartilage out, just supporting it so it can't collapse, and see if that improves their perception of nasal airflow.

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If it does, that's a positive modified Cottle maneuver. And we realized that patient after patient after patient was saying yes. Even if they did have a deviated septum, even if they had large turbinates and allergies or nasal polyps- Sh ... we realized that this is still a significant contributor to what brought them into our office, nasal airway obstruction.

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So once we started to identify that and then treat it, we realized, wow, this is, this is more than just icing on the cake. And in some cases, you would be a perfect example, not having to have the septum straightened, but having enough strengthening of your nostrils has improved your airway to the point that you don't really feel like you need anything else.

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And I know you've seen that during exercise. Mm-hmm. I know you've seen that benefit during your sleep, monitoring your sleep quality. And that's true across the board. So in summary, we, I think, by and large, we're neglectful in fully examining for this as physicians because we didn't have much to offer patients twenty or thirty years ago besides a pretty invasive rhinoplasty where we would Transfer cartilage, and it's still done, and there are- Sure

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patients that need that today. Yes. A lot of patients still need something like that today. Uh-huh. So we'll use cartilage from the ear or cartilage that we can harvest from the septum. Uh, it's become real popular to use a cadaver donor rib cartilage. Wow. Uh, and use that. It's nice. You can carve it into perfect shapes and sizes that you need.

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But that's all we had until, you know, like I said, 15 years ago. And so once we had less invasive but still very effective options like VivAer It was kind of a, well, why not try this first? Why not be less invasive, see if we can help the patient, and go from there? And so obviously it's been very effective.

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I, I don't know the tally of how many of these procedures have been done, but it's well into the six figures. Yes. Uh, and those patients by and large are really feeling better. Oh, that's amazing. Yes. Based on what I heard from Vivero, it looks like over 130,000 patients have been treated, so like you... just like you said.

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And yeah, maybe painting a little bit of a picture of what could people expect if they were to-- They're saying, "Okay, let me just even visualize, what could this look like for me?" If they're starting to say, "Check, check, these things could fit." Yeah. And, uh, I know the people always accuse doctors of lying, but this is really not, not a big deal.

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This procedure- Yeah ... is not, and I know you can attest to that too, Mollie. Yes. Exactly. So it's often an office procedure, so we're not, um, taking most of these patients to the OR. In fact, when I do this procedure in the OR, it's only because I have to be in the OR for other reasons. When doing other nasal or sinus surgery or something, I can therefore do this in the OR.

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Um- If we're doing this as a standalone procedure, it's, it's universally done in the office under local anesthesia. Yeah. With that anesthesia, at least in my practice, what that looks like is a lot of topical, so gels- Mm-hmm ... in the nostrils, further back, even under the lip to try to give some kind of regional numbness like you might have- Yeah.

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Mm ... uh, going at, going for dental work. And then the instrument, this VivAer works using radio frequency, so it generates heat, and that heat injures the cartilage. You think, "Why in the world am I having a procedure that's causing injury?" We use that word intentionally. We're injuring the cartilage on purpose.

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We want it to scar. Uh-huh. So cartilage and all soft tissue is stiffer when it's scarred. Mm. So that's what we're trying to create by treating three or four spots underneath, inside the nostril with that heat. It's about sixty degrees Celsius, so it's pretty hot. The gel and anesthesia is typically not enough, so once the patient is pretty numb from the gel, then I will follow that with some injections.

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And those hurt, kind of like if you are getting a filling or something, it hurts for... Uh, my dentist always says, "This is gonna pinch." I think that's the wrong word. It, it just flat out hurts. But- Yes ... it hurts, um, just for a second. Mm-hmm. And then the nostrils are pretty numb, and you don't feel that heating.

