Transcript episode #39:What do Ear, Nose, and Throat Diseases Have To Do With Pregnancy?
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00:00 Today I have an otolaryngologist, head and neck surgeon on the podcast and yes, this actually does relate to pregnancy.
00:15 Welcome to the All About Pregnancy & Birth podcast. I'm your host, Dr. Nicole Calloway Rankins, a board certified ob gyn physician, certified integrative health coach and creator of The Birth Preparation Course, an online childbirth education class that will leave you feeling knowledgeable, prepared, confident, and empowered going into your birth. Quick note, this podcast is for educational purposes only and it's not a substitute for medical advice. See the full disclaimer at www.ncrcoaching.com/disclaimer.
00:47 Hello and welcome to another episode of the podcast, episode number 39. I am so glad you're here today. Now today's a little bit of a different episode. My guest today is Dr. Brad Block. Brad is an otolaryngologist, head and neck surgeon. They are also known as ENT doctors or ear nose and throat doctors and he practices in Long Island, New York and I found Brad when I put out a call in a Facebook group I belong to for physicians about anyone who maybe wanted to come on my podcast and talk about issues that they see that affect pregnancy. And I was kinda surprised when Brad responded because I don't normally think of ENT and pregnancy as kind of going together, but he shares a ton of great information on today's episode including things like how to deal with nosebleeds. They are actually very common in pregnancy. He talks about how to deal with rhinitis of pregnancy, which is just kind of the stuffiness allery sort of things that can happen in pregnancy as well as some ENT issues that are related to babies. So I know I learned a lot with this episode and you are going to learn a lot too.
02:03 Now before we get into the episode, let me give a quick listener shout out. This is to pumpkin mama 31, I love that name, and she left me this review on Apple podcast and it's titled so helpful and it says, "Dr. Calloway Rankins is full of unbiased information. I've found so many of her episodes helpful during this pregnancy. She also offers free downloadable resources on her website. Side note, I listened to this podcast in the car and her intro song always makes me smile in dance the little." I love, love, love that. Love the hop popping in the car to the intro music to the podcast, and you appreciate it. The information that I put out to thank you for that lovely review pumpkin, mama 31. Now, speaking of free resources, I would love to have you join me in my free live online class on how to make a birth plan that works. I take the confusion out of making a birth plan, give you a super clear process, how to make a birth plan that works to help you have the birth that you want. I do the class about three or four times a month. Women love it. Go to www.ncrcoaching.com/register to sign up for the next class and grab your seat. That link will of course will be in the show notes.
03:19 And if you want to go even deeper with me helping you get ready for your birth, then check out my online childbirth education class, The Birth Preparation Course. This class gives you everything you need to be knowledgeable, prepared, confident and empowered to have the birth you want. Very comprehensive covers mindset, details of labor, how to push a baby out, C-sections if it comes to that information to help you get started in the postpartum period and off to a great start as a mom. So definitely check it out. You can go to www.ncrcoaching.com/enroll. That link will also be in the show notes and the free birth class is a great way to get a flavor for The Birth Preparation Course. So again, the free class is www.ncrcoaching.com/register but if you're wanting to hop on into the class, The Birth Preparation Course is www.ncrcoaching.com/enroll.
04:10 Nicole: Okay, so without further ado, let's get into the episode with Dr. Brad Block. All right. Hey Brad, thank you so much for agreeing to be on the podcast. I really appreciate you coming on.
04:24 Brad: My pleasure, Nicole.
04:25 Nicole: Yes. So why don't you start off by telling us a little bit about yourself, your work, and your family.
04:31 Brad: I grew up on Long Island. I went to undergrad at University of Pennsylvania and then med school at SUNY Buffalo and then finally did my residency at Georgetown in otolaryngology, which is ear, nose, and throat. It actually should be technically otorhinolaryngology cause oto is ear, rhino is nose and larynx is throat. But we sometimes just go by ENT. So I did my training in ENT and then ended up back on long Island. I never thought I'd end up there, you know, not far from where I grew up, but here I am.
05:02 Nicole: That's funny how that works. I'm the same way. I'm like that close to home.
05:06 Brad: Yeah. You know, they say you end up living within 50 miles of your mother-in-law. But my mother-in-law lives in Zurich, Switzerland. So I would be having a hard time. My Swiss German is terrible. Our three year old's Swiss German is now much better than mine, so I wouldn't be able to practice medicine there. So I guess I should get into that part of my life as well. So after I'd finished my training, I moved to Manhattan because you can't really live in the suburbs and be single at the same time. And so I commuted out to my office on Long Island and while I was living in Manhattan, I met my now wife. We moved to Queens as a first step to making our way back to the burbs. And now we've settled in the burbs. We have currently two boys, a three year old and a one and a half year old. They're 18 months apart with a third boy due on the heels of the second one. And there'll be one months apart. And so we will have...
05:58 Nicole: Oh my goodness
06:00 Brad: Three boys in three and a half years.
06:02 Nicole: That is crazy. And a very full household.
06:07 Brad: Yes, I'm 40 or I'll be 40 by the time this comes out. So it was by design. We had three children that are so close together in age cause we knew we'd be front loading the work, but then they'd be that much closer growing up. And so then when you have other activities, like if you're bringing one to soccer practice and they're close enough in age, you bring both to soccer practice and then you know, things would get easier from there. At least that's the plan.
06:29 Nicole: Yeah. Our girls are two years apart. It's that I'm not even that far off and they're 9 and 11 now and it totally works now. They're like best friends. It's harder in the beginning, but I do like them being close now. But we were a two and through family, you know, after two we were done.
