What an ENT Surgeon Learned From Watching People Breathe

By Dr. Carmen Chiran |  7 min read

Before you read another word, take one breath. Not a deep, deliberate, yoga-class breath, just the next ordinary one. Notice where it goes. Upper chest? Belly? Does it feel shallow, or does it reach somewhere lower?

Most people, when they try this, are slightly surprised. They had forgotten they were breathing at all. Remembering breath is what this article is about.

The ENT Angle Nobody Talks About

In twenty years of clinical practice, I have spent a significant portion of my working life inside the upper airway. The nose, the sinuses, the larynx, the structures that make breathing possible, these are my professional home. I know what a deviated septum looks like under endoscopy. I know the particular sound of a collapsing airway. I know what it means when a child is a chronic mouth breather and why that matters far beyond the obvious.

But somewhere along the way, I started noticing something that was not in the anatomy textbooks.

When patients came to me with breathing difficulties, the clinical picture was often clear: obstruction, inflammation, a structural problem with a structural solution. But when I looked at the people sitting across from me again and again, not just the scan, not just the endoscopy findings, I started noticing something else. A particular quality of stillness. A way of taking up as little air as possible, as if breathing too fully might draw attention.

Breath disorders, I came to understand, are rarely only about breath. They are about safety. About permission. About whether a person believes, somewhere beneath the level of conscious thought, that they are allowed to inhabit their own body fully.

That kind of observation, which only years of clinical practice make obvious, belongs somewhere with room for both the anatomy and the human being within it.

What the Nose Actually Does

Let me give you the clinical picture first, because it matters more than most people realise.

The nose is not simply an air inlet. It is one of the most elegantly engineered structures in the human body, and most people treat it as an afterthought until it stops working.

When air enters through the nose, it is immediately filtered by coarse nasal hairs and the mucus-lined walls of the nasal cavity. The turbinates, the three curled bony shelves on the lateral nasal wall, create turbulent airflow that warms and humidifies the air to body temperature before it reaches the lungs. Without this conditioning, the delicate tissue of the lower airways would be damaged with every single breath.

In clinical practice, chronic mouth breathing, particularly in children, is associated with altered facial development, poor sleep quality, and reduced respiratory efficiency. The consequences reach far beyond the airway: into sleep, into concentration, into the cardiovascular system over time.

The nose is the designed route. The mouth is the emergency exit.

When Breathing Goes Wrong

Every clinician learns this early: we understand a system most clearly when it fails.

When the nasal airway is obstructed by chronic inflammation, polyps, or a deviated septum, breathing shifts to the mouth, triggering a cascade of consequences that begins quietly. Sleep quality deteriorates. The upper airway loses tone and collapses during sleep, producing the pauses of obstructive sleep apnoea. Oxygen saturation drops repeatedly through the night. The cardiovascular system, never designed for this, begins to show the strain.

When the diaphragm loses its central role — as it does in people who breathe habitually from the upper chest, a pattern reinforced by chronic stress and anxiety — the body recruits accessory muscles in the neck and shoulders. Tension becomes chronic. The breath becomes shallow and fast, maintaining sympathetic activation even in the absence of any genuine threat. The body stays, physiologically, in a state of low-grade alarm.

The body is listening to how you breathe. It is drawing conclusions.

The Science Behind Conscious Breathing

What makes breathing unlike almost any other bodily function is that it sits at the intersection of the voluntary and the involuntary. Your heart beats without your permission. Your kidneys filter your blood whether you remember them or not. But breathing, you can consciously control, you can slow it, deepen it, hold it, change its rhythm entirely. And yet the moment you stop paying attention, it continues anyway.

Slow, extended exhalations activate the parasympathetic branch of the nervous system, shifting the body toward its natural state of rest and recovery. Rapid, shallow breathing activates the sympathetic branch, the “fight or flight” response. Breath is the only autonomic function with a direct conscious handle. Every other lever — heart rate, digestion, immune response — you can influence only indirectly, through behaviour or time. The breath is the only vital function you can reach right now, with your next exhale.

