*For the published technical article click here: https://www.sleep-journal.com/article/S1389-9457(18)30356-3/abstract
“Those need to come out!!”
Does your child really need tonsil or adenoid surgery? Does chronic sinusitis or the “sinus headache” really exist or is it something else? Why does it almost never get better even with treatment in the long-run? Should we always sign up for wisdom teeth removal or dental extractions for crowding? Why do doctors recommend removal of the uvula or turbinates for snoring when they actually serve a function? Why do celebrities look so odd from facial cosmetic treatments? Why has “open rhinoplasty” with placement of cartilage “grafts” in the nose become the norm for aesthetic nasal surgery, when simpler techniques are available?
Conventional wisdom tells us that specialists will give us useful answers to these problems.
But, what if the information we get from these specialists is incomplete or worse, inaccurate due to a number of factors…should we still blindly undergo the procedure and take the medications? In his book the Black Swan, part of a collection known as the Incerto, the author Nicholas Nassim Taleb introduces the concept of the Ludic Fallacy. The ludic fallacy, a most unique and brilliant concept that is almost opposite to conventional viewpoints explains how extrapolating success from games, or school-type sterile conditions makes one perfectly de-conditioned to understand and prepare for real-world concepts, where reality may not ascribe to a pre-ordained set of rules. It may be due to this Ludic Fallacy, where the best standardized test-takers, (students who survived the pre-med and med-school game) have entered the real world of human disease to see the physical manifestations of disease as causes of disease instead of simply as signs of the disease. They have potentially developed a blindness to the invisible dynamic forces that actually cause the diseases, but because these ideas do not fit in the long-standing models created by other physicians, and because of incentives that cause them to be overly conservative in ideas and also financially motivated to continue the status quo of surgical options.
Christian Guilleminault MD (with others) a Stanford scientist largely unknown to many specialists has re-discovered ancient knowledge that most sleep, breathing, nasal and facial aesthetic problems is actually due to a human flaw in facial structure that promotes mouth-breathing during sleep. Seemingly harmless on first glance, this common facial structural problem and its resultant mouth-breathing state cause extensive problems from sleep apnea to premature facial aging and nasal bridge “humps”.
In short, the concept (we call it “#breathewrong”) works as follows: Throughout the course of human evolution, the jaws have been progressively shrinking, from the large snout of our ape-like ancestors, to the relatively flat faces of our current selves. These shrinking jaws create less room for our tongue to rest comfortably in a closed mouth. So, in individuals with more petite jaws, when muscle tone is reduced during sleep, the jaws can spring open, causing the tongue to fall backwards into the throat or airway. This is exacerbated with increasing age (less tone) and increasing obesity (larger tongue). Also, the smaller upper jaw (called the maxilla) causes insufficient room for the nasal passage and nasal septum to develop, creating a bending and extruding effect (large, twisted or deviated noses). This further predisposes to mouth-breathing due to a blocked nose, and creates additional aesthetic issues associated with a “weak chin”.
So, who cares about night-time mouth breathing? We all should. When the jaws are open, and the tongue is free in a low-tone state to collapse back into the throat, serious problems can occur. First, as our bodies attempt to take in air (or inspire) during the tongue collapse or obstruction, a vacuum effect (or negative pressure) is created in the throat creating snoring, and stretching or damaging our throat tissue. This creates a sound annoying to our sleeping partners, or an observing parent, and causes throat pain, dryness and discomfort. The disruption in breathing also causes our oxygen levels to temporarily drop, which creates headaches (like altitude sickness) and poor sleep quality.
So, why is this not common knowledge? There are many answers to this question, and we will explore this in depth in this book: 1) Flaws in the medical research and peer review process, 2) excessive specialization or compartmentalization (for example where one specialist sees only one aspect of this problem and only treats the specific symptom instead of the big picture problems, 3) The hidden conflict of interest that the specialist must face where they are rewarded for more procedures or treatments even if dated or only marginally helpful (These asymmetries are outlined in Taleb’s most recent Incerto book: Skin in the Game. 4) Long-propogated misunderstandings of the actual cause and effect of these problems in the medical and dental education process due possibly to the Ludic fallacy (see above) 5) well-meaning but misinformed patients and families who request or even demand unnecessary procedures or medication without realizing the harm they risk, sometimes even further mislead by “internet research” that is actually thinly veiled marketing material produced by the specialists.
Further, the book discusses the #breathewrong concept in details, including useful evidence, and discussing disease entities in detail, including case reports that many will relate to!