06:43 Brad: Yeah, no three everyone's like, are you going to try for the girl? You're going to try for it to go, yeah. You know we are going to miss out. I'm not going to go to a father daughter dance and my wife's not going to be picking out wedding dresses with a girl, but no, three three is enough. We're done.
06:58 Nicole: Yeah. People asked us the same thing like aren't you going to try for a boy? And my husband's like, no, we're not. We're good. So let's get into what exactly does an otolaryngologist, head and neck surgeon, what do you do? What is your day to day work like? I think people are gonna find it interesting. And I did too when you reached out and said, Hey, can I come on and talk about things in pregnancy? So I'm definitely glad to have you here, but what do you do on a day to day basis?
07:25 Brad: So anything that revolves around the ear, nose, and throat are in our jurisdiction. So we're one of the few specialties that can see both kids and adults comfortably. So our patients range in age from a couple of days old to geriatrics. I think it's relevant because we're speaking to pregnant women. If you have a kid that's having breastfeeding difficulties, you'll see a lactation consultant. And then they might notice a tongue tie and a tongue tie is where the tongue is actually attached to their mouth, to the floor of the mouth. I usually just a little membrane that's easily cut. We just do it in the office, a little cut with a scissor. And then the way that I do it, I don't numb it because the kid calms down much faster if you get them on the breast immediately and then it's done. They calm down, they're now breastfeeding and it usually works out very easily. So I might see my one patient might be four days old and having trouble breastfeeding and my next patient might be a 90 year old who's having difficulty swallowing.
08:25 Nicole: Okay, so that's a nice wide range.
08:29 Brad: Another patient might be a four year old with ear wax because their pediatrician is having trouble. Maybe they're having pain in the year, maybe they're having ear infections. And then my next patient might be a 45 year old with nasal polyps. They can't breathe through their nose and can't smell anything or gets chronic sinus infections. And that might be my morning. And then in the afternoon I might go to the operating room. So we have a nice variety where we see a large range of problems as well as, you know, we have to do procedures as well as we just spent some time in the operating room.
08:58 Nicole: Well that's pretty cool. I think I didn't really have an appreciation for how much you guys see. So that's good to know. So let's talk about a couple of common things that I know I see in pregnancy that are ENT related that I would love for you to share your knowledge with us about. And the first one is nosebleeds, particularly in the beginning part of pregnancy. Do you ever see pregnant women that have issues with nosebleeds or what can you tell us about how to deal with nosebleeds?
09:26 Brad: So nosebleeds are very common and it's time to see an ear, nose, and throat doctor about it. When it gets inconvenient, the likelihood that somebody's going to bleed out from a nosebleed is pretty unlikely. And if that's happening, then don't wait for an appointment with an ear, nose and throat doctor go to the ER. But if it's, you know, you're getting nosebleeds every so often it's getting on your clothes, it's getting on your sheets, then you know, then it's time to see and ear, nose and throat doctor. And sometimes we'll find a little blood vessel. Sometimes it's like a little knuckle of a blood vessel that's just sticking out of the front of the nose. And when I mean the front of the nose, I mean like it's really inside the nose. It's not going be in a place you're gonna be able to see. And it's typically from the septum.
10:03 Brad: And so we might recommend at the beginning is just moisturization. And so you might want to use a salt water spray. But typically I have people use something that's more of an ointment, like Vaseline or Neosporin. You don't want to gob it up because if you inhale really quickly and aspirate it, meaning it goes down the wrong pipe, your lungs can absorb it. So you just have to use a really thin film in the front of the nose. But in the same way that you're going to use an oily moisturizer on your hands or your skin to trap the moisture in, it really needs to be the same like greasy consistency like a mass saline or a Neosporin. And the way that I have my patients do it is I have them put it on the tip of their finger and then stick their finger up their nose.
10:44 Nicole: Okay, so this is like permission to kind of pick your nose.
10:49 Brad: Cause you'll be able to feel that dry crusty area is that might be the area that's bleeding.
10:53 Nicole: I never knew that before. Okay. So how often do you do with them to put this in the nose like Vaseline and...
11:00 Brad: I have people do it at night until the nosebleeds stop. The reason I don't have them doing in the day is because if you do it in the morning that gelatinous Vaseline is going to warm up to your body temperature and then it's going to be, you're going to have this greasy stuff leaking out of your nose all day. So got to do it at night. It'll be less of a mess.
11:18 Nicole: That's a really easy thing to do.
11:19 Brad: And then if it persists and it's one particular vessel, then we can cauterize it pretty easily. An interesting thing that sometimes happens in pregnancy is you can get something called a pyogenic granuloma, which is a scary sounding word, but a relatively benign problem. You'll get this benign growth of blood vessels. It's basically a tumor, right? But it's benign. You can see them in the mouth, you can see them in the nose, and if you just gently brush them and they start to bleed and they start to bleed quite a bit. So you can sometimes just wait until the patient delivers and then they'll usually just go away on their own. But they can be such a nuisance because they just bleed over and over again. And most of the time you can remove them in the office. You know, you're not to want to take someone who's pregnant to the operating room. Most of us can do it fairly easily in the office. There might be some bleeding as we're doing it, but we get that under control. And then you don't have to worry about brushing this little thing in your nose and you know, ending up with a bad nosebleed in a restaurant or at work or wherever you happen to be.
12:21 Nicole: Got it. Nice. So as far as nosebleeds go, if it's like pouring out of your nose and not stopping, obviously go to the ER because that's a problem. But in general you can just try that Vaseline or Neosporin at night on your finger and that'll help. And if it keeps getting bad, then just make an appointment with you and you guys can typically fix it and cauterize her as it cut off the blood vessels in the office. Exactly. Yeah.