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Yes. So when we do the procedure, and you experience this Uh, uh, the way I describe it to patients, I, I think most people would agree, it's almost like ironing a stubborn wrinkle out of a shirt. So we're using that heat. When I'm, when I'm doing this, I mean, sometimes the, the patient's head is turning in the chair because I'm putting that much force- Mm-hmm

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to the side towards the corner of the eye, straight up, to get that heat and to really remold, to mo- remodel and mold that cartilage into a different shape. Now, it doesn't change the appearance. I've known you for a long time. Your nose looks the same, right? Yes, exactly. So it doesn't change the appearance, but it sure changes the functionality.

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And- Definitely ... so that's what we're trying to accomplish, and it's extremely effective. What's very gratifying, while the full effect may take two to three months, six months to, to settle in, patients can typically notice right away some improvement- Yes ... just from the initial heating Uh, so it's very gratifying for us as, as providers to be able to see that immediate improvement As the patient, it was quite gratifying too.

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It was like okay, we're getting some sort of measurable, felt experience and felt change very quickly. So to that point, I'm wondering if there's a typical kind of patient or someone as it relates to sleep apnea using a CPAP, kind of a bit of what person- Huge. Yeah, yeah. Yeah. Huge. So you know, you and I talked a long time from the last one.

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We- It was a long recording. We had so much to cover about how lousy we're doing as a society in treating sleep apnea, and a big portion of that is how poorly tolerated CPAP is. So CPAP, for those who are not familiar with the acronym, is the, the breathing machine, the Darth Vader mask that- Yes ... people wear to continuously or well, to blow air in when you're inhaling is the easiest way to say it, to prevent the airway from collapsing.

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So it's extremely effective. It's still considered the gold standard of sleep apnea treatment if it's not sitting in your closet. Mm-hmm. That's if you're wearing it and using it appropriately. So many times, and I'm not just throwing the, the pulmonologist and the neurologist under the bus, as otolaryngologists, as ear, nose, and throat surgeons, we often- Right

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ignore the nasal airway, prescribe a CPAP for a patient, and then when they don't tolerate it, we're already moving on to other alternative treatments instead of trying to help the, the nasal delivery of air actually work. So, so many times we, we don't appreciate nasal valve collapse. We don't appreciate the deviated septum or inflammatory nasal polyps that if that was addressed, the CPAP mask would be a heck of a lot more comfortable.

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So that's, again, uh, as I like to say, the nose is central- Mm ... figuratively, but literally- Yeah ... involved in sleep apnea and sleep-disordered breathing. So we all, all specialties, we must look at the nose, make sure it's optimized Before any treatment, but certainly CPAP where the air pressure is primarily delivered nasally.

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Yeah, absolutely. Would you say this also would apply for kinda just the average individual that's looking to optimize their, how they're feeling, how they're sleeping? I don't know if you've seen this, but I often am hearing of people slapping on mouth tape and then, but still having trouble breathing, which I'd imagine would be some concerns.

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That's my thing with the mouth tape, right? You know, you and I and our, our merry band of sleep advocates . Yes. Uh, you know, in general I get the idea of mouth tape, but ag- as I said a moment ago, more than 50% of people have a deviated septum, and then other people are also entitled to have big turbinates and nasal polyps and things So before you're taping your mouth shut, let's get a look at whether your nose is open, right?

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That's all-- That's my only comment. People message me all the time, "Is mouth tape safe?" Well, it's like, well, what does your nose look like? Yeah. So yeah. I, I think so many, so much of your audience are maybe not sleep apnea patients, but- Mm-hmm ... biohackers and really elite athletes and people- Mm-hmm ... looking for maximal performance, even mental performance- Yes

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in optimizing their sleep. Absolutely, uh, it's worth evaluating the nasal airway and making sure it's optimized, and it starts right here with the nostrils. Yes. I mean, so many people are looking to improve heart rate, HRV, and all these metrics, and you can imagine, I mean, since they're so linked up with how we're breathing, that to overlook something like this- Yeah, it's all interrelated, right?

