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137: Are You Breathing Right?

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137: Are You Breathing Right?

Apr 11, 2023

Most men go their whole lives assuming they are breathing just fine. Some of those men may have a breathing dysfunction and do not know it. That was Mitch's case when a stray thought during a jog led to meeting with a specialist and learning he had a severely deviated septum after 30+ years of thinking he was breathing just fine. Dr. Sarah Akkina is back to discuss functional breathing, treatment options available, and some basic test you can do while you listen to check your breathing.

Episode Transcript

This content was originally created for audio. Some elements such as tone, sound effects, and music can be hard to translate to text. As such, the following is a summary of the episode and has been edited for clarity. For the full experience, we encourage you to subscribe and listen— it's more fun that way.

Mitch: Guys, have you ever thought if you're breathing right? Like, are you really even . . . Right?

Troy: Like, are you really breathing or breathing correctly?

Mitch: Breathing enough, breathing the same as other people. I don't know.

Scot: Troy already struggles to sleep. I hope he doesn't struggle with breathing.

Troy: I know. This is getting really basic. Now you're going to increase my anxiety about my breathing.

Mitch: Right?

Scot: Do you feel like you're breathing right, Troy?

Troy: Now that you ask, now I'm very focused on it and I feel like I'm not taking deep enough breaths. Yeah, now I'm thinking about it.

Scot: I feel that way too. I also kind of have a bit of a deviated septum and have allergies. Sometimes one of my nostrils closes up so I can't breathe through my nose super easy, so I'm breathing through my mouth, and I wonder if that's good or not. So, yeah, I don't know.

Dr. Akkina: Short story is it's not great, actually.

Scot: Oh, okay.

Mitch: All right. Well, this is "Who Cares About Men's Health," where we aim to give you a bit of information, inspiration, and maybe a different interpretation of your health. And today, we're going to be talking about functional breathing with a specialist you just heard. Are you breathing right? And if not, what can it lead to and what can we do about it? So, as always, bringing the BS, we have Scot Singpiel. Hello, Scot.

Scot: I am with Troy. Now I am anxious after hearing the breathing through my mouth . . . I'm a mouth breather, and that's not good, Troy.

Troy: Yeah.

Mitch: Oh, no. As well as Dr. Troy Madsen. He is our MD. Hey there, Troy.

Troy: Hey, Mitch. I'm here and I am breathing right now, but I don't know if it's correct.

Mitch: And I'm Mitch Sears, and I'm just a guy who's working on himself. I actually went through surgery and everything. I did not realize that I was having as much trouble breathing as I actually did until I was in my 30s. And now, it's not quite the outcome I was expecting, but it is surprising how much of a difference it is. So I thought we'd talk about it today.

And to kind of give us a little bit of light on what functional breathing is and what that means is Dr. Sarah Akkina. And she has quite the specialty and background, and I'm going to try to say some of these words, but she is from the Department of Otolaryngology. Is that just ENT?

Dr. Akkina: That is correct. Ear, nose, and throat, otolaryngology, head and neck surgery, all similar things.

Mitch: And you are also assistant professor and director of the Facial Plastic and Reconstructive Surgery at University of Utah Health, right?

Dr. Akkina: Correct. Yes. Yeah, the director in the Department of Otolaryngology,

Mitch: Dr. Akkina, talk me through this. What is functional breathing and does that mean that there's dysfunctional breathing? And how do we define that?

Dr. Akkina: So it's such a common story, exactly like you're saying, Mitch, where so many people who may have had issues with their nasal breathing since birth, that's just normal for them, that they can't breathe through the left or right side of their nose. And until someone comes along and points that out, you may not necessarily realize that you have an issue breathing through your nose.

There are also folks who of course . . . everyone having nice physical activities in which they probably eventually break their noses, those folks often do recognize where there was a pre and post really good function, and afterwards they realize, "Hey, I can't breathe through this side of my nose."

So the amount of air you're getting through your nose is pretty important. That helps us regulate a lot of functions in our body, of course. And the other important thing for nasal breathing overall is it helps filter air, right? So your nose is meant for you to breathe through. It has lots more filters than just if you're mouth breathing, for instance. So that's one function.