12:45 Brad: One last tip about nosebleeds, the right way to stop a nosebleed is to, because most nosebleeds are from the front of the septum. That septum is that thing in your nose that separates one side from the other. And what you're going to do is you want to pinch your nostrils shut so that you can't breathe out of your nose. You're going to want to make sure you open your mouth because otherwise you're holding your breath. So pinch your nostril shut, because a lot of people I find pinched the bridge of their nose, which is that place where your glasses sent, thinking that they're forming a tourniquet, they're cutting off the blood supply. That's not where that blood supply comes from. The blood supply comes from a bunch of different places, none of which are there. So you want to pinch your nostril shut that way you're applying pressure to the septum. Now sometimes what happens is the blood will drip down the back of your throat. That's just the blood taking the path of least resistance. That doesn't mean it's not working. And that's why we have people tilt their head forward so that they're not swallowing the blood or aspirating the blood. They can just like spit it into the sink.
13:39 Nicole: Oh, so often you see people tip their head back with the nosebleeds. So you're saying, tip your head forward.
13:45 Brad: If you're over some nice upholstery, then you should probably tip your head backwards, make your way to the bathroom or the sink, and then tilt your head forwards. So the only reason to tip it backwards so that you don't mess stuff up, but you really want to tilt it forward while you're applying pressure. And there's really, at least in my practice, there's really no role for ice. Ice isn't doing anything. The blood vessels that are really supplying the nose are from behind. They're from below. Ice isn't getting anywhere, so there's no role for ice.
14:15 Nicole: Awesome. Really good information. I did not know any of this. I'm like embarrassed to say I didn't know any of this stuff, so I'm really glad that you're sharing this useful information.
14:24 Brad: Well also kids get nosebleeds and you know the state after pregnancy is having children. So this is all useful information for parents.
14:32 Nicole: Yeah, for sure. For sure. Now another common thing that I see in pregnancy is kind of allergy, sort of rhinitis symptoms. What are your recommendations for that?
14:43 Brad: This is a tough one. So rhinitis of pregnancy and you know, you and I discussed this a little beforehand. The papers that I've read on it really said that nasal steroids don't help, which is really unfortunate because that's our mainstay of a stuffy, drippy nose. It would be a nasal steroids like Rhinocort, Flonase. None of them have ever been proven to be superior to the other ones, so whichever one really tastes the least foul would be the one that I would recommend. Although Rhinocort is the only one that's class B in pregnancy. I'm not sure if your listeners know what class B means.
15:21 Nicole: Yes, sure. If you want to talk about it, go for it.
15:23 Brad: You know this better than I do so please correct me. A class a means the medicine's been studied on pregnant women and determined to be totally safe to the fetus. Class B means it hasn't been studied but there are no reported ill effects and they've studied it on pregnant animals in ridiculously high doses and also found to have no ill effects. And class C means no reported problems in humans, but in ridiculously high doses it has been shown to cause a problem with animals. So like something like Flonase, right? You're just spraying it up your nose. But the way the studies are done, they're actually injecting pregnant rats or whatever animal model they're using with a much higher dose than you would ever be seeing. Which is why in humans that there are no reported ill effects because the amount that's actually absorbed into the bloodstream and it makes its way to the fetus is negligible if not zero.
16:14 Brad: But that's how we find those different classes. So Rhinocort is the one that I recommend cause it's class B. If it's allergic rhinitis, which means you have someone that has known allergies, but if it's rhinitis or pregnancy then typically it's just saline and then you know, something that also we had discussed beforehand was Sudafed. So Sudafed is a brand name. Pseudoephedrine is the medication and the FDA put this with the pharmacist about five years ago. So Sudafed had to scramble and come up with a different formulation, which is phenyleffrin. That's the stuff on the shelf that barely works. I mean if it works at all, pseudoephedrine works really well. So you have to, if you're looking for that stuff, you have to make sure you ask the pharmacist for it because in large quantities you can use to cook meth. That's why they keep it back there. Not because it's dangerous so it can keep you up at night cause it increases your blood pressure, increases your heart rate. But Sudafed is also a class B in pregnancy, so that can work really well for a stuffy nose.
17:11 Nicole: Yeah, and that's the same thing I say start with nasal spray. I had always said Flonase. Is Rhinocort over the counter. I don't know actually.
17:18 Brad: Yeah, the all of the nasal steroids are now over the counter.
17:21 Nicole: Okay, well that's good to know. I'll have to switch to recommending Ryan accord then. And then the issue with like medicines and pregnancy, it's really difficult to do studies of medication in pregnancy. There not a whole lot of women who are raising their hand and say, hey, I'll volunteer for you to give me this medicine and let's just kind of see what happens during that pregnancy. So it can be challenging. So we go on the best information that we can, but I like the idea of like just start with plain old salt water that's low risk and then nasal spray. It's not getting into your whole body in bloodstream. So that's a reasonable next step. And then what about over the counter stuff? Like is Zyrtec or Claritin or any of that stuff? What are your thoughts on that?
18:05 Brad: Well, so Claritin is interesting. They got the indication as non-drowsy because they made their dose low enough that it doesn't make you drowsy, but it also doesn't help very much. So Claritin was the first generation after something like Benadryl, which makes you super drowsy. So it was really the only non-drowsy on the market for awhile. But then Allegra, then Zyrtec and now Xyzal is over the counter. I think Allegra might be class D, you don't want to take that, but Zyrtec and Xyzal are very effective. Xyzal is kind of a derivative of Zyrtec for all the organic chemists out there is the livoisomer of Zyrtec, which means if the Zyrtec molecule looks like your hand, the Xyzal is just your left hand.
