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Can Sleep Problems Cause Benign Positional Vertigo?

A few days after my 3rd son Brennan was born, I suffered from classic benign positional vertigo. Looking back on the course of events, I had a eureka moment last night that literally kept me up in bed.

 

Benign Positional Vertigo (or BPV) is a well-described inner ear condition that otolaryngologists like myself treat all the time. The classic description is when you feel dizzy, like the room is spinning, just after a sudden head movement, either up or down, or side to side. The spinning will usually last a few seconds, and you may have residual nausea and imbalance for hours to days. It’s typically preceded by an infection, head trauma, stress, or in many cases, no significant events at all (50%).

 

The Dix-Hallpike maneuver is performed to make the diagnosis and the Modified Epley is then continued on to cure the problem if the Dix-Hallpike is positive. In my experience, the Epley maneuver works about 80-90% of the time to cure the problem instantly if the Dix-Hallpike is strongly positive. It’s one of the more gratifying maneuvers/procedures that I perform.

 

When I developed BPV, I didn’t have an infection, or had any kind of head trauma. The only thing I can remember is that I was severely sleep-deprived the prior few days with all the excitement surrounding Brennan’s birth. I had the classic symptoms: spinning lasting a few seconds aggravated by sudden head turns, particularly every time I lay down in bed or rolled over to the left. After performing the Dix-Hallpike and Epley maneuver on myself, the condition got better.

 

The explanation for BPV is as follows: Your inner ear has three semicircular canals in three different planes, each filled with fluid and a sensor that sways back and forth, depending on which direction you turn your head. Essentially, these three paired semicircular canals tell your brain your head position. At the ends of each of these canals, there’s a sensor that sways back and forth, depending on which direction your head moves. Small calcium carbonate stones are stuck to the top of these sensors, making them sway easier. 

 

The theory is that if one of these stones falls off, and as you move your head into a certain position, the stone moves to the top of the semicircle. Then the stone takes a few seconds to slowly move down the canal, until it reaches the bottom-most/gravity dependent position in the semi-circle. During movement of the stone, fluid waves are transmitted to the sensor which sends a one-sided signal to the brain, which thinks you’re moving your head.

 

Various models and even surgical findings (of otoliths, or ear stones) confirm this theory. But here’s a more plausible explanation, based on my own experience. Stones are constantly regenerated and some fall off the sensor occasionally. However, if you suffer head trauma, more stones may become dislodged and produce the symptoms. But why would a viral infection cause a stone to become dislodged? In most cases, there’s no history of infection or head trauma at all.

 

Any infection, whether a common cold or sinusitis, causes swelling in the nose and throat which narrows the upper airway, which narrows the throat even further, leading to more obstructions, causing more reflux, leading to more throat inflammation and narrowing. (I discuss my sleep-breathing paradigm in much more detail in my book, Sleep, interrupted.)

 

What’s probably happening is that sleep deprivation of any kind, including that period after a new baby is born, sleep apnea, upper airway resistance syndrome, or insomnia, can all heighten your nervous system, leading to hypersensitive sensors. It’s like when you get a migraine and certain noises or bright lights can make you cringe. In the same way, a hypersensitive inner ear sensor can over-react to any extra form of stimulation, including otoliths. 

 

If you take this concept even further, if the other parts of the inner ear are also extra sensitive, then you can have anything from hyperacusis (sensitivities to certain sounds or voices) to ringing. This could apply to Meniere’s as well.

 

So ultimately, it may not be the free-floating stone, per se, that causes your symptoms, but that if your nervous system is extra sensitive to stimulation due to various forms of sleep deprivation or added stress, then you can suffer classic BPV symptoms. 

 

Am I completely out of line, or am I on to something? Please give me your opinion in the box below.

Is the XMRV the True Cause Of Chronic Fatigue Syndrome?

Q: How can I tell if I have a cold or an allergy?

 Q:
How can I tell if I have a cold or an allergy?

A: Allergies are more common after exposure to certain environments, such as spring pollens, cats, or dust. You can suffer from sneezing, watery, itchy, runny eyes, or nasal congestion. Colds usually progress and improve over a course of 3-5 days, typically with fever, chills, aches, headache and a runny nose.