It also helps humidify air as you're breathing it in. And places like Utah, where we have a very dry climate, it's important to get all that humidity that you can.

But also at night, too, if you are mouth breathing at night, you have a higher likelihood of having things like sleep apnea because it's actually easier to obstruct.

Mitch: Whoa.

Dr. Akkina: Yeah. So having the base of your tongue collapse your airway or things in your pharynx collapse a little bit more, that's more common if you're only mouth breathing.

Mitch: So what are some of the things I guess that can interfere? You mentioned something about the tongue. We've talked about the actual structure of the nose. What are the main things you are checking for to see if the person is breathing right or not?

Dr. Akkina: Yeah. So when I see a patient, my number one question for them too is what they're experiencing, of course. Whether they, again, have had some trauma history, have had surgery in the past, or things like that, I want to know.

And then certainly, the next step is what does their nose look like? So really common areas to have obstruction are the septum like, Mitch, I heard you experienced. So your septum, that's the middle part of your nose that divides the left and right side. For a lot of folks, that can be crooked.

Now, having a crooked septum doesn't necessarily mean you have trouble breathing on the side that it's pushed to, because an interesting adaptive part of our body, again, probably to improve the humidification and filtering of air as we breathe it in, is your turbinate on the other side ends up getting big.

So turbinate, big long word, again, that's actually bone in your nose. You have three sets of them on either side, and they look like little . . . basically kind of seashells. So another word that we call them is actually conchae for the bones in them.

Mitch: Oh, okay.

Dr. Akkina: But yeah, those turbinates can actually variably swell, and they do often swell, for instance, in response to allergies. Was it Scot or Troy, did you mention you had some nasal allergies?

Scot: Yeah, that's me.

Dr. Akkina: Yeah. So, Scot, your turbinates are probably swelling in reaction to these allergens that you're breathing in your nose. So, for you, it might be more a turbinate issue where the turbinate is just getting in the way of that airflow into your nose, and happily we have both medical and surgical treatments that we can use to address that.

So those are a couple examples. One of the other big examples is the outer part of your nose can collapse. So that's called lateral wall insufficiency in my world. And that's something that we can help with things like Breathe Right strips. Have you guys ever seen the strips you can put on your nose to kind of help stabilize the side wall? Or nose cones you can literally put in your nose to help stabilize from the inside. So those things all support a floppy nasal wall, but we can also do surgeries to help that too.

Mitch: Is that a technical term? Floppy?

Dr. Akkina: Yes, highly technical.

Mitch: Wow. Okay. I'm sure a lot of maybe listeners and at least the people in the room right now are thinking, "How would I know?" I'm going to share my experience in a minute, but I've been breathing my whole life. How on earth am I going to know that maybe I'm not breathing quite right?

Dr. Akkina: Funny story, I was in a yoga class recently and my yoga teacher had us doing these breath exercises where you literally close one side of your nose with your finger and try to only breathe out of the other side, and then vice versa. And after class I was like, "Oh, you must make sure that you're breathing through both sides to be able to do this." And she's like, "Oh, yeah, my husband actually tried to do this, couldn't do it, and realized his septum was totally pushed to one side." So he's going to come see me now.

Mitch: Wow.

Troy: Wow.

Dr. Akkina: So that's an easy test initially, is to literally use your finger, pinch off one side of your nostril, and see if you can breathe through both sides of your nose independently.

Troy: And I'm guessing we all just did that.

Mitch: Absolutely.

Troy: I just did. It seems to work.

Scot: Both nostrils good for you or was one a little . . .

Troy: No. They seem to work okay.

Dr. Akkina: Good.

Troy: But I'm hearing very clearly that breathing through your mouth is not ideal and you probably should be breathing through your nose.

Dr. Akkina: Yeah. There are a lot of other things that I kind of haven't gotten into that are a little bit more technical, but there's a really great book actually called "Breathe" that goes through some of the interesting concepts of nose breathing versus mouth breathing.