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Yeah. Right. Exactly. Circling back a little bit, so anything for us to be aware of with as it relates to RinAir that we need to know about? Yeah. I'm glad you brought that up. So RinAir is another procedure. It's very similar to this VivAir. The, the instruments that we use are slightly different. Mm. But where they share a lot of similarities is they use radio frequency to treat parts of the nose.

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So I, I neglected to mention, we, with the, the VivAir device, we don't only treat the nostril, we're also able to use that heat to shrink the turbinates inside, and another structure called the septal swell body. Hmm. This is a structure that's obviously existed for millions of years, but we've only been talking about it for, I would say, ten years or so, but it's turbinate-type tissue, so spongy tissue at the top of the septum, and it gets engorged and swollen just like the turbinates do and blocks the airway.

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So with either hand piece, the VivAir or the RinAir, we'll talk about the indications for RinAir in just one second, that can be used to shrink those down. So we're treating multiple parts of the nasal airway, improving it. And if you think back to high school physics, which is a long time ago for me- Yeah, same.

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Every, every millimeter of improvement in the cross-sectional diameter of the airway, the patient feels that improvement in airflow to the fourth power. Those, uh- Wow ... laws of aerodynamics is why, that's why an airplane flies. It's what gives a wing lift, and we're, we're using the same principles inside the nose.

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So even if I just get you one millimeter, two millimeters, you're gonna feel substantial improvement, and these devices do much more than that So the Rhinov. Rhinov is primarily indicated for the millions, tens of millions of patients that have chronic postnasal drip. Mm-hmm. It can be runny nose out the front, but by and large, it's patients that maybe even subconsciously are constantly drowning in mucus.

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Mm. And they may present to our offices in a lot of ways. Sometimes they may come in complaining of the postnasal drip, but a lot of times this would be a chronic cough patient that hasn't responded to all kinds of medic- medicines and Inhalers and asthma treatments and things like that. It could be someone that comes into our office for hoarseness.

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The mucus is very salty, very irritating to the vocal cords. Hmm. And just like a stretched out guitar string, if your vocal cords are swollen, they're not gonna resonate and produce the same tone as a normal vocal cord would. So any or all of those patients that suffer from this excessive postnasal drip, and it might be allergic phenomenon.

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Many times it's non-allergic, especially as we get older. So, you know, in your 40s, 50s, 60s and up, this becomes more and more of an issue. Some patients notice increased drainage and runny nose when they're eating. There's something about the stimulation to make saliva. Sometimes there could be some cross-wiring, and it makes our noses run.

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Hmm. So any or all of those people who have that often also have nasal airway obstruction. And so we're able to use the Rhinitear handpiece deeper in the nose to use that heat to interrupt some of the nerve stimulation to make all that snot- Oh ... but also to shrink down the turbinates and the septal swell bodies too.

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So both of these are very elegant, minimally invasive. I mean, these are held on the surface of a tissue. They're not, uh, even piercing the tissue, so very minimally invasive. But I know that procedure also has hundreds of thousands of patients treated- Sure ... by now with really effective, uh, results. I mean, in general, we talk about 85% improvement in drying up the nose.

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We don't want it to be 100% dry, right? We need some mucus. Yes. Yeah. So 85% or so is that sweet spot for these patients. So glad you kind of walked us through that 'cause it just, it feels for me like so many of the people just on the ground that I'm speaking to, again, just don't know that all of these things are available, like you said, that can get so targeted and not have to look like how we might have used to think that these procedures might look or the old- Yeah.

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A postnasal drip patient in yesteryear, 30 years ago, they may have gotten a very invasive sinus surgery- Yes ... that didn't even help the problem, right? And it's what the surgeons had at the time, and they were trying- Right ... to help the patients. But now we have these technologies, and I, I agree that there still is a lot of work to raise awareness, uh, of these treatments and for patients to consider having them done There is, you know, there is some concerns about, uh, access, right?