18:47 Nicole: I've never heard of Xyzal.
18:49 Brad: The name is ridiculous because there are studies that show that the more X, Y, Z a drug has in its name, the better it sells. It's literally X, Y, Z , A, L that works really well for allergy symptoms. It can dry you up a little bit because it has some anticholinergic effects, which just means it can dry up a runny nose, but it's not that great at drying up a runny nose. It's mainly for itchy symptoms, so like sneezing, itchy, watery eyes, itchy throat. That's what your oral anti-histamines are going to be for. So Xyzal and Zyrtec are the two that I would recommend in pregnancy because of their effectiveness. But you know they can make you drowsy so you probably want to take them before bed.
19:32 Nicole: Awesome. And I'll be the first to admit, you know, although I'm an OB GYN and my expertise is in pregnancy, a lot of times people think that we know how to treat every single condition that pops up in pregnancy and we may not know all of the nuances. So we often rely on our colleagues in the specialty fields about things to give us some advice. So don't always feel like your OB GYN is going to know every single thing about what happens in your body during pregnancy. Of course we have a general idea and we know what's going on with the baby. But again, it's great to have your expertise in recommendations about that particular area, which we never look at as ob gyn's, period. So.
20:13 Brad: Well that's what I say about, you know, sometimes a patient will go to urgent care and then I'll end up correcting a diagnosis or changing a diagnosis or changing a plan and they'll say, well how come they didn't say that? And my reply is usually if I can't do the ear, nose and throat, those three things better than someone who has to know everything about everything than I really shouldn't be doing what I'm doing. That's my job. My job is to know these three things and only these three things really, really well.
20:41 Nicole: Yeah. Perfect. All right. And again, I agree about the Sudafed, the phenyleffrin that's over counter is useless and you have to get Sudafed and it's more dangerous. You have to get the pseudoephedrine Sudafed or did generic from the pharmacist. It's annoying. But that's what you need to do in pregnancy. Alright. Now one thing you also mentioned that we talked about beforehand is ear issues that can flare up in pregnancy. So why don't you tell us a little bit about that?
21:08 Brad: Well, so there are a couple of issues that if you have them already tend to progress in pregnancy. And so if you've never heard these words before, it probably doesn't apply to you. But two things in particular. One is otosclerosis, so otosclerosis it's actually an ear condition that's more common in women than in men. And you have these three little ear bones in your middle ear. So that's the space that's behind the ear drum. You can't really see. And one of these ear bones, the last one can actually develop something kind of like arthritis where you get some extra bony growth on it. And because those ear bones work like a lever system, if that bony growth is going to prevent it from moving, well if you can't move then you're not going to hear very well. So you might end up with a more rapid progression of your otosclerosis so you have maybe a little bit of hearing loss, you're not sure.
21:58 Brad: And then it gets worse during your pregnancy. Come see the ear, nose and throat doctor and we'll be able to do a hearing test on you. And we can usually tell from the hearing test alone if it's otosclerosis, nothing urgent would need to be done. If anything, if it was really a problem, then you could get a hearing aid and then at some point it could be addressed surgically. Although some people choose not to have the otosclerosis addressed surgically, they just wear a hearing aid, so that would be one thing. Just anyone with a unilateral hearing loss. If you don't have, sorry, one year, if you can't hear very well out of one ear, actually if you can't hear very well out of both ears, you need a hearing test. You need to see an ear, nose and throat doctor and especially if it's progressed rapidly, that tells us that there might be more urgent issue.
22:40 Brad: Otosclerosis happens to not be an urgent issue, but in that situation, definitely you need to see an ear, nose and throat doctor. You need to get a hearing test. The other thing that we can see flare up is Meniere's disease. So Meniere's disease is not that common, but you'll see patients have a complex of symptoms. They'll have episodes of vertigo. Now first, the word vertigo can be confusing. It just means that you feel the room is spinning around you. Vertigo is not a diagnosis. If someone tells you that they have vertigo, they're just telling you like they have back pain, like this is their symptom, but it's not the diagnosis. There are a couple of different diagnoses that can cause vertigo. So if you feel the room's spinning around you, you usually happen concurrently with a roaring sensation in your ear, a roaring sound, some hearing loss, and a sense of fullness in your ear.
23:26 Brad: And it'll happen for a few hours at a time. That's what Meniere's diseases. And you don't need all four of those things to be diagnosed with Meniere's disease. But that's the classic presentation. And because that happens because of kind of like these fluid changes that happen in the inner ear. So the inner ear is not where those ear bones are, that's the middle ear, the inner ear is your cochlea and the semicircular canal, it looks kinda like a snail shell. If you happen to see it on like a cat scan or an MRI cause you get so close to this skull, we can't just look at it without imaging. So there'll be fluid imbalances there that can trigger these episodes. And certainly you have fluid shifts in pregnancy and electrolyte changes and that can influence that problem. So if you have that problem, then you need to make sure, hopefully if you have Meniere's you have an ear, nose and throat doctor that you see fairly regularly, you're going to want to keep a closer eye on that. And usually it's treated with a low salt diets. Sometimes we'll put you on diuretics, but this is a situation where your ear, nose, and throat doctor and your OB GYN are going to have to work together in order to keep you comfortable.
24:29 Nicole: Awesome. All right. Anything else? Any other ear issues or are those two of the main ones?