And not only does it affect things like sleep apnea, but it can even affect the air that gets into your sinuses, for instance. So sinuses, those exist behind our cheeks, behind our forehead, between our eyes, and those can get blocked, obstructed, things like that. Especially for Scot, if you have allergies, unfortunately.

So nasal breathing kind of helps to improve the aeration of those areas too. So lots of stuff going on with just breathing through your nose. That's why, as humans, we're meant to breathe through our noses and it's an issue if you can't do it.

Scot: So hearing that also, if I'm practicing more breathing through my nose, does that just make it easier then to breathe through my nose?

Dr. Akkina: Yeah. And you'll notice if you try to do more breath exercises where you're just really trying to close your mouth and breathe through your nose more, oxygen exchange, CO2 exchange, things like that can actually be shown to improve over time.

Scot: Wow.

Troy: I will say, too, sitting here, it's not a big deal to just breathe through my nose. That's not a problem. But I do notice if I'm exercising, I'm running . . .

Scot: Bragger.

Troy: I'm doing all right, yeah. But if I'm exercising, I just can't get enough air. Is that a problem or is that pretty typical?

Dr. Akkina: Yeah, I would say that can indicate that you might have some of that nasal wall collapse. So a lot of folks with nasal wall collapse, they do okay when they're just breathing normally, like sitting recording a podcast like this. But yeah, when they're exercising, trying to sleep, things like that, when you're horizontal and things in your nose can swell a little bit more, that's when you have problems. And that can suggest that you have some anatomic causes for that that we could look into and try to improve.

Mitch: So say you're listening right now, you've done the little nose trick, you're driving, you're whatever, and you're like, "Oh, no, I should probably go get this looked at." Who are they going to? Do we start with a PCP? Do we go straight to someone from an ENT or something?

Dr. Akkina: Yeah, I think your end goal is to probably end up in an ENT/otolaryngologist's office. You can ask your primary care provider to take a quick look, and a lot of patients that I see do come through their primary care providers who said, "Oh, this patient definitely has big turbinates," or has a deviated septum, things like that.

But going to a nose specialist is I think really helpful. There's a lot of knowledge that we have about other parts of the nose and making sure we're optimizing function as a whole. We've talked about Scot's allergies a decent amount. That's another thing that we can help treat or point patients to treatments for. So, yeah, I think it's a great idea to see your ENT.

And then the other aspect that we haven't touched on yet is when we're considering these things that affect your nose, of course there are appearance changes that can happen. So if the very front of your septum is deviated or pushed over, we may have to do an open surgery where we're basically opening your whole nose up to be able to fix those areas. And you want to make sure that you're going to someone who can put everything back together in a nice way.

Mitch: Is that why my ENT kept asking if I needed a plastics consult?

Dr. Akkina: Yes, that is.

Mitch: I started to take it personally where I'm like, "You guys, you said you're going deeper. You said it wouldn't change anything on the outside." "Well, sure, just in case." And it's like, "Ugh."

Dr. Akkina: Yes. And that's a big divider, and it's important to know. Yeah, we've established, A, maybe you have problems breathing through your nose. B, are those functional problems also concurrent with appearance problems? And one of the most common reasons that I see, especially men in my practice, is because they've had nose fractures before. They're at the bars or they're MMA fighters or they're just running with their dog and tripped on the sidewalk and broke their nose. So there's a factor of trying to fix that broken nose in addition to fixing their breathing. And I think going to a surgeon that can help you with both is ideal.

Troy: So what you're saying is if you have a deviated septum, you can get your insurance to cover not only the correction of that, but also a nice nose job.

Dr. Akkina: Not exactly. And I do want to be clear on that.

Troy: Okay.

Dr. Akkina: So fixing nasal fractures, yes, insurance indications for that. So if you've definitely broken your nose a few times and you're looking for those bones to be reset in a better place, then yes. And if trauma has also accordioned your septum so that you can't breathe anymore, things like that, yes, we can absolutely work with insurance and often use that to get that covered.