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And I- Mm-hmm. You know, we talked about the exorbitant costs a lot of times of rhinoplasty when we're talking about a nasal valve, uh, obstruction, nasal valve collapse patient. Um, these are much less expensive than that, and there is good coverage with Medicare, for example. Uh, some commercial payers will pay for these procedures, but the company that makes these, Aaron Medical, they're working hard day and night to try to improve access.

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Mm-hmm. But even, even on a cash pay basis, uh, these procedures, considering the upside, are, are Worth it, in my opinion, and many patients agree and will pay cash for them. Absolutely. Yeah. I mean, I was surprised and impressed with how, to your point, as compared to when you think of a proper surgery, I mean, when we look at the pricing, and like you said, it sounds like it depends on state by state and particular physicians, but- It's a nut.

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Yeah, it's a nut ... Yeah. But, um- We're burning hairs. Exactly. Exactly. But often it's gonna be a bit more attainable than some of these other procedures, is what I've at least uncovered. And, you know, just further paint the picture for people, I just can't say enough that the experience is so... I don't wanna throw around, like, a lunchtime procedure or something, but really it's something where you can, within a very short period of time, with not the longest period...

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I mean, you are gonna be feeling some of that, and it's gonna take a little bit of time to recover. But, I mean, I was going back to yoga and all these things in a relatively short period of time. Probably in a week, or maybe- Yeah ... even a little bit less, you know. You're- Exactly. I tell patients to expect about 72 hours where they're gonna be really stuffy.

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Yeah. But again, that's how these patients have lived for 20 or 30 years, so it's- Yes ... I mean, it's not a radical change. No. I just ma- mainly manage their expectations that they're not gonna walk back to their car- Exactly ... feeling fixed. It's gonna take... But they'll see improvement in a couple weeks at least.

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Yes. And then, you know, certainly in two to three months it's dramatically better. Exactly. And the effect tends to last, it may not last forever. Mm-hmm. What our studies, you know, we, we started a lot of these trials 10 to 12 years ago, um, but a lot of these results have held up at least five, seven, 10 years.

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Uh-huh. But what happens, uh, with, you know, gravity works, so, uh, over time and as we're washing our noses and just living life- Sure ... things can relax again, but then the procedure can be repeated. So- Yeah ... it's not like you're burning any bridges, even though we're, we're burning parts of the nose. No pun intended.

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We're heating parts of the nose. Yeah. No pun intended. Yeah. You can do it again if it's indicated again. Sure. Yeah, absolutely. Okay. So did we leave out, before we shift over to a bit about how you're managing your own sleep and how people can, you know, locate physicians if they wanna- You're always checking up on me.

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You're always checking. I always check. I know. This is the real intention with this podcast. What's the latest? Yeah. Which, what can you teach us? Yeah. So before we do, did we leave anything major out? Are there surprising candidates for this that we didn't include? Anything, anything that we missed? Yeah. I think, you know, it's always good just to recognize that one size does not fit all.

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I mean- Mm-hmm. Yeah ... this really is a, a procedure that's effective in the right patient, but it all is predicated on the physical exam and identifying Which of those three legs of the tripod the patient has, many times they have all three, and what might be the best option to improve the nasal airway or the chronic rhinitis, the chronic drainage.

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So of course, it's predicated on that. There are other technologies to consider. There... You mentioned some of the things that are over the counter. I often will have my patients try those first- Mm. -before we even consider a procedure. Sure. And yeah, like you, they finally get tired of putting something on their nose every night.

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Yes. Or they react to the adhesive in the tape or whatever. But at least that's further evidence that this procedure's going to help Um, but many people that have to p- move forward with more, um, definitive treatment. We talked a little bit about the functional rhinoplasty with donor rib cartilage. I mean, there are patients where if their nostril is just laying down on their septum and where there's not much cartilage left from prior rhinoplasty, there's a lot of scenarios where this procedure won't do much.