24:35 Brad: Just one piece of advice for all those expectant mothers out there. After your kid is born, please don't clean their ears with Q-tips. Well, probably the worst part of my day is having to clean really impacted wax out of small children because the parents think they're supposed to. Yur parents cleaned your ears and now you're cleaning your children's ears and you know there's a word out there, eargasm, it feels good to you. I know how people feel and they use it and it feels good. And then you feel clean because your wax does look a little bit like dirt, but it's not dirt. It's there for a reason. And if you see a big glob coming out, then think of it the same way you would think of like a bowel movement, right? If your kid has a big bowel movement, you're not going to think, oh my goodness, what else is in there? You're going to think, oh great. They must feel so much better now. So the big global wax comes out, it doesn't mean there's a whole bunch more in there. It means great. It came out. The ear's doing what it needs to do. So the body has a system for making wax and pushing it out and the less you interfere with it, the better it works. So just please when you're giving your kid a bath, use the wash cloth and just wipe the outside. Don't stick anything on the inside. Otherwise you're gonna end up in your ear, nose, and throat doctor's office for an unpleasant experience of having the ears clean. I mean it's not always unpleasant. Sometimes it's super easy, but sometimes it's not.
25:51 Nicole: Okay. I have to confess, I use Q-tips every single day. I think it's because I fall into that eargasm category. I don't know. It just feels good.
26:02 Brad: Exactly. It feels good. Sometimes I'll ask patients, well, do you use Q-tips in? The answer I get is I try not to and I don't know what to say to that. What do you, can you try? You being attacked by Q-tips and you're trying to fend them off? I try not to. Just don't just know stick them in your ear.
26:18 Nicole: I don't do it like I try not to get deep with it, but...
26:20 Brad: Oh, come on. I know. I know. I hear that every day. No, I just go. I don't put it in. If you're using it at all, you're putting it in too far.
26:28 Nicoel: Okay. Noted. Noted. Dr. Block. I will try to stop using Q-tips.
26:33 Brad: It's good for cleaning grout between tiles. It's good for arts and crafts. It's good for applying makeup, but not for the ears. When there's a sign on the box,
26:42 Nicole: I ignore the sign. But you're saying we need to stop and definitely don't do it for your kids.
26:49 Brad: Well, realistically I would imagine most people that use Q-tips don't end up in my office. Right. Most people use it just fine. But the other reason not to use it is because you're stripping the wax away from the canal skin. And actually that protects your ear skin from ear infections. The ear is the only face hole that's supposed to be dry. Your nose is wet, your mouth is wet, your eyes are wet, your ears are supposed to be dry. So if you get water in there, it doesn't evaporate so quickly cause it's kind of a cave. So that can make the skin kind of mushy. And when that happens, skin can break down and then you get an infection. And that's what swimmer's ear is. So that's the other reason not to use it. The last reason is cause I guess if you jam it in far enough, you can poke a hole in your eardrum. But in five years of residency and eight years of practice, I think I've seen that like three times. So that's less of a concern than pushing the wax in and stripping the wax away.
27:37 Nicole: Okay. Alright, got it.
27:39 Brad: All right, wax a lecture over.
27:42 Nicole: All right. One more thing I wanted to touch upon in pregnancy is I'm seeing more like studies and information and people investigating this is sleep apnea and pregnancy. And part of this is because we'll be honest, America in general is more overweight and obese than we have been and you know, we need some work on that. And that spills over into pregnancy and sleep apnea is more likely when you're overweight or obese and it can lead to an increased risk of gestational diabetes and preeclampsia. So what are your thoughts about sleep apnea in pregnancy?
28:16 Brad: Well first just a quick primer on what sleep apnea is. As you get deeper and deeper into sleep, the muscles of your body relax and they can relax so much that your throat actually closes. Well, people get concerned that they're going to choke and they're not going to breathe and they're not going to wake up, but it doesn't work that way. What happens is your body then senses that you're not breathing and it brings you into a lighter stage of sleep. In this lighter stage of sleep, you have more muscle tones, then you start breathing again. Well, but now your body's going to try and get into deeper sleep again. So it's going to relax again. So you end up spending all night trying to get into deeper sleep, but never quite spending a good amount of time there. So you can be chronically tired from sleep apnea.
28:54 Brad: But the other thing that happens is every time you're not breathing, you're holding your breath. So what happens is your lungs not having much oxygen in them, the blood vessels in them will shrink in order to retain the oxygen that you have. And then your heart has a harder time pushing blood through your lungs. So this can lead to cardiovascular issues. So irrespective of your weight, sleep apnea, untreated is an independent risk factor for congestive heart failure, heart attack, stroke, early death. So it's really a medical condition that needs to be managed and the higher body mass index, so the more you weigh, the more likely you are to have sleep apnea and the more severe it tends to be. Now this doesn't apply specifically in pregnancy for a couple of reasons. One, the more you weigh, the more fat deposits you have throughout your body, including your throat and your neck.
29:42 Brad: And so if you're gaining baby weight, that doesn't necessarily apply specifically to that. The other thing is because of the progesterone, progesterone has a stimulating effect on your respirations, so you tend to not have those episodes as frequently because of other things going on in your pregnancy. But if you do have sleep apnea, it will likely get worse just because there is collateral weight gain in pregnancy as well. So it definitely needs to be managed as well as just the fact that it's affecting, you know, it's affecting your cardiovascular system. So I don't know the specifics on how it could affect the baby, but it's a medical condition that should be treated. And there are couple of ways to treat it. The most popular and common way is CPAP, which is where you'll put a mask on and that mask forces air into your airway which keeps the airway open.