But for those cosmetic aspects, you do want someone who, one, is really experienced in putting cosmetic noses together. And two, because of that, that's not covered by insurance, right? So any changes in the true appearance as opposed to just resetting bones from a fracture or fixing the septum from a fracture, that's cosmetic work.

And it's important to think about that for your own wellbeing and own thoughts and decide if that's something that you want to change at the same time. Because it is very easy and common for us to do both functional and cosmetic surgery at the same time.

Troy: Yeah. So you're doing it all in the same operation, just one gets billed to insurance, the other you're paying out of pocket for it.

Dr. Akkina: Exactly.

Troy: Okay. Well, let's say someone like myself, I've admitted many times on here that I'm a horrible patient and I don't like to go to doctors. And like we've talked about, I have no problem just breathing through my nose right now, but if I'm exercising, I find I just can't get enough air. Are there things I can try to do before I go and see a doctor for that?

Dr. Akkina: Yes. So some of the really common things I'll recommend patients try . . . And on the insurance side too, we actually always generally have to show that patients have tried conservative measures before we're doing surgery.

So one of the big things is using nose sprays. So things like salt water spray, Ocean spray, saline spray, all the same thing. You can get them at your local pharmacy, drug store, grocery store, everywhere. And just using a few squirts of that maybe before and after exercise to help flush the stuff in your nose out that might be causing congestion or obstruction, always super helpful.

Next level up is using something called intranasal steroids. Fluticasone would be one example. And that gives an actual steroid spray to parts in the nose that could be getting inflamed, whether that's from vasomotor rhinitis type things or allergies. Again, that kind of helps calm things down.

Vasomotor rhinitis actually is a special case where if you notice that your nose is running a lot in the cold, like in Utah winter, or when you're specifically exercising or even things like eating spicy food, that can be helped with another type of spray.

Scot: Is fluticasone the same as the brand Flonase? Is it that in the generic?

Dr. Akkina: It is. Yeah, exactly.

Scot: All right. I do take that for allergies.

Dr. Akkina: Nice.

Scot: That would also help the swelling of my thingymabobbers if they were swollen?

Dr. Akkina: Your turbinates? Yes, it would. And one other comment I'll say to that, Scot, is when you're spraying these sprays in your nose, one trick is that you don't actually want to spray straight up, right? Everyone thinks their nose is just this front little part that you can kind of touch and see, but your nose actually goes back, right? So it goes towards your ear.

So I always counsel my patients when you're using sprays, put that little spray nozzle in your nose and point it towards the same side ear. And that's how you're actually going to get it onto the turbinates and acting where it needs to act.

Scot: Oh, great. Thank you.

Dr. Akkina: Yeah.

Troy: And the Breathe Right strips, do you think those make a difference?

Dr. Akkina: I do. The tough part with them is, obviously, every time you're exercising, you don't necessarily want to stick a sticker on your nose. So that's a little bit of the limiting factor with those.

But I have a lot of patients who don't necessarily want to move to surgery try the Breathe Right strips, and honestly at least use them at night or if they are going to anticipate heavy running, things like that, and they do really well with them.

And that's one of my indicators to say actually that if the side of your wall is stabilized by that sticker, you would do well with surgery. So I think it's always great to try if you're thinking about it and notice that you have an issue with that.

Mitch: So there are all these options that we try first, right? With my own road to a surgery, they had me do these nose sprays. I have apparently been using nose sprays wrong my whole life. I learned that too, point towards your ear. But what if it's still not working? What if you're still not quite breathing right? Is the next option surgical? We actually have to fix the structures?

Dr. Akkina: Yeah, after those medical and kind of device applications, if you're still having issues . . . And quite frankly, especially for a deviated septum where there's a very fixed blockage, you may not have a lot of improvement with some of those other measures. So surgery is often the next option we turn to. And I'd love to hear, Mitch, what experience you had with it.

Mitch: Oh, it's juicy.