To submit your own questions about better breathing and better sleep, visit our Ask Dr. Park forum at: http://doctorstevenpark.com/forum/ask-dr-park.

Sleep Is The New Black: 5 Steps to Get What You Need and Want

When a Need Becomes A Want

Imagine a day when you can wake up naturally on your own, on time, without an alarm clock, revived and refreshed in the mornings, ready to face whatever challenges that may come your way. You work hard, and play harder, and when you hit the pillow, you fall asleep instantly, sleeping soundly and restfully, without a care in the world.

For most of us, however, things are very different. Getting a good night’s sleep is the holy grail of modern society. We all want it, but it remains as elusive as ever.  So the question is: how can we get more of what we all want and need? The answer is simple: Change your mindset.

Can You Get Instant Sleep?

You may have guessed by now that this article is NOT about the latest sleeping pill on the market. Although it would be easier to pop a pill to get some sleep, the results wouldn’t last too long. In fact, many of the short term solutions out there that promise better sleep fast, only deliver just that: speed without substance. Also, if clinical studies are any indication, taking a sleeping pill isn’t proven to help you get to sleep faster than a sugar pill will.

Sleep in modern times has become commodity—something to be bought, measured and traded. In some cases, it’s even thought of as a nuisance. Who can sleep when there’s so much to do, and so little time to do it in?

More often than not, we ask ourselves, “What can I take (or do) to sleep better?,” rather than, “How can I think differently about my sleep in general?” By cutting out the initial step where we change how we think about sleep, we set ourselves up for failure.

However, if you’re willing to shift your mindset for the benefit of getting more sleep, here are some steps you can take to help you on your quest. Take the time and effort to go through each step and in no time at all, you should be getting the kind of restful nights sleep you need and desire.

Step 1: Learn From Sleep

In yoga or any other discipline where proper breathing is emphasized, observing your breathing before you take control is a common theme. This is what’s emphasized long before the stretching or the poses. Similarly, it’s good practice to observe your sleep quality and habits, being mindful of which activities, foods, or habits give you a good night’s sleep versus a bad night’s sleep. Write down these observations in a daily sleep log, including times you went to bed and woke up, and how you felt in the morning. Once you’re able to observe, reflect on and document your sleep qualities and characteristics, it’s time to either fine-tune your sleep or even undergo a complete sleep makeover.

Before you begin to make any changes to your sleep patterns, it’s important to get yourself in the right frame of mind. Rather than say to yourself, "I just want to sleep better," think about and even write down why good sleep is important to you. I know that this sounds elementary, but clarifying the end result in this way, rather than setting sleep up as the ultimate desired goal, can help you leverage more of what you want in the long run. After all, it’s not the sleep itself that you probably want, but the results that good, quality rest can yield, like your health and vitality. So ask yourself the following clarification questions:

•    If you are able to achieve better quality sleep, what will it enable you to do, feel, or accomplish?
•    Will it allow you to enjoy more of what life has to offer? Like more time to enjoy spending with friends and family without having to struggle with fatigue and exhaustion
•    Will you look forward to getting up in the mornings and not dreading it like you do now?
•    Would losing weight and feeling healthy be important for you?

Next, write down your answers to these questions and rank them as goals in order of importance. Then picture in your mind what you ranked as being the most important aspect of getting better sleep. It may be that you could play with your children without feeling a sense of overwhelming fatigue or being able to look and feel well rested and refreshed at work and throughout the day. Picture them until these visual images evoke the emotions you desire. Anchor these feelings to the specific goals you want to achieve.

Finally, think about the consequences of not doing anything at all. Will you continue to feel too exhausted to do anything? As I’ve stated earlier, without changing the way you think about sleep, as a means and not an end itself, nothing will change even after you get the sleep. This is why sleeping pills let us down, literally.

Step #2: Change The Way You Think About Sleep

Earl Nightingale, a self-improvement guru from the 50′s in his classic recording, The Strangest Secret, states, "We become what we think about." If you are constantly thinking about your ultimate goal, then your actions will reflect your ultimate goal. Just like every important habit in life, you have to take small consistent steps. Always keep in mind your ultimate goal. Then give yourself a reasonable timeframe in which to accomplish your goal and to set small manageable initial tasks for yourself.