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Yeah. And so obviously, a full thorough physical examination by your provider and, and discussion about pros and cons is indicated. But by and large, I think patients can consider this as a minimally invasive option amongst many options they could consider. And because it is minimally invasive, give it a try and see, see how much it helps.

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I love that. So I think that would, that would be the leaving, the leaving gift, kind of what I'd want to leave behind. Yeah. It's not for everybody, but it's for a lot of people. Exactly. And just to kind of underscore what you said about the Cottle maneuver, do you think it's still something that people as they're, like, listening, do you believe in the using the fingers to kind of see- Yeah.

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That's how it's just- Can they just do that? Yeah, that's fine. Yeah. Okay. So many times, I might have said this last time, but patients will describe how they've learned to sleep with their fingers there. Oh. And they'll get a couple hours of sleep just holding their nostril open. Ugh. You, you don't have to live like that.

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We have a lot of- Yes ... a lot of treatments for this. Yes. And it is an absolute life changer. Obviously, you and I are passionate about sleep quality. That's not okay. We have something that is this simple- Yes ... uh, that's effective within weeks to months, that you do not have to live like that and sleep like that.

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Yes. I'm so glad you said that. And if anyone's kind of wants to see on the Vivaer website, they have kind of a visual of how to do that, just, you know, taking your two fingers, pressing against kind of the side of your nose. Do you feel relief when doing that? And then that could be indicative of maybe speaking to someone like yourself, uh, to see if they could be a good candidate.

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Sure. Great. Okay. Well, so yay, you're back. It's been three years. So we do ask everyone four questions on how they're managing your sleep, but also through the lens of your expertise. If there's anything extra that we should know about from your expertise, ear, nose and throat, et cetera, let us know, or outside of the bounds of that.

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So the first question is, what does your nightly sleep routine look like right now? Yeah, I mean, it-- you always make me feel guilty, but I- ... I really have gotten better than four or five years ago, um- Okay ... you know, from, from both a, a sleep hygiene, you know, the, the buzzword that we all use- Totally ... but even, even from an acid reflux standpoint, so.

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Mm-hmm. You know, it all really starts when you're Well, starting, you know, my goal is still six to seven quality hours of sleep. Not just being in bed, but- Sure ... actually being asleep and cycling through all the stages of sleep for health. Well, that starts well before putting your head on the pillow, right?

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It starts with when you're turning your brain off- Mm ... when you're turning off the blue light that's hitting- Mm-hmm ... your retina, when you're turning off all kinds of stimulation and getting your body ready to sleep. So things that I've done even since the last time you asked me that question. I know you're famous for your orange glasses.

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So I have, I've become obsessed with blue light blockers. You know, even on airplanes. Come on. I, I don't do it, like, if I'm giving a nighttime presentation, I still wear my normal glasses. Sure. But- Yes ... I know you're not afraid of it We've not lost our minds. You, you go to parties with your orange glasses, but I'm not quite there.

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Yeah. I live in Austin, you know? It's quite accepted. That's true. That's true. Uh. You gotta keep Austin weird, right? Yeah, exactly. So you're doing, you're doing your part. Uh-huh. Um, but other than that, like, I mean, really, after dusk, I always try to see sunrise, get that on those pink rays on my retinas. Okay.

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Sunset, too. Mm-hmm. You know, you and I live in Texas, so we see a lot of sunny days. But as soon as the sun's below the horizon, then I'm putting on my blue light blockers- Mm ... my orange glasses. And so it starts there. And it really, you know, I will watch some TV. I like to read on an iPad as opposed to books typically.

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Mm-hmm. Sure. So there is some blue light, but at least it's- Mm ... you know, not right in my face. Yep. And I am using my blue light blockers. I've become more obsessed about, um, you know, not having my phone. I mean, I- I'm on call sometimes. Sure. Unfortunately, I'm too old to take call. Hopefully my junior partners are listening to that.