30:29 Brad: Another way is somebody called a mandibular advancement device, which is like a kind of like a bulky retainer and that holds your jaw forward like it gives you a really big underbite while you're sleeping. Oh, that pulls your jaw forward, that pulls your tongue forward, which can increase the size of your airway. Now that doesn't work for everybody and you really need to work with either an ear, nose and throat doctor or a sleep medicine doctor to decide which of those is right for you. I'm biased I think in ear, nose and throat doctors. The way to go cause we can take a good look at your airway and assess where the obstruction is coming from. Sometimes it's coming from the tonsils and so tonsillectomy is necessary. Sometimes it's a more involved surgery where we're taking some of the pallets. Sometimes we take some of the back of the tongue.
31:09 Brad: Sometimes you'll see an oral surgeon who actually slides the jaw forward, so they actually break your upper and lower jaw and slide it forward and reset it. It's called a maximum mandibular advancement. None of this is done during pregnancy, so this is just, you know, the reason that it can be complicated, it's not like the CPAP, which is that mask, is the beginning and the end of management of sleep apnea. There's a lot more nuance to it in that and so definitely something to look into. And what will happen is your bed partner will hear you have these choking and gasping episodes where you are, and then you'll start breathing again. So that's happening. Then it's time to talk to your doctor about it.
31:47 Nicole: All right, good. And then you touched upon this a little bit already, but you talk about that you see kids other than clipping the tongue tie, what are some other things that you might see kids for in the first, let's say three months or so? You know, right after baby's born.
32:03 Brad: One thing that's done in newborns in the United States is something called an otoacoustic emissions. And that's the newborn hearing test. Interestingly, the ear makes sounds of its own. They're barely perceptible, but we have this machine that we'll put in your baby's ear and it'll make a click and then your baby's ear will actually make like an echo. It'll echo that sound. So that's how we can tell if your baby can hear. If you fail that well then you're going to need to see the ear, nose, and throat doctor in order to figure out why. Frequently it's just we just retest them and then they end up passing. But sometimes it will require more of a workup. So if you failed the newborn hearing test and that would be an a reason. Another common problem we'll see, are noisy breathers. And so this is a common phenomenon where the parent will think that the kid has a stuffy nose cause they're making all sorts of snorty snugly gurgly sounds to quote Dr. Seuss.
32:52 Brad: Generally the suits work, so sometimes the kid will present with a stuffy nose, but it's really not a stuffy nose. It's actually coming from their larynx voice box. But a voice box in a baby sits much higher than a voice box in an adult. And that's why your baby is able to lie on their back and drink and you can't, you'll choke. So yeah, interesting phenomenon. The larynx starts off really high and it actually interdigitates with the epiglottis interdigitates with the uvula. So the uvula's a little punching bag that then goes down to the back of your throat and that overlaps quite a bit with the larynx. And that's one of the way that milk gets sent in such a way that avoids the voice box so that you're not choking when you're lying on your back. But don't try this at home. If you're listening to this, you're an adult.
33:38 Brad: And yes, you shouldn't be drinking something or eating, swallowing, anything while you're lying on your back. And so the larynx can sometimes be floppy. So the cartilage, if you feel the ear of a newborn, their ears are very soft and the ears are made of cartilage. If you feel your ear, it's much harder. So it gets calcified as you age. So the larynx, the voice box is also made of cartilage and it can be very floppy and it's also very small. So sometimes it can be collapsing as the kid's breathing and it's making a scary sound. And that's the most common reasons for that. The sound is stridor. So if the sound is made on the inhale, it's like, and that's stridor. And that can be the airway collapsing. If that's happening, definitely make your pediatrician aware and you'll probably need to be seen by a ear, nose, and throat doctor where we'll put a little camera in the baby's nose.
34:30 Brad: It turns at the end so that we can get a birds eye view of the voice box. And usually we can find it. And more often than not, it's from something called laryngeal Malaysia and laryngeal. Malaysia just means floppy larynx and it's floppy. But as the kid gets older, it hardens and also the diameter gets bigger. So even if it collapses a little bit, it doesn't make a difference. And usually they'll outgrow it. It can be a problem if it's interfering with feeding and sleeping and then an intervention might be necessary. So that's noisy. Breathing is probably the most common reason we'll see kids in the first couple of months of life aside from tongue tie.
35:03 Nicole: Okay. Alright. Alright. So let's just wrap up with a few questions about kind of how you feel about your work. So what do you feel is the most rewarding part of your work?
35:13 Brad: So one of the reasons I got into ear, nose and throat doctor was I remember being a med student and seeing a kid with really, really, really big adenoids. So the adenoids are similar to the tonsils, except they sit in a way back in the nose and they can form an obstruction. They can block the back of the nose and if your nose is blocked, you'll find it's hard to eat. So some of these kids, they just have these chronically stuffy drippy noses, or maybe they're snoring loudly. Sleep apnea actually can happen from big tonsils and adenoids, but in its more severe form, they can have so much trouble eating that they're not growing. And that's what happened to this one kid in particular. He was taken to the operating room, the doctor removed the adenoids and the next day the kid was eating like it was not a problem at all.
35:56 Brad: So they had gotten from, I just remember him eating like soup from a spoon and just having to hold his breath between bites. It was such a dramatic effect and in adenoidectomy, the complication rate is extremely low. Know it's a general anesthesia, but you know, typically you don't need to stay overnight. You're home the same day. There's not that much that goes into recovery and yet you make this dramatic, dramatic change in the kid's life. And that's really what attracted me to my specialty in general is because a lot of what we do, a lot of these interventions, they're relatively low risk, but they're high reward. We end up making a huge difference in the patient's quality of life, be it a kid or an adult. Even something as simple as ear wax, right? Someone comes in, I can't hear, I can't hear, and they think they've got something and then you look inside and it's a wax.