Dr. Akkina: Yes. The tough part of surgery, it's of course under general anesthesia, so you have to work with your doctor to make sure you're a good candidate for that. But overall, for a standard septoplasty and turbinate reduction, it's maybe a one- to two-hour surgery that can be pretty quick, and you have to let that swelling and everything recover for a few weeks. But afterwards, after that few weeks' downtime, most patients have really significant improvement.

So, yes, general surgery, anesthesia, all that, but after a few weeks of downtime, you can notice a big difference in your nasal breathing, which you do all day every day, right? So most patients feel like it's a good return on investment, we'll say.

Mitch: And that was kind of my experience. Just to kind of talk about what I went through, it was actually during the "Who Cares" mid-May 5K, which is coming up. I was starting to run again. I was starting to get more active and it just seemed like even the littlest bit of activity, I was breathing through my mouth. It wasn't much, and all of a sudden I had to switch to my mouth.

And it got even worse. I started to notice when my allergies were flaring up . . . I've always had some of the worst allergies. If I walked into someone's house and they had a cat anywhere in the house, I would stop breathing, my eyes would swell, etc. And seasonal allergies too, they'd get really, really bad every year and it seemed like I had to be on all these meds and everything to keep it so I can even breathe right.

And so I'm like, "Man, maybe I should go get this looked at." I met with an ENT, and they numbed my nose. They shot a whole bunch of lidocaine up there and then they got this scopey thing and she went to put it up my nose, and she couldn't get it in. She's like, "Well, you've got a really deviated septum." And that's something I had never even thought about, because usually when you hear deviated septum, people can see it.

Scot: Think Owen Wilson.

Mitch: Oh, sure.

Scot: Looks like he has one, but I don't know.

Dr. Akkina: Yes. Multiple fractures he also looks like he's had.

Mitch: So the septum is the little in-between bone all the way up, right? It's not just at the front of your nose.

Dr. Akkina: Yeah. So another fun thing you can do as you're listening is literally stick your fingers into your nose and you can feel your septum. The very front part of your septum is what we call the membranous septum, but just behind that is where the cartilage starts. So your septum is made of both cartilage in the front usually about two to three centimeters, and then bone behind that. So you can have crookedness of any of that part all the way to the back of the nose.

And so the front part that you feel . . . and you can only feel, imagine, a centimeter. And remember, your septum is actually going about three to four centimeters behind that at least. So you can only feel and see a very small part of your septum.

Mitch: Wow.

Dr. Akkina: And that's why a lot of folks do use cameras or endoscopes, as you experienced, Mitch, to see further back.

Another important thing I just want to add is if you feel like you have one-sided nasal obstruction, there are other obviously rare causes of that, such as tumors, inflammatory diseases, things like that. So that's something that we can get a better idea of using a camera.

Not to, of course, scare anyone. It's much more rare for you to have trouble breathing through one side of your nose because you have a tumor. But that's another reason why it's really great to see a specialist who can evaluate all those things for you.

Scot: And I suppose if you have a tumor, it would probably manifest itself, like I've been normal breathing my whole life and now all of a sudden I feel an obstruction and I didn't get hit or anything.

Dr. Akkina: Yeah. Exactly.

Mitch: They then switched to, I guess, the pediatric endoscope to get back into the back and found out . . .

Scot: They needed something a little smaller for you, Mitch?

Dr. Akkina: The kiddie scope, we say, yes.

Mitch: They got the kiddie scope so they could get up there. And that's just it. I've had friends and everyone who have deviated septums, and you can see them. I didn't even imagine. So they were able to weasel in back there and they said that my turbinates were extraordinarily inflamed. And so they put me on meds for a while. It didn't really help. And they suggested I get a septoplasty.

What exactly did they do to me, I guess? I fell asleep, right? General anesthesia. I woke up, my nose was super swollen, there was stuff shoved all the way up there. They were delightful. But are they breaking things? What is going on in there?

Dr. Akkina: I think of septoplasty in two levels. So, first level, it sounds like what you experienced, is where we're making cuts inside the nose. All cuts are inside and we're basically lifting the skin up on either side of that cartilage and the bone that makes up the septum, and then we're literally cutting out the crooked parts.

