Primary Care Physician wants me to get second opinion

[GaryGarland]

Hi All,
I had a physical friday, and surprinsingly, my primary care physician (who scripted me for my sleep study, and is of the mindset that i should have surgery for the OSA), was surprised (and i think annoyed) that the ENT i went to didn't want to cut - the ENT kept pulling out the BMI index and telling me to loose weight, and scripted me - per my request he wrote apap with humidifier and a week or so later he was amenable to additionional scripting so i could get a full face mask) - anywhoo, i APPRECIATED that the ENT didn't want to cut (though presumably he'd have made far more with insurance) - he wants me to lose weight, and then reevaluate.
my primary thought i was a good candidate for surgery and suggested i get a second opinion with another ENT.
Mind you, as much as i like the forum, i'd love to be off a machine, though i've read horror stories (gasoline at back of throat, inability to use a nasal mask alone anymore, read about recurrence of the fatty tissue after a few years) etc.
i know there's no harm in getting a second opinion (okay, i'm ugly and dress funny) - but i'm concerned that doc number 2 will be a butcher, look at my elbow, and say, "yeah, you need some lasering" just for the dinero. My ENT believes if i lose say, 40 pounds i may not need the machine, the sleep lab felt with a titration of 14 losing weight may put me to say, 8 versus 14 (so no real benefit from my perspective), and the wellness program i've joined said i need to lose roughly 40 pounds to be at the upper end of the appropriate BMI for myself.
Thoughts/opinions?

[Slinky]

Eh, if you'd rather have the surgery, go for it, go find an ENT who will see things your PCP's way. Personally, I prefer PAP therapy. I'm a wusp about surgery. Any surgery. Losing (or for some gaining) weight is not easy, its no picnic and it can be discouraging as h*ll but its a battle you should wage for reasons other than just hoping to squeak by w/o a CPAP (besides CPAP some times helps one lose some weight). And frankly, adjusting to CPAP therapy beats the stress and angst of trying to lose (or gain) needed weight in my book. We all have our likes and dislikes - me? CPAP is the "easy" way out for all it seemed to take me forever to get the right device, the right mask and the right pressure.

[Wulfman]

WHAT surgery?

Den

[Debjax]

(gasoline at back of throat,

??????????? WHA? Gasoline at back of throat?


Besides, I'm sick of getting parts of my body cut. WAY too many surgeries in the last 2 years for me.

[jnk]

Gary,

Here's your second opinion, from Allen Blaivas, M.D. Print it out for your doc:

PAP is the "gold standard" and the most effective therapy for obstructive sleep apnea (OSA), . . . A good sleep center will . . . improve the long term compliance to CPAP. . . . Surgical procedures for OSA are unpredictable and generally less effective than PAP. . . . Nasal reconstruction targets extra or distorted tissue in the nose that blocks the flow of air. The advantage of the nasal reconstructive surgery is that, even though it does little for treating sleep apnea itself, it might make a person better able to tolerate PAP treatment with a nasal mask. -- http://www.healthcentral.com/sleep-diso ... -apnea/pf/

Or if he has in mind UPPP, maybe your doc would accept WebMD's opinion ( http://www.webmd.com/sleep-disorders/tc ... ea-surgery ) :

Surgery for obstructive sleep apnea (OSA) is usually not done unless other treatments have failed or you are unable or choose not to use other treatments. . . . Experts generally suggest trying continuous positive airway pressure (CPAP) before considering surgery. . . . In adults, uvulopalatopharyngoplasty (UPPP) is the most common surgery used to treat sleep apnea. There is no clear research on how well UPPP works for sleep apnea. UPPP may stop snoring, but apnea episodes may continue.

This means that after UPPP, you may not be able to use an APAP that uses snores to adjust therapy. WebMD continues:

Limited research indicates that about 40% to 60% of people who have UPPP see an improvement in their symptoms.

Those are pretty lousy odds, in my book. WebMD contiues:

You may still need other forms of treatment, including continuous positive airway pressure (CPAP), after surgery. You will need sleep studies after surgery to make sure periods of apnea do not continue or return.

My summary of the above is that nasal surgeries may help PAP therapy go better. Palate surgery may make it go worse and may make using an APAP impossible. Either way, you are still likely to need to keep using PAP therapy, depending on the results of the sleep studies that follow.

Then there are all the awful possible side effects of palate surgery, which you alluded to:

http://books.google.com/books?id=jUEFn5 ... &ct=result

Page 115 of that book says this:

"If one were to select only young, otherwise healthy, nonobese, mildly apneic snorers with identifiable, correctable abnormalities (large tonsils, drooping palate, long uvula), success with UPPP and tonsillectomy, by any measure, might exceed 90% of patients. Contrarily, if one selected obese, severly apneic snorers with a bulky tounge, receding chin, and flabby narrowed hypopharngeal air passages, success with UPPP would be unlikely. Somewhere in between those two extremes falls the majority of snoring and sleep apneic patients. For them the probablility of success versus failure of UPPP is often unpredictable."--Snoring and Obstructive Sleep Apnea By David N. F. Fairbanks, Samuel A.