36:42 Brad: You take out the wax. It's like a miracle. They leave the most satisfied person in the world and all you did was suck out some wax. So that's my field. Now, you know, if you're an academic otolaryngologist and you're doing things that can be much more involved, right? Some ear, nose and throat doctors get very involved in head, neck cancers, big sinus tumors, inner ear problems with inner ear tumors and other very complicated conditions. So it's not always that straightforward, but that's the stuff that I find our bread and butter is the stuff that I find most rewarding.
37:13 Nicole: Awesome. Now on the flip side, what's the most frustrating part of your work and don't say Q-tips.
37:18 Brad: I was going to, I was going to, it was really going to be pediatric earwax. Pediatric earwax because yeah, sometimes all it is, it's a little scoop. It's a little nothing. But sometimes if it's really packed in there, you know, you have to get mom or dad to help us hold them down. They're getting upset, it's uncomfortable. And sometimes they have to come back a second time cause we have to soften it up with some drops. That's rare. It's rare that wax wins, but it can happen so that's sometimes the most. One of the more frustrating things. That being said, that gives me some perspective on my job, so that's the most frustrating part of my day. Then lots of too frustrating day.
37:54 Nicole: Yeah. Now, how have your personal experiences as a parent influenced your work?
38:00 Brad: I have a lot more understanding for the parents and what they're going through and it gives me a glimpse into what may be going on in their head in terms of beating themselves up for things that they're doing or things that they're not doing or things that they perceive to not be doing well. If I can plug a colleague of ours, Alison Escalante has a Ted talk, a TEDx talk on the should storm, she talks about, you know, you hear from everybody, I should be doing this, I should be doing that. We end up as parents beating ourselves up a lot. And so that, you know, it gives me a little glimpse into the mind of the parents and it helps me have some counseling with them that allows them to leave really a lot less stressed than they were before. And had I not been a parent, I never really would have considered those thoughts.
38:46 Nicole: Gotcha. Being a parent, it changes you, you know, and so many ways. And I think as doctors we all change a bit after we become parents, especially if you take care of anything related to kids, you know, you're like, you're all doing the best that you can. And sometimes it's tough.
39:02 Brad: And a lot of times I'll see a parent and they're seeing me for the first time, probably haven't gone to the doctor for many years. And the reason that they're in is because they just had a kid. So now they're looking after themselves. So when you have kids, everything just has a lot more gravitas to it. So you know, you end up needing to, you know, sometimes we take care of ourselves less well because we don't have time now that we have kids, but some people end up taking care of theirselves better because they didn't do it before, but now they have more of a more skin in the game.
39:29 Nicole: Right. Yeah, for sure. So what is one piece of advice that you would give to expectant parents? If it's the Q-tips again you can say it. If not, what's the one piece of advice you'd like to give? And that can be from your perspective is just not necessarily as an ENT, but just as a parent.
39:47 Brad: For us, sleep training was probably our best move. Our first one actually forced us to sleep, train him at four months old. That's when he started turning over. So we couldn't papoose him anymore. So we didn't papoose him, but he needed that in order to sleep. He fell asleep un-papoosed and then he woke up at around 11 o'clock at night. I went in to try and rock him back to sleep and it didn't work. Cause every time I put them down you would wake up crying again. And so after half an hour of this, I went back to bed, turned to my wife and said, I think it's time to sleep train him. She was not mentally prepared for this. So she went into the room. She tried the same thing except this time he was crying in her arms and crying in the bed. So she said fine, it's time she put him down.
40:33 Brad: Then for two hours after that it was nonstop crying. Non stop crying until ultimately he cried himself to sleep and then the next night an hour, the next night, 15 minutes and then that was it, that was sleep training, but back to the, you know when we ended up doing that with the second one we ended up doing doing it at six months old and he had a different way where he would like cry for like five minutes and then stopped for five minutes and then cried for five minutes and then stop. So we had no clue when he was actually winding down. And around that time there was a New York times article that came out about sleep training and all it was was all of the different methods that were out there. And all it said was you just find the one that works for you. None of these might work for you.
41:23 Brad: All of these might work for you, but you know it's important that your kid sleeps and it's important that you sleep. It's important that you find a solution. It was the least judgemental article and yet you go to the comments section, of course, the worst of humanity and the vitriol in that comment section about you're damaging your kid for life. You're a monster, right? That's what happens with parents, right? Like you hear from the person at the grocery store or you hear from friends, you hear from neighbors and they're telling you what to do as if they have some authority. And this article, which you know, there's a pediatrician who counsels patients on this all the time and they said there's no right answer, but now you have all these other people that claim to be have the answer. And you know they can make you feel pretty bad.
42:11 Brad: So that's my bit of parenting advice is we found sleep training that works for us, we recommend, and it was kind of forced upon us. It all went to pot when he was less than two and he managed to climb his way out of the crib. He our little Acrobat. So that has become its own challenge. But you do what works for you. You know, you take your pediatrician's advice, take your OB GYN advice, take your other doctor's advice, but you really need to find what works for you and try not to let other people make you feel bad about your choices.
42:41 Nicole: Yep, I agree with that 100% for sure. For sure. So why don't you tell us where people can find you. I know you have your own podcast. Tell us about that and where can other people find you.
42:51 Brad: I have my own podcast, so it's called The Physician's Guide to Doctoring and you can find it at www.physiciansguidetodoctoring.com or if you just look that up wherever you find podcasts, Spotify, iTunes, Stitcher. My Twitter handle is @physiciansguide, and this is for clinicians of any type and our mantra is everything we should have been learning while we were memorizing Krebs cycle. So Krebs cycle, if you don't know what it is, then it's probably not the podcast for you, but it really everything that relates to being a doctor and how to doctor better. So I'll have different specialists on talking about what every doctor should know about their specialty, but I also have other experts on how to talk to patients about losing weight, how to have that conversation was one of my favorite ones. It was just how to have an effective conversation, not how to do it, but what words to use and what words not to use.