Mitch: Oh, okay.

Dr. Akkina: Yeah. We do have to be careful to keep a small part of the front part of the septum and the top part of the septum to stabilize your nose because that's the part of the septum that actually gives your nose its support.

So just like a building, there are a couple beams there. As long as you have this wide of a beam at the top and along the front, then it's stable and okay. So we're very careful to do that.

And then the rest of it, actually the entire rest of your septum, we can take out.

Now we do have to be careful at the top of your septum because that connects to your brain, basically.

Mitch: Oh, yeah. Sure.

Dr. Akkina: The base of where your brain sits. So I always talk to patients that there's a very rare risk when you're getting a septoplasty that you could cause some sort of break in that top part of your septum that connects to where your brain is sitting and cause a leak of brain fluid. Yes, it sounds scary. We can fix it if it happens. It's extremely rare. But again, that's why you want to go to someone who knows what they're doing, is familiar with the nose, and can make sure they have nice techniques to prevent that.

Mitch: And what's the second type?

Dr. Akkina: Second type is what I'd call an open septoplasty. So that's the one where if the very front of your septum, so that part that you can feel with your fingers, if that's crooked, that gets to what I was saying about the structure of the nose. To replace that part, we actually have to make a cut usually on the bottom part of your nose, or your columella, and then rest of the cuts still inside the nose. We basically lift up all the skin and then approach that very front part of your septum, and we can do things to that front part to make it straighter. Sometimes I have to cut just that entire front part out and essentially remake it with the other cartilage from the back part of the nose.

Mitch: Oh, wow.

Dr. Akkina: Yeah. And that's how we can re-support and restructure to improve breathing in that area.

But as you can tell, that's a much more extensive procedure. So you're talking more like average three hours for most folks, and we're lifting all that skin up, taking cartilage apart, got to put it back together again at the end. And there can be changes with that and changes in the way it looks after.

Troy: What's the recovery like with that?

Dr. Akkina: So recovery from the first type, just going inside the nose, is pretty quick. So we do often use splints called Doyle splints. So there are these silicone splints that sit in the nose.

Mitch: They are the worst.

Dr. Akkina: They're not fun. It's true.

Mitch: No, it's fine. It's good.

Dr. Akkina: Yeah, they serve a pretty essential purpose for us because it helps . . . I talked about that skin that we have to dissect off of that cartilage and bone. Those splints help that skin sit back together so that it heals nicely.

One of the other risks of doing a septoplasty is if you have breaks in the skin on either side, when you heal, you can actually get a septal perforation, or a hole in your nose. Not fun if it happens. Sometimes you'll hear whistling when you breathe in and out. Not a fun party trick for the person who it's happening to.

Mitch: It's all day, every day.

Dr. Akkina: Yeah, all day, every day. So that cannot be fun.

You also might have paradoxically more nasal obstruction because the air is not moving smoothly through your nose. It's becoming turbulent because it's going around this hole. So not the best problem. And one way that we can just make sure that everything heals nicely is using those Doyle splints to help make sure that that skin is nicely healed together.

So those most folks will leave for anywhere from 3 to 10 days. I would say average is more a week. That's what we do for most folks. And then we get those splints out and usually people are feeling pretty great after that.

Swelling in the head and neck does take time to go down. So I always tell my patients ultimately a full six months is what I'd anticipate to just kind of slowly get better over time.

For the open septoplasty, because there's swelling and dissection in so much more of the nose, that ultimately can take 6 to 12 months for all that swelling to get better. But people are usually feeling much better in that kind of two-week period. After we take the splints out from a week and then some of that acute swelling goes down, you notice a difference. It's pretty impressive for a lot of patients.

Mitch: I made the person film as they pulled these gigantic things out of my nose.

Dr. Akkina: Yeah. There are popular TikTok channels about . . .

Scot: What?

Dr. Akkina: . . . splints coming out of the nose.

Mitch: There are scabs and everything. You don't even realize. The whole thing comes out. I'll show the video later, but you can see . . .