Ask yourself, would you sign the following form?:

http://www.southatlantaent.com/client_i ... t_UPPP.pdf

[GaryGarland]

JNK, many thanks. one thing i found out "by accident" is that i have a deviated septum - first visit to ENT (when i asked for apap machine) he didn't say anything - but after last visit, i saw my report (in my file which he had me bring to his scheduling person) and it said i have a deviated septum - the guy never even said anything to me - that could explain why i often have difficulty nose breathing - so now i'm wondering if i should get the schnoz fixed to improve nose breathing with the apap - generally i breathe MUCH BETTER with the swift lt ramming air up my schnoz - after the first 2 or 3 minutes i don't notice it anymore; however for a few nights my nose had clogged up in the early morning, on my side, making me remove the mask and just read versus sleep (okay, i cheated and napped a bit without the mask - first time in about 6 weeks!)
i've actually aclimated to the machine - yeah, it's not sexy, and if i want to cheat on my wife somehow and sleep over at some "chick's place" i doubt carrying my apap with me would get me a second night o passion, however the machine and it's monitoring gives me confidence that it is improving my health. or at least my deep sleep.

[GumbyCT]

Thoughts/opinions?

Either get a trach or a New PCP. I vote for a new PCP.

[jnk]

JNK, many thanks. one thing i found out "by accident" is that i have a deviated septum - first visit to ENT (when i asked for apap machine) he didn't say anything - but after last visit, i saw my report (in my file which he had me bring to his scheduling person) and it said i have a deviated septum - the guy never even said anything to me - that could explain why i often have difficulty nose breathing - so now i'm wondering if i should get the schnoz fixed to improve nose breathing with the apap - generally i breathe MUCH BETTER with the swift lt ramming air up my schnoz - after the first 2 or 3 minutes i don't notice it anymore; however for a few nights my nose had clogged up in the early morning, on my side, making me remove the mask and just read versus sleep (okay, i cheated and napped a bit without the mask - first time in about 6 weeks!)
i've actually aclimated to the machine - yeah, it's not sexy, and if i want to cheat on my wife somehow and sleep over at some "chick's place" i doubt carrying my apap with me would get me a second night o passion, however the machine and it's monitoring gives me confidence that it is improving my health. or at least my deep sleep.

You always make me laugh, GaryGarland! " . . . sleep over at some 'chick's place' i doubt carrying my apap with me would get me a second night."

My understanding is that, technically, most of us have a SLIGHTLY deviated septum, relatively speaking, unless we accidentally were born with a perfect nasal tract. I think it's all about HOW BADLY deviated it is, as far as whether it is worth getting it fixed:

"Estimates are that 80 percent of all nasal septums are off-center, a condition that is generally not noticed. A "deviated septum" occurs when the septum is severely shifted away from the midline. . . . In some cases, a person with a mildly deviated septum has symptoms only when he or she also has a "cold" (an upper respiratory tract infection). In these individuals, the respiratory infection triggers nasal inflammation that temporarily amplifies any mild airflow problems related to the deviated septum. Once the "cold" resolves, and the nasal inflammation subsides, symptoms of a deviated septum often resolve, too."--http://www.entnet.org/HealthInformation ... Septum.cfm

Don't sleep with your mask off, or you may not get a second night with anybody, including yourself! And real passion happens when we're awake, so CPAP has nothing to do with that. But don't cheat on your wife.

jeff

[LoQ]

I saw an ENT, a surgeon who was chief of Rhinology and Sinus Surgery at the local hospital, and he told me, without even looking in my mouth, that the odds of surgery helping ANYONE get off of CPAP are not high enough to consider it. Sometimes it helps temporarily, and lots of people who have it end up worse than before. Some people are helped by it, but not with enough predictability that I would even consider it.

The pillar procedure is new, and already they are having to modify the way that is done. My surgeon said it was too new to know whether it might help or harm. Let someone else be the guinea pig.

[nate fry]

I had lots of the surgeries oct. 21 and have to say they were all a success. I feel way better. If you have a real good ent they can do wonders. If you have a bad one it's not so good. If your curious feel welcome to ask. I had a septoplasty, turbinate reduction with radiofrequency, tonsils out uvala readjusted and tongue advancement. I would do it all over again in a minute.

[deltrol]

Primary care that focuses on the optimum level of health and wellness is the primary need of an individual. Attaining the highest level of health is truly difficult to achieve. But if there are physicians that are truly committed in providing the highest level and comprehensive approach to care then worry no more. Good to know that they are there, not just to treat us, but to provide the optimum health and wellness that we need.


primary care

[cotech50]

My ENT didi cpap. He told me surgery was the old way and now only used when all else fails. There are many things much worse than having to use a pap to sleep!!!

[mstevens]

I would do whatever treatment I thought was most effective for my OSA. I'm confident that this means xPAP for me and for nearly everyone.

In my opinion, there is good reason to believe that UPPP is both limited and temporary in its benefits.

Surgery, to many physicians, seems "definitive" and more of a "sure thing." It's quite telling when surgeons don't want to do it. Cutting and sewing is *fun*. It's what surgeons trained to do because that's the sort of treatment they like. Let's not ignore that it's considerably more profitable than office visits. When a surgeon wants to do something other than surgery, I listen.