43:40 Brad: I had an episode on advocacy that can teach doctors how to do for people who are not involved in advocacy, what's the least amount that you need to do to influence the outcome of congressional and state legislature decisions? I'm going to be recording an episode soon on Medicare for all. That's a big topic with the elections, so I'm going to have a health economist talk about what physicians should know about Medicare for all. It's a really wide ranging podcast and there's stuff on there. Certainly that applies to anybody, but my intended audience is really any type of clinician, doctors, dentists, therapists, physical therapists, audiologists, speech therapists, anyone who interacts with patients. It's going to have a lot of material that's relevant for you and the other place that people can find me is just my practice. If you go to www.entandallergy.com we're the largest ENT practice in the country.
44:31 Brad: We have offices in New York and New Jersey where all the way out on long Island as far as the Hamptons. And we're far up in New York as far as Middletown. And we have a number of offices in New Jersey, different offices in all five boroughs of New York city. And our saying is call us today, you see us today. So if you call or go on our website early enough in the morning, then we will be able to find a physician that will be able to see you that day. We're not open on Sundays, but we do our best to try and accommodate people cause we realize if you're having an active nosebleed right in the middle of pregnancy and you want to make sure you're seen by an ear, nose and throat doctor, then we'll do our best to get you seen. So that's E and T, ear, nose and throat and allergy.com all one word and yeah, can find us there.
45:15 Nicole: Awesome. And I will link to all of that in the show notes. So that's it. That was an awesome conversation. I really appreciate you being on. I know I learned a lot for sure and I will, I can't let go of the QTIP thing clearly, but I will try to stop. Yeah, exactly. Yeah. Well I appreciate your time and this great information, so thank you so much for coming on.
45:41 Brad: My pleasure.
45:42 Nicole: Okay. All right. Talk to you later. Bye. Bye.
45:45 Okay, wasn't that another great episode? I learned so much information that I really didn't know, so I found it incredibly useful and I'm sure you did too. Now, after every episode where I have a guest, I do something called Nicole's notes where I talk about my top two Or three takeaways from the episode and here are my notes from today's episode.
46:04 Number one, I just want you to be mindful of how it's not like an exact science in terms of how we determin that medications are safe during pregnancy. Most of it is based on animal studies. As you can imagine. Not a lot of women are necessarily lining up, you know, raising their hand saying, sure, I'll volunteer to take this medicine during my pregnancy and you can just figure out how it affects me and my baby. You know, not a lot of women gonna volunteer to do that. I know I wouldn't, so I don't want you to get frustrated if you talk to your physician and they don't have necessarily a ton of great information about the impact of some medications. Now, I don't want this to cause you to not take a medication that's decided that you need to take it during your pregnancy for sure. Do that, but just be mindful of what you take. Don't take things unless you absolutely need it and just understand that the information that we have on safety, a lot of it is based on animal studies and then also kind of looking back and see how it's affected pregnancies in the past.
47:16 Now the second thing that I want to mention is that your obstetrician or a midwife is not necessarily going to know everything about your entire body. A lot of times I see women once they get pregnant, especially if it's their first baby, anything that happens to them while they're pregnant, they're calling their OB doctors. So they, you know, do something as tiny as like stub their toe and they're calling the OB doctor and would you call your obstetrician if you weren't pregnant? You know what I mean? So I guess I'm just trying to say that not everything is directly related to your pregnancy and your OB Dr. may not be the best person to take care of some issues that pop up during pregnancy. I've seen some women get a little bit upset if they're OB doctor's like, well I don't think I should see you for this particular concern. Well it's because we don't know everything about everything. Of course we know a lot about pregnancy and how to take care of things during pregnancy, but some things are best treated by other physicians or providers. So sometimes things pop up. Your OB Dr. may not be the best place for you to go to get the care that you need.
48:30 And then the third thing that I'm going to say is, okay, true confession. I recorded this episode like three, four months ago. It's been awhile and yes, I am still using Q-tips every single day. Yes, y'all. I can not let go of the Q-tips. I don't know what it is, but just everyday I just got to clean around a little bit. So you know, bad doctor here. I'm still on team Q-tip all day every day, so forgive me Dr. Block. I'm still using the Q tips.
49:00 All right, so that's it for this episode. Be sure to subscribe to the podcast and Apple podcast or wherever you listen to your podcast and I would love it if you leave an honest review in Apple podcast. I love to give shout outs on the podcast and it helps women find the show. Also, don't forget about the online class on how to make a birth plan that works. You can register for the next class www.ncrcoaching.com/register. I don't do it often. Seats are limited, so be sure to grab your spot or if you're interested in hopping right on into my childbirth birth education class, The Birth Preparation Course, you can learn more about that at www.ncrcoaching.com/enroll. Now next week on the podcast, I am talking about obesity in pregnancy and how that affects pregnancy. This is something that actually one of my Instagram followers asked me to talk about, so I'm going to talk about that next week, so come on back next week, and until then, I wish you a healthy and happy pregnancy and birth.
50:03 Today's episode is brought to you by Women's Wellness Coaching by Dr. Nicole Calloway Rankins. Head to www.ncrcoaching.com to check out my free one hour mini course on how to make your birth plan as well as my comprehensive online childbirth education class, The Birth Preparation Course with over eight hours of content and a private course community. The Birth Preparation Course will leave you knowledgeable, prepared, confident and empowered going into your birth. Head to www.ncrcoaching.com to learn more.