How will you know when you’ve succeeded? Again, Nightingale states, "Success is the progressive realization of a worthy ideal." Stated another way, making gradual progress toward your goal is considered success. But this takes effort that you must ingrain into a daily habit.

I’ve written various articles in the past on specific steps you need to take to obtain better quality sleep. What I want to focus on here is the mindset that’s necessary to progress towards your worthy ideal, rather than specific steps. Take, for example, the common habit of eating close to bedtime. In New York City, it’s almost a norm that you’ll come home late and eat dinner just before crashing in bed. Or you may have erratic work schedules.

Eating late close to bedtime prevents quality sleep because juices from your stomach can be actively suctioned up into your throat, especially if you stop breathing once in a while (for most modern humans). This not only wakes you up (before you turn over), but also inflames your throat with stomach juices, causing post-nasal drip, throat clearing, chronic cough, and a lump sensation in your throat. (I explain in much more detail why this happens in my book, Sleep, Interrupted.) Drinking alcohol before bedtime is even worse—by relaxing your muscles, it aggravates the obstructed breathing episodes.

Many of you take my advice and have reported to me dramatic changes in not only the quality of your sleep, but your overall sense of well-being and improved productivity during the day. However, there are some of you who absolutely can’t or even refuse to change, for various reasons. Excuses include: I get home too late from work, I have to exercise, or I’m not going to stop going out with my friends. Some insist on a pill for the throat pain, hoarseness, lump or cough, despite the fact that changing your eating and alcohol habits alone may be enough to help. Even if a medication is given, there’s a very low chance that you’ll feel any better in the long run. It’s like giving a cough medication when you continue to smoke 2 packs per day.

Step #3: Don’t Fixate on Sleep

Another mindset change that’s necessary to achieve the goals you desire is to simply become more flexible. In the international bestseller, Thick Face, Black Heart: The Warrior Philosophy For Conquering The Challenges of Business and Life by Chin-Ning Chu, the author points out that one small blade grass, unlike even the tallest trees, can withstand enormous gusts of wind by yielding and bending to the force.

Similarly, the demands of modern society pose many challenges for sleep and rest. Although it may be true working late is an inevitable part of your job, you’d be amazed how well you can work around these challenges once you make sleep a priority.

Yes, we all have certain limitations with our schedules, our jobs and other commitments, but what I’m describing is the limitation of your mind. If your main priority is to sleep better, and you have obvious nighttime habits that are clearly detrimental to your sleep quality, you’ll have to first change your mindset. Only by changing your values and priorities can any real change begin to happen.

If you can’t change your work schedule, you can order out and eat while at work. You can exercise in the morning rather than in the evenings. You can have a large lunch and eat a small snack early after coming home from work. You also have a choice in whether or not to go out late drinking with your friends 2 times per week. Once you decide to make changes you’ll see that there are always options available. Whether or not you choose to make these changes, however, is up to you.

Simply by being consistent with and not resisting the natural biorhythms of our nature, many people have found that not only can they work better, they can enjoy the fruits of their labor that much more. Isn’t that, after all, the ultimate benefits of sleep and work?

The Hidden Truth About Allergies Revealed

Everyone knows that allergies cause sneezing, itchy, watery eyes, and nasal congestion and that for some people these symptoms can be more severe than for others. For these people allergies can feel like a curse, making them feel sleepy, irritable and downright miserable. There are many medical explanations for allergies, including the theory that the body is overreacting to the typical allergens.

But there’s one other reason why some people with allergies are more affected than others, and this has to do with their jaw size. If you had normal-sized jaw anatomy, then it’s less likely an allergy attack would bother you; in fact, it’s less likely you’ll even have allergies in the first place. Let me explain.

Why Your Jaw Size Matters

If you have smaller than normal jaws, it means that there’s less space for your tongue, so it takes up relatively too much space, especially when you’re on your back due to gravity. Even worse, whenever you’re in deep sleep, due to muscle relaxation, you’ll stop breathing to wake up and turn over. During these breathing pauses, a vacuum effect is created temporarily, which literally suctions up your normal stomach juices into your throat and nose. It’s been shown that stomach bacteria and digestive enzymes can be found in sinus and lung washings. This leads to inefficient sleep, which eventually makes your nervous system and immune system overactive.