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But, um, keeping the phone far away- Oh ... and certainly where it's on theater mode. Yes. Do not disturb, whatever. Mm-hmm. I don't even use... Like, I turn the light off on my alarm clock. Great. Uh, I got this from our friend Theresa Power. Yeah. I, I can't see a clock from where I'm sleeping. So even... I still wake up in the middle of the night 'cause, you know, I have to pee or whatever, but I really try not to even be aware of the time- Mm.

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Yes ... 'cause that contributes to my anxiety. Sure. Like, "Oh, I gotta get back to sleep 'cause I gotta get up in an hour." Of course. Um, so I've become more and more obsessed about that. Certainly we didn't... I didn't finish my thought about food and alcohol, but really trying to wrap that up- Mm ... a couple hours, at least an hour before I'm gonna lay down, both from a sleep hygiene standpoint and from an acid reflux standpoint.

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Um, so it's all important. All these little changes make a big difference. Absolutely. I don't take a lot of supplements myself, but- Mm-hmm ... uh, you know, I, I know those can be helpful, um, to many, many people, too. But I just try to... My actions, that's, that's really what I try to do before bed. Yeah, I mean, it's the good news, bad news insight, is that most of this is largely free and behavioral, and yet sometimes- Yeah

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for a lot of people, it's like, "Well, just give me the pill. Give me the gadget." And the truth is it's what you said. It's setting ourselves up for success all throughout the course of the day, so. Well, the pills may put you to sleep, but they don't put you into good, restorative sleep, right? That's right. So- Oh, yeah

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you, you still gotta do this stuff anyway. Yes. There's no cutting past it, for sure. There's no shortcuts, yeah. Exactly. No free lunch. And then the second question is what might we see in your morning sleep routine with the idea that how we start our day can impact our sleep? Sounds like you already pointed to a bit of the, the light piece for sure.

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Yeah. But anything else we missed? Yeah. I naturally wake up, um, pretty early, and, uh, where we are in central time zone, I would say sunrise, the sun starts peeking out in the 6:00 hour, maybe closer to 7:00. Mm-hmm. Um, but I always try to be outside if I can Even if it's cloudy, like right now it's pouring outside.

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But even on a cloudy day outside, the amount of lumens that are hitting your retina compared to being inside, uh, I mean, it's a thousands of time order of magnitude more. And that's really important 'cause that's when the blue light is good. That's when it's telling your body, "Okay, it's okay to wake up," and it suppresses the melatonin, the, the sleep protein.

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And so I really try to do that. A lot of times I'm on an airplane or going to the hospital or whatever, so even looking out the window is better than nothing. But nothing beats being outside without glasses and letting the light at an angle. Mm-hmm. I know you love the pink light, and that- Yes ... that's the best 'cause the angled- Yeah

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light is literally getting straight into your retina. Exactly. And that restores your rhythm. That tells your circadian rhythm that it's okay to be awake. It's time to be awake. Mm. Yes. Yeah, that's, that's the biggest thing related to sleep I do in the morning, yeah. Um- Perfect. Perfect. It sounds like a pretty consistent- That's why I, that's why I like to exercise.

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Yeah, that's why I like to meditate. All that kind of stuff- Yeah ... that's good for health, but- Great ... specific to sleep, it's, it's letting light hit my retinas. So- Real light. Real light ... I mean, yeah, it's such a big deal, and I know, like you said, we're both in here in Texas, so I can feel the difference as compared, I grew up in Maine, and there was not the amount of ample light that we have here.

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Uh- Right ... lived in New York for years, and the difference, I mean, definitely we've got some powerful sun for a lot of the year. So it does allow for that. Yeah. And then the third question would be visually in your space, what might we see in your nightstand or in your environment? Yeah, so simplified. I mean, I usually will have...