This is not folk wisdom. A 2023 scoping review in Brain Sciences found that breathwork interventions yield significant improvements in anxiety symptoms for patients with clinically diagnosed anxiety disorders. A 2021 study in Scientific Reports found that even a single session of deep, slow breathing improved vagal tone and reduced anxiety markers in both younger and older adults. What mystics intuited across millennia, that the breath is a gateway to the inner state, is now measurable in a laboratory.

What Civilisations Made of It

Every civilisation that looked closely at what it means to be human looked, sooner or later, at breath, not because it is merely functional, but because something in its nature seemed to reach beyond function entirely. It arrives unbidden. It departs without ceremony. It is the first thing and, in all probability, the last.

In Sanskrit, the word for breath is prāṇa,  the animating principle that breath carries, not breath itself. In Chinese medicine, qi. In Hebrew, neshama means both breath and soul. In Greek, pneuma — both spirit and wind. Traditions separated by centuries and continents, arriving at the same intuition: breath is more than gas exchange. It connects the interior to the exterior, the finite to the ongoing.

Science has not disproved this intuition. In many respects, it has given us more precise language for it.

A Passage From the Book

What follows is from the philosophical heart of the first chapter of Anatomy of Being, a book I have been writing alongside my clinical practice. The chapter is called Breath. Its central question is: Am I present?

“There is a question I find myself returning to, in the consultation room and outside of it: Am I present?

Not in the general sense, not the broad philosophical question of whether I am living fully or wasting my days. In the specific, immediate, physiological sense: am I here, now, in this breath, in this moment?

Most of us, most of the time, are somewhere other than our breath. This is not a moral failing. It is the natural condition of a mind capable of memory and anticipation, two extraordinary gifts that come at a specific cost. The cost is in the present tense.

Breath is the corrective. Not because breathing mindfully is some kind of spiritual achievement, it is almost absurdly simple, but because the breath is always and only now. You cannot breathe yesterday’s breath. Every breath is a return to the only moment that actually exists.

I think about this often in my clinical practice. When a patient is frightened, and they often are, though they rarely say so directly, their fear almost always lives in time. In the diagnosis, they have not yet received, but are anticipating. In the symptoms they have catalogued across weeks of anxious nights. The fear is real, and it deserves respect. But the body sitting across from me is here, now, breathing. That fact is unnoticed, but it is everything.

The philosopher Simone Weil wrote about attention as a form of love, the act of truly attending to what is in front of you as a moral and spiritual practice. Breath, I think, is attention made physical. To follow a single breath from entry to exit, the slight cool of the inhale, the brief suspension at the top, the warmth of the exhale, the quiet pause before the next, means to practise, for a moment, being entirely here. Not performing presence. Not thinking about presence. Being present.”

One Practice You Can Use Today

Every chapter of Anatomy of Being closes with one evidence-grounded practice, something you can do immediately, without equipment, wherever you are. This is the practice from Chapter 1.

The Anchor Breath

The extended exhale activates the vagus nerve, shifting the autonomic nervous system toward parasympathetic dominance. Heart rate variability improves within minutes. Cortisol begins to drop.

1. The Arrival: Take one ordinary breath without changing it. Simply notice where it goes.
2. The Inhale: Breathe in slowly through the nose, four counts. Direct the breath toward the belly.
3. The Pause: Hold for two counts. A resting hold, not a straining one.
4. The Exhale: Breathe out slowly through the nose, six counts or longer. The exhale is longer than the inhale. This asymmetry is what activates the parasympathetic response.
5. The Return: Repeat for five to ten cycles.

Use it before a difficult conversation, after receiving difficult news, at the transition between work and home, or in the first minutes of waking. Anywhere. The breath requires nothing. It is already there.