This is why it’s important to avoid eating too close to bedtime. The more juices you have in your stomach, the more it’ll come up and cause nasal inflammation. And since alcohol is a strong muscle relaxant, indulging in a glass of wine before bedtime can make you stop breathing more often and cause more stomach juices to come up into your throat, in addition to heightening your immune and nervous systems.

What You May Not Know Will Surprise You

Sometimes, what seems to be allergy symptoms may not be related to allergies at all. Whether or not your allergy testing is positive, you may be suffering from non-allergic rhinitis or chronic rhinitis, which is linked to sleep breathing problems or silent acid reflux (LPRD). With non-allergenic rhinitis, your nose becomes sensitive to temperature, pressure, humidity changes, chemicals, odors, and emotions. Non-allergic rhinitis responds somewhat to allergy medications, so you may think you have an allergy problem.

One of the most under-appreciated things that most allergy sufferers (and doctors) don’t think about is getting a good night’s sleep. It’s been shown that lack of quality (or quantity of) sleep can adversely affect your immune system through the following mechanism: a low-grade physiologic stress response is created which heightens your immune system, making it over-react to common pollens or other allergens. (The same process occurs with your nervous system, too). So how does this relate to allergies?

Hay Fever Defined

Hay fever (or allergic rhinitis) results in congestion, sneezing, runny nose, irritated eyes and other annoying symptoms for more than 35 million Americans every year. It occurs when your body has an allergic reaction to something in your environment. During this time of the year, ragweed is the most common cause of hay fever, though mold, pet dander, dust mites and cockroaches can also cause allergies year-round.

When your body comes in contact with these allergens, your immune system kicks into overdrive. At the initial allergen exposure, the body creates an antibody called immunoglobulin (IgE), which rests on a type of white blood cells called mast cells. After repeated exposure to the same allergen, a massive release of histamines and other inflammatory mediators occurs. The end result—runny nose, watery eyes and sneezing.

When Allergies Cause You Misery

Obviously, a little sneezing and congestion never hurt anyone. For most people, these symptoms are no more than a mere nuisance and most can get by without any medications or for others, simple over-the-counter medications (see chart). However, some people with allergies feel completely miserable, with poor sleep and severe daytime fatigue.

As I alluded to in my book Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, anything that causes swelling or inflammation in your nose or throat can set off a vicious cycle where due to narrowing of the upper air passageways, the soft tissues of the throat (palate and/or the tongue) start to obstruct your breathing, which creates a vacuum effect in your throat that suctions up normal stomach juices into your throat. This causes more swelling and inflammation in your throat and nose, aggravating this self-perpetuating cycle.

Steps You Can Take

During allergy seasons (trees during the spring, ragweed during the fall, molds all year round), there are a number of conservative step you can take to lessen your symptoms, to more formal medical treatments:

● Stay indoors during high pollen counts with air conditioning (check pollen counts on pollen.com)

● Wash your hair before going to bed if you’ve been outdoors during the day. You don’t want to rub your face on your pollen-contaminated pillow all night long

● Most plants release pollens in the early morning, so if possible stay indoors until after 10AM. Pollen and molds can also be high in the late afternoon and early evening hours

● Wash your bedding every week in very hot water

●Invest in allergy-free bedding (if you’re allergic to dust mites)

● Try the Asian custom of taking off your shoes before entering your living spaces. Think about all the microscopic dust, pollen, molds and dirt that get tracked into your house, where your toddler is crawling on.

● Invest in a HEPA filter for your bedroom

● Keep pets out of the bedroom

● Remove rug or carpeting from the bedroom

● Finish eating at least 3-4 hours before bedtime

● Avoid alcohol within 3-4 hours of bedtime

● Regularly practice yoga, breathing, tai chi, or some form rhythmic meditative breathing (which also includes swimming).