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I have a phone charger, but it's several feet away from me. Uh, again, who knows what the, uh, uh, EMF or whatever- Yes ... you know, the concern about. Yeah. But it, it's absolutely not illuminated, nor is my alarm clock. Um, you know, I have- Great ... it set in where it's the face that would show the time or whatever is totally dark.

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Um- Perfect ... I have a, a lamp with, uh, you know, now you, you have to use LED bulbs. Yes. Uh, which that's a whole nother podcast about how they're- Uh-huh ... eliminated- Totally ... healthy incandescent bulbs. I know. But, um, so I have a lamp with a, you know, a warm tone and low lumen intensity, um, LED bulb. Couple books, whatever books I'm reading in my iPad usually.

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That's it. The simplicity. Yeah, that's often what we see is the... 'Cause sometimes we'll still have some people that come on, maybe they're not fully, they're sleep adjacent, and they're like, "Listen, I'm still struggling with my sleep." And oftentimes some of the people that are still struggling, it's like they have 27 things on their nightstand or all these different accoutrement.

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So many people fall asleep with their AirPods in listening to a podcast. Like- Yeah ... hopefully in the future people aren't listening to this trying to get to sleep. I know. You need to turn your brain off. The irony of it all. Right? Yes. Um- Exactly. So yeah. Yeah. Simplify. And get- Simplify. Yeah. Well- No light for sure, and, and probably minimal electricity, right?

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Exactly. Exactly. Well, to that note with the simplify, what have you, so far to date, what would you say has made the biggest change to how you kind of think about your sleep or interact with your sleep? Or said another way, maybe biggest aha moment in your relationship to your sleep? Yeah. You know, I used to wear it as a badge of courage, like I think many surgeons do.

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Sure. That, oh, I, I don't need to sleep. I'm a vampire. We're vampires, you know. I have- Yeah ... I'll sleep when I'm dead. I have too much to do. And it's been a total paradigm shift is- Right ... uh, I have too much to do not to sleep. You know? I'm not gonna go to- Mic drop. Right? I'm gonna- Yes ... I'm not gonna go to one more bar.

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I'm not gonna, you know, watch one more TV show or have that one more glass of wine or whatever because I mean, sleep is, is the superpower, right? Mm. It-- for whatever I have to do the next day, the patients that I'm gonna work on, the companies I'm gonna run, the decisions that I'm gonna make that, I mean, even just driving- Yes

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you know, tomorrow deserves me going to sleep now. And, uh, so that's been the, the biggest simplification, but paradigm shift for me is, you know, you do need sleep. So I've really committed to the six to seven. I don't always exactly get that asleep- Sure ... but I'm, I'm certainly in bed that long, so I could.

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Mm-hmm. Mm-hmm. And, uh, another little thing is You know, I, I usually wake up before my alarm, but sometimes I'll sit there and just try to doze off and get just a few more minutes of REM sleep. You know- Mm-hmm ... that's often when we're, we're getting our REM sleep, and that's some of the most restorative sleep we can have.

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And when we think about dementia- Mm-hmm ... you know, as an ear, nose, and throat surgeon, dementia's kind of our disease because- Mm-hmm ... the number one risk factor for dementia is unaided hearing loss. It's not- Mm ... smoking. It's not hypertension. It's not diabetes. It's not using- I didn't realize that ... a hearing aid when you need it, number one.

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Mm. Number two is untreated sleep apnea- Yes ... because of the, because of the hypoxia. That rings true, for sure. Yeah. So, so dementia is absolutely an ear, nose, and throat disease. Wow. And I have a strong family history of, of dementia. And so, you know, even an extra 10 or 15 minutes of REM... You know, we, we talk- Mm-hmm

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so much about how sleep is when you clean your central nervous system. You clean your brain. All those neurofibrillary tangles that we see when we autopsy brains that, that had Alzheimer's and other degenerative disorders, that's when that stuff is flushed out. So again, it is foolish to think that you don't need sleep or you can get away with four hours or you're Superman or whatever.