For example, in deciding whether or not to have their child undergo tonsillectomy for snoring and sleep disorders, a specialist typically will recommend treatment. But, are they recommending the correct treatment? Are they “Fooled by Randomness?”, (The title of another book in Taleb’s Incerto. Is this truly in your child’s interest? Does the specialist truly understand the cause and effect? Is there evidence for the alternative perspective? By re-evaluating the medical literature, one can find the answers to these questions, but not via the typical channels because of the reasons highlighted above. By looking at the paradigm through a new lens, we can gain new understanding. In one large scale paper that reviewed many studies (Cochrane database), it was found that almost half of children do as well with time as with surgery. This makes surgery still sound appealing, right? Fifty percent success is still success, right? But, another meta-analysis (large study of many studies) shows that half of children who are treated with surgery are unsuccessfully treated. When taken alone, these studies show fifty percent success…This is ok, right? But, when analyzed together, we realize, that the same fifty percent of children that would have improved with time are the same cohort that had surgery success, while the fifty percent that failed surgery are possibly the same fifty percent that failed to improve with time. Thus, the surgery may truly be of limited value, opening the possibility that the alternative view, as outlined above, related to facial growth may be the real issue. In other words, the fifty percent that experience sufficient facial growth with “outgrow” their symptoms, and the other fifty percent, where both time or surgery are failures, have not undergone sufficient facial growth to outgrow their sleep disorder.
And of course, in many cases, the answer for parents and patients is: “Above all do…less”. But, not every time, and in many cases, by providing us with a wrong answer that makes us feel satisfied, we do not seek or have access to the proper, safer, smarter answers.
We always want to do the right thing for our health and our families by seeing the best expert we can find for our ailments. But what if the experts were not as truly expert as we thought or worse, actually were recommending actually harmful treatments while we blissfully and ignorantly feel in control? The smile, the excellent manners and white coat all contribute to our feeling of trust in the experts, but what if the trust is misplaced in many cases? What if the answers are completely misleading and even backwards? How can we even test for this when nearly all of the experts have similar perspectives? Is there a way to prevent flu transmission beyond “wash your hands”? Are the flu and strep really different manifestations of the same problem? And what does this all have to do with aesthetics? Small jaws also result in reduced aesthetics and accelerated facial aging. So, when we see disastrous aesthetic results in celebrities, we need to guess no further as to why failure is so common. The goals of the failed cosmetic surgeon is to “remove wrinkles”. While wrinkles are associated with aging, they are not what actually causes our perception of aging. In reality, aging is due to the mismatch of our facial soft tissue (skin) with a shrinking facial skeleton, causing drooping with gravity. Thus, the simple act of restoring the balance between soft tissue (ie brow position, cheek height, jawline) with the smaller facial skeleton is all that is required, if it can be done with no collateral damage. We all are witnesses to the odd look of the “wrinkle removed” socialites and actresses. In contrast, the celebrities with the largest cheekbones and jaws have more favorable soft-tissue to skeletal mismatch, so tend to “age gracefully”, although in People magazine interviews always ascribe their luck to their amazing exercise and diet regimen, or personal skin-care line (always available for sale, but actually generic skin-care)…
Finally, the book explains our “#about-face!” concept, where patients and families can be empowered to address the problem directly and effectively without being beholden any further to the sometimes harmful and lucrative business model of the specialists and their treatments. “#about-face” is about reversing the shrinking-jaws process in kids and adults, and how to treat the nose and prevent mouth-breathing without excessive risk with wearable devices or with limited procedures. Readers will become experts in understanding theirs and their children’s disorders, and for the most part will be able to find DIY solutions that are less risky and more effective than what they would ever believe…In addition to medical treatments that focus upon jaw closure, and nasal opening strategies, the #aboutface concept also uses knowledge from another of Taleb’s Incerto books, “Antifragile”, where the process of shrinking jaws is reversed counter-intuitively via exposing our bony skeletons to constant stress, they will become more robust, reversing the diminishing jaw effects described above.
2 Breathewrong Concept: Propogating a flawed idea endlessly
3 The nuts and bolts of the dynamic airway and face
4 Analyzing the conventional view of the airway and why it may never change: Ludic Fallacy, confirmation bias, compartmentalization, hidden conflicts of interest (asymmetry of knowledge), misuse of statistics, mistaken cause and effect models,
5 So what does this mean to you? (How does this manifest clinically?
Nasal congestion, sleep apnea, chronic tonsillitis, sinusitis, headaches
6 A better way to fix the problems yourself
7 A better way to fix the problem with simpler, safer rhinoplasty
8 Preventing respiratory infections with humidification and mouth closure
9 Rethinking aesthetics of the face to avoid the alien celebrity look at all costs
10 Performance and improved sleep. Is the airway/face relevant?
11 How to deal with specialists when you need to! A guide for patients and primary care providers
Target audience: Anyone who is not completely satisfied with their treatment of any respiratory ailment or facial aesthetic problem by the conventional treatments or wants to learn more