A few natural and/or herbal remedies include:

● Regular irrigation with nasal saline. There are many options, including a Neti-pot, saline sprays, mists, pumps and squeeze bottles. The key is to find something you’re comfortable with that you’ll use every day. ●

Butterbur and stinging nettle extracts are two herbs that have anti-allergy properties. You can find them at any health food store or order them online. If the above conservative options are not good enough, you can try any of these over-the-counter allergy medications:

● Loratadine (brand name Claritin, Allavert, etc.) or Zyrtec. Zyrtec is stronger, but has a slightly higher chance of making you drowsy. If you take it regularly at night before you got to bed, this any potential drowsiness won’t be an issue and this effect wears off after a few days. ● Diphenhydramine (Benadryl). This is an older, stronger antihistamine, which can definitely make you drowsy. It’s also used to severe allergic reactions and rashes.

● Oxymetazoline (Afrin) can be used for severe nasal congestion only occasionally and should be used no more than 2-3 days at a time.

If you also have nasal congestion, then you can get the "-D" version of the various antihistamines. The D stands for decongestant, which is usually an oral version of phenylephrine or pseudo-ephedrine. This can sometimes be stimulating, so if you’re sensitive to these medications, don’t take it just before bedtime. If you have high blood pressure or a heart condition, talk to your medical doctor before taking these specific medications.

There are a number of prescription medications for allergy: Allegra (which should be coming out over-the-counter soon), nasal steroid sprays (Flonase, Nasonex, Rhinocort, Nasacort, Veramyst), and Singulair. Astelin is an antihistamine nasal spray. Different people respond differently to each of these medications, so it’s important to talk to your doctor about which one may be right for you. My preference for moderate to severe allergies is to use one of the topical nasal steroid sprays on a regular basis, since it works much better at preventing allergies, as well as treating it. In general, these sprays are not absorbed into the body in significant amounts and can be used for long periods.

Allergy shots (immunotherapy) are another option that you may want to consider if your allergies don’t respond to medications or if you don’t want to depend on medications as much. With immunotherapy, the sufferer receives regular injections of purified allergen extracts for between two to five years. The goal of immunotherapy is to rewire the immune system so it no longer overacts to allergens and causes hay fever.

Putting It All Together

If you have an underlying sleep-breathing problem such as obstructive sleep apnea or upper airway resistance syndrome (most people to some degree—I explain why in my book, Sleep, Interrupted), then it’s likely that you’ll have some kind of allergies or nonallergic rhinitis, whether mild or severe. Not only will your nose be overly sensitive to allergens or weather changes, it can also be irritated by your stomach juices.

This process supports observations that children who were bottle-fed as infants have higher rates of allergies later as children. It’s been suggested that bottle-feeding promotes jaw narrowing and dental crowding, which leads to smaller airways. This occurs despite the protective effects of the mother’s antibodies in breast milk, since it may be given in a bottle. So the next time you suffer from seasonal allergies or even year-round allergies, resist the temptation to simply take a pill. Go down the list of conservative options I’ve outlined, and most importantly, optimize your sleep quality. Any activity that’s calming and relaxing to your nervous system (yoga, breathing exercises, tai chi, swimming) can also help to alleviate your symptoms. Many of you will be surprised to find that conservative and simple lifestyle changes can lead to many more allergy-free, symptom-free days.

A Link Between Sleep Apnea and Diabetes Confirmed—Again

It’s almost a given that you’ll see headlines regarding sleep apnea every few days, about how it’s linked with heart disease, diabetes, high blood pressure, weight gain, and sudden death. Unfortunately, it’s gotten to the point where you’re likely to yawns at these findings because you’re so inundated with more interesting medical news and other celebrity media stories. Bare minimum, you might glance at the brief article and think, "that’s interesting," and then go on to the next story. 

 

Recently, there’s been news about the National Transportation and Safety Board making recommendations about mandatory screening for all commercial airline pilots, commercial truck drivers, ship pilots, and transit train operators, in light of many recent events including pilots that fall asleep and miss their destinations due to undiagnosed sleep apnea. Yawn.

 

A recent Johns Hopkins study showed that if you have severe sleep apnea, you have a 46% increased risk of dying compared with those that have mild to moderate sleep apnea. Yawn. We already know this information. Sleep apnea patients have a much higher risk of dying from heart attacks or strokes.