Why I Am Writing This Book

Anatomy of Being takes eleven body systems — breath, hearing, the voice, the heart, the gut, the skin, sleep, pain, tears, the immune system, the brain — and moves through each one along the same path: what it is, how it works, what happens when it fails, what civilisations across history have made of it, and what philosophical question it raises for how we live.

The first three chapters sit entirely within my ENT world. Breath. Hearing. The Voice. These are the systems I have spent two decades studying and operating on. They are also three of the most profound entry points into questions about presence, attention, and self-expression that philosophy has ever asked.

The clinical and the contemplative are not in tension. They are the same inquiry, conducted from different angles.

Frequently Asked Questions

Is nasal breathing really better than mouth breathing?

Yes, and the evidence is clear. Nasal breathing filters, warms, and humidifies air before it reaches the lungs, and produces nitric oxide in the paranasal sinuses that improves oxygen uptake by up to 18%. Chronic mouth breathing in children is associated with altered facial bone development, poor sleep, and reduced academic performance. In adults, it contributes to snoring and obstructive sleep apnoea. The nose is the designed route; the mouth should be a backup, not a default.

Can breathing exercises actually reduce anxiety?

Yes, and this is now well supported by research. A 2023 scoping review in Brain Sciences examined 16 clinical studies and found that breathwork interventions produced significant improvements in anxiety symptoms across multiple diagnosed anxiety disorders. The mechanism is physiological: slow exhalation activates the vagus nerve and shifts the autonomic nervous system toward its parasympathetic state, measurably reducing heart rate, cortisol, and subjective anxiety. Even a single two-minute session of slow breathing has been shown to increase heart rate variability.

How do I know if I am a mouth breather?

Common signs include waking with a dry mouth or sore throat, snoring, feeling unrefreshed after sleep, and persistent nasal congestion. A simple observation: sit quietly for two minutes and notice which route your resting breath takes. If it is predominantly through the mouth when you are relaxed and not exercising, it is worth discussing with your GP or an ENT specialist, particularly if you also have poor sleep.

What is the diaphragm, and why does it matter for breathing?

The diaphragm is a dome-shaped sheet of muscle stretched across the base of the ribcage. It is the primary muscle of breathing: when it contracts downward, it increases the volume of the chest cavity and draws air in. When it relaxes upward, air flows out. Diaphragmatic breathing is more efficient and less effortful than upper chest breathing, and it directly activates the parasympathetic nervous system. Under chronic stress, many people shift to shallow upper chest breathing, and the diaphragm gradually loses its dominant role, contributing to both physical tension and a persistent low-level state of physiological alert.

References

1. Lundberg JO, Weitzberg E, Lundberg JM, Alving K. Nitric oxide in exhaled air. Eur Respir J. 1994;7(9):1577–1583.
2. Magnon V, Dutheil F, Vallet GT. Benefits from one session of deep and slow breathing on vagal tone and anxiety in young and older adults. Sci Rep. 2021;11(1):19267. PMID 34588511.
3. Banushi B, Brendle M, Ragnhildstveit A, et al. Breathwork interventions for adults with clinically diagnosed anxiety disorders: a scoping review. Brain Sci. 2023;13(2):256. PMID 36831799.
4. Tortora GJ, Derrickson BH. Principles of Anatomy and Physiology. 15th ed. Hoboken: Wiley; 2017.
5. Zaccaro A, Piarulli A, Laurino M, et al. How breath-control can change your life: a systematic review on psycho-physiological correlates of slow breathing. Front Hum Neurosci. 2018;12:353. PMID 30245619.

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Medical disclaimer: This article has been written by Dr. Carmen Chiran, ENT Specialist, for educational and informational purposes only. It does not constitute medical advice and is not a substitute for a consultation with a qualified healthcare professional. The clinical information in this article is based on current guidelines and evidence at the time of publication. If you have concerns about your health or your child’s health, please consult your doctor or ENT specialist.