Scot: No, that's fine.

Troy: It's all right, Mitch.

Mitch: But you can see on my face the second those things came out, it was like someone was shooting air from an air cannon or something up to my nose. I could breathe better than I think I ever was able to before. It's crazy. And I know that I was swollen and whatever and I hadn't breathed for 10 days, but it was significantly different.

And it's been kind of interesting thinking back on this. I got it, what? A year and a half, two years ago? And the thing that I've noticed the most is when I run, it takes a little bit more effort until I have to switch to mouth breathing, which is nice. It's not a huge difference, but it is the allergies. It's like I suddenly have a higher tolerance or capacity. I can breathe. I'll still have a reaction. When the trees are blooming and things, I still get a sniffle. But I'm no longer in that place where I'm getting sinus headaches and infections. I can manage it with some of the medications that I had already been taking. And so that was a big success for me, I think.

I thought I was going to suddenly become an athlete breather, but at the end of the day, now I don't have to worry about allergies as much and it's a big life improvement.

Scot: Dr. Akkina, is that because of the surgery or is Mitch just imagining that?

Dr. Akkina: No, I think that can be a great effect from this surgery. One other caveat I'll add is sometimes when people can breathe better through their nose, they're getting more allergens in their nose. So then they have to be sometimes a little more regular of just making sure they're using some of those things like saline sprays or irrigation plus their Flonase.

But the other great thing is that when your nose is more open because there's not this big septum obstructing it, then you can actually get those medicines back into your nose where they need to go.

So I still think it's . . . most of my patients say overall, even if they've had allergies that they're dealing with, they're really happy that they did the surgery because they can get medications around their nose more. And exactly like Mitch said, they're just breathing better and it just feels good.

Mitch: Yeah. I was basically told that my turbulence . . . turbinants? What are they called?

Dr. Akkina: Turbinates.

Mitch: Turbinates were particularly giant after a lifetime of being inflamed. And so I know they cut a whole bunch back out there. It was explained to me that I have more room just overall, right?

Dr. Akkina: Yes, exactly. And the turbinate surgery, that's something that we often pair with fixing the septum, like you said, because usually if the septum is crooked to one side, then the other side's turbinate actually is filling that space. So doing both together is the optimal way to open that nose up and get that air getting through.

Scot: So I've had a deviated septum, at least I think I do, for as long as I can remember. I don't even know how it happened, right? But I know that one side of my nose, when I do the plug the one nostril test, is more difficult.

Dr. Akkina: Yeah.

Scot: I'm kind of curious, that I would like to have it looked at. Do I just go in and then you just go, "Well, it's not too bad. Probably we're not going to do anything," and then that's that and we never see each other again? Or am I heading towards surgery if I go in, I guess?

Dr. Akkina: I would say it just totally depends on the evaluation. And please do come see me, Scot. We can look at your nose together and see what's going on. And I can even show you on the camera and everything, all those little nooks and crannies inside your face and we'll see what's going on.

If medication is a good option for you, we'll talk through that. Depending on what I see on your septum or your turbinates, we can just talk through different options of what surgery may look like if the medicine and other conservative measures are not helping. We can just go through it all together.

Scot: The thing that Mitch said that really kind of made me think about it is just the allergies thing. Allergies isn't quite as bad. I don't know that I'm exercising hard enough to justify.

Mitch: I don't think I was.

Scot: I'm not sure I'm a well-oiled machine.

Dr. Akkina: I think the allergies is a big part, and a lot of my patients have concurrent allergies with something obvious obstruction-wise in their nose.

Now, I do always have to say, as a surgeon, I cannot cut out allergies. Allergies are just how your body is responding to the environment and we do have wonderful allergists who specialize in figuring out a great way to manage your allergies.

But when you have allergies plus these obvious blocked points in your nose, those are the things that I can address definitely with surgery. But for the allergies, we may always have to have you using steroids in your nose, rinses in your nose, things like that. But at least we can do things to get those medications better delivered inside.