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That, that's, that's exactly the opposite of true. Yes. We need sleep, especially to be healthy into our older years. Absolutely. I'm glad you pointed to from that kinda cognitive decline, and it's only was around 2012 the discovery of glymphatic drainage with a G. You know, this- Mm-hmm ... cleansing of the brain while we're sleeping.

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So it's kinda relatively- Right ... new-ish territory to get that there is such a link-up from our sleep and such an opportunity to have this preventative thing that, that we're participating in every single night. Yeah. Right? Yeah. So I, I appreciate that you're pointing to that. So important. For sure. Yeah.

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Okay. And so then if people are listening and they are saying, "I did not even maybe know that this was a thing," when we talk about the air, Rhineair, all the airs. How can they investigate, take the next step? 'Cause that's our big thing, too, is how can we make this practical. It's all well and good to learn these things, but how do we actually get people in action?

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So what are some of the ways that they might be able to find someone like yourself? There's many ways. So the, the company again is Aerin Medical. A-E-R-I-N, so it's two words. So aerinmedical.com I believe is the website. And so many of the studies that my practice has participated in, many, many great practices around the world have, are listed there, but there are a lot of animations.

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There's nothing gross. There's not gross surgery videos or anything. Yes. It's very easy to consume for a non-medical person, but very informative. And one of the functions there we love as physicians, the... You can type in your zip code, and the, the patient can be routed to physicians in their area that offer this service.

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Most of us do. It's... Providers really believe in it. So that website- Mm-hmm ... is trying to connect the patient to the providers. Uh, they do a good job on the various social media platforms as well, same company. So LinkedIn, Instagram, those types of things, you may find some. Um, and then of course, people are welcome to reach out to me.

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I'm- Yes ... I'm mostly active on LinkedIn, like, from a business perspective. Yeah. I, I have an Instagram, but it's for, uh, barbecue seasoning that I'm marketing, so. Because part of your polymath ways. So, but you're welcome to f- You're welcome to take a look at that too. Um, that's The Grill Doctor, right? But, um, so I'd be happy to direct you to, um, my friends and colleagues in your area too or talk more about it.

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That is amazing. Uh, this is technology that I really believe in. When I need it, I'm gonna have my, one of my partners do it to me. Um, so absolutely- That's great ... um, want people to consider it. Ugh. Well, I mean, I am very grateful that this technology exists and that we've got thoughtful and really clearly physicians that care, that want to make a difference, want to get those clear results, and people like yourself that are prioritizing their own sleep.

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I definitely would want my surgeon to be just like you and prioritizing all these things. Yeah. You want them to have a good night's rest before they're cutting you up, right? Please, please. Please. For, for all involved. Right. Let's prioritize that sleep. But yeah, thanks so much for the work you do. Thanks for letting us know more about this.

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I will include all of the kind of next step details in the show notes so people can find that physician locator, can learn more about working with you if they want to. Also hear more about, we went more in depth on our part one episode of some of the things that you are very masterful in, and we went more into all kinds of topics, including sleep apnea and beyond.

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So lots of steps that people can take. That was a good one too. I listened to it recently. Yeah. And it, it still holds up even though we did that three years ago. It's hard to believe. Right? I know. Um, but still, yeah. Look at us now. That's a good one too. Exactly. Well, thank you so much for taking the time.

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Yeah. Thank you for having me again. Yes, I appreciate it. Awesome. And just keep doing the work that you're doing. It makes such a difference. Love you too. You've been listening to the Sleep Is a Skill podcast, the top podcast for people who wanna take their sleep skills to the next level. Every Monday, I send out the Sleep Obsessions newsletter, which aims to be one of the most obsessive newsletters on the planet.

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Fun fact, I've never missed a Monday for over five years and counting, and it contains everything that you need to know in the fascinating world of sleep. Head on over to sleepisaskill.com/newsletter to sign up

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