Scot: And I'm not exactly sure how to ask this, but is it just self-reported, "I feel an improvement. This is better," or do you have some sort of a device that is actually telling if I'm breathing better through my nose?

Dr. Akkina: Yeah, it is primarily self-reported. So we have a lot of really great validated patient surveys, basically, to self-report symptoms. And then that in combination with my exam is how I counsel patients on what to do.

Historically, we have had things measure basically airflow in your nose, but they're a little bit tricky to use. There's not great inter- and intra-rater variability reduction. So, yeah, typically right now we're using patient-reported outcomes and our exam.

Scot: So if we did some steroids or we did some sprays, then I would go, "Yeah, I'm feeling pretty good," and that's how we would decide.

Dr. Akkina: Yeah. Exactly.

Scot: Except for there's a survey that's been validated that . . .

Dr. Akkina: Yes. It's a fun name. It's called the SCHNOS. That's the one that I use.

Scot: Come on.

Mitch: Of course.

Troy: Is that an acronym or something, the SCHNOS?

Dr. Akkina: It is, yes. I'm glad you guys like that one.

Troy: I do like it.

Dr. Akkina: The SCHNOS is great because it's the standardized assessment both of the function and cosmesis. So that's what we use.

Scot: How is that spelled?

Troy: Yeah, I was trying to figure out how does that acronym work?

Dr. Akkina: It's SCHNOS.

Scot: Okay. I always thought there was a Z in schnoz, but I guess . . .

Dr. Akkina: Not this SCHNOS. It's a special SCHNOS.

Troy: Well, I was going to say I have never focused so much on my breathing. This entire podcast breathing through my nose, and I've gotten through it breathing through my nose the whole time, so maybe that's a good sign. I don't know.

Dr. Akkina: Great sign.

Mitch: Well, guys, I hear that we're very self-conscious about our breathing and I'm sure everyone listening is as well, but what did we learn today?

Scot: "Mouth breathing, bad" is I guess what I learned. And I should really have this thing looked at. I've threatened to do it for a long time and I've had other people in my life that have had it done and they talk about how great it is. I guess I'm falling to the man trap of, "Well, it's probably not that bad. It's not bad enough to really go in and do something." But maybe I'll take a step and I'll let somebody like Dr. Akkina figure that out for me who knows a lot more than I do.

Mitch: Cool.

Dr. Akkina: Yes, please come to see me. It's an important point. I mean, these are often quality of life issues, but we want to improve your quality of life. I think it makes sense to get it looked at and just see what we can do.

Mitch: And how about you, Troy?

Troy: My takeaway is it sounds like if I just practice breathing through my nose, things will probably go even better there. I recognize that it sounds like things aren't ideal, just the issues I have when I'm exercising, so I'm going to try and breathe through my nose more when I exercise and see how it goes.

Scot: How about those cones? You thinking those cones might be a good thing for you to try?

Troy: Stick cones in my nose when I'm running?

Scot: Or a nose strip?

Mitch: Get it really wide.

Troy: Yeah, maybe so.

Scot: All right. Mitch, how about you? Takeaway?

Mitch: This was something I had never even thought about. It was just a stray thought I had while I was jogging and listening to a murder podcast. It was just like, "Am I breathing weird?" And it led down this whole avenue of seeing whether or not it really was something that could improve my life.

And so thank you guys so much for playing along and listening to this story. And thank you so much, Dr. Akkina, for joining us to kind of let us know a bit about breathing and what we can do to improve it.

Dr. Akkina: You are so welcome. Thank you guys for having me. And Scot and Troy, I expect to see you in my office soon.

Mitch: Both of them?

Troy: I didn't realize I was on the hook here.

Mitch: You bring the phone and you record it.

Troy: Oh, I'm the one recording?

Mitch: Yeah.

Troy: Yeah, that's what I'm going to do.

Mitch: Emotional support.

Troy: I'm going to record this. That's right.

Mitch: So if you are listening and you have been doing the nose strips or have ever considered that maybe breathing is something that you might want to get looked at, you can contact us at Again, that's Thank you for listening, and thank you for caring about men's health.

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