 

A study now shows that your risk of developing diabetes is 2-3 times higher if you have severe sleep apnea and you have daytime sleepiness. We already know that sleep apnea is independently linked to diabetes.

 

I guarantee that many more studies will be released repeating these same findings over and over again, linking or associating one variable to sleep apnea, without flat out saying that one causes the other. 

 

I wonder what will it take to significantly elevate sleep apnea awareness in this country? Celebrities with sleep apnea? We already have a few including Rosie and Regis. Politicians with sleep apnea? With the congress being mostly older men, I’m guessing about 1/3 to 1/2 of our leader have at least some degree of sleep apnea.

 

Mandatory Sleep Apnea Screening for Everyone?

This is an incredible story, but unfortunately, it probably happens more often than you think. The NTSB (National Transportation and Safety Board) recently investigated a Hawaiian airline incident where both pilots fell asleep and missed their destination by 18 minutes. Air traffic control was able to wake up the pilots, who turned around and landed the passenger plane safely. The captain was later diagnosed with obstructive sleep apnea.

 

There are numerous other reports of train, bus and tracker trailer accidents, many of them fatal due to the driver having suspected obstructive sleep apnea.

 

After a long investigation, the NTSB recommended that all long-distance truckers, airline pilots, bus drivers, merchant ship pilots, and train operators should be screened for obstructive sleep apnea. This is a step in the right direction, but what about the rest of the population? 

 

It’s been estimated that  24% of middle aged men and 9% of women have at least mild sleep apnea. This is one of the most often cited statistics from 1993. I would think that with the obesity epidemic, the numbers are now much higher. A recent study looking at active independent seniors (ages 71-87) showed that 55% had significant sleep apnea. These numbers are much higher for seniors that are hospitalized. 

 

You don’t have to be a commercial pilot, truck or bus driver to be at risk for sleep apnea. Everyone is at risk. If you have untreated sleep apnea, you are over 6 times more likely to get into an accident. Your reaction times are worse than being legally drunk. Snoring alone alone without sleep apnea also increased your risk by 300%. 

 

Truckers will argue that most commercial accidents are caused by passenger vehicles. All it takes is one sleepy passenger car driver to cause a major bus accident. 

 

Interestingly, another study showed that snoring men with daytime sleepiness or witnessed apneas drive more than others. It’s a scary thought. What they’re probably doing is to choose an activity where sustained vigilance is needed, but unintentionally, they are placing themselves and others at increased risk.

 

I admit that there are logistical and financial implications to putting into place a universal screening program for sleep apnea. Besides the costs alone, what do we do with people who can’t drive the bus or work at all while waiting to be cleared? What about all the people who can’t tolerate any of the treatment options? Do they go on disability? Do they have to switch to other careers? 

 

On the other hand, the potential benefits are enormous. Treating the remaining 90% of undiagnosed sleep apnea patients will significantly lower the cost of providing healthcare since it’ll prevent or significantly lessen the severity of many medical conditions such as hypertension, diabetes, obesity and cardiovascular disease.

 

Given all these issues, what do you think about universal screening? Please respond with your comments in the box below.

UPPP Revisited for Obstructive Sleep Apnea

The uvulopalatopharyngoplasty (UPPP) procedure is probably one of the most controversial issues in sleep medicine for sleep apnea treatment. Despite study after study showing limited success rates, surgeons continue performing this procedure. Some in the sleep community are adamant that with such low success rates, it should not be performed anymore. But then there are studies that come out once in a while that show there’s some benefit to this procedure. With all the conflicting information and confusion, who are you to believe?

 

A recent paper published in the Mayo Clinic Proceedings concluded that there’s still a role for the UPPP in some sleep apnea patients. While not "curative" in all patients, a significant number of people had improvements not only in their sleep apnea scores, but also in quality of life measures. (Take a look at my response to Sleep Apnea Ed’s blog here.)

 

With the UPPP, the overall "success" rate is found to be around 40% in numerous studies. You could say that it doesn’t work most of the time (60%), or that it worked 40% of the time. Is there a way to predict who’ll respond and who won’t? A common screening system developed by Dr. Friedman showed that if you have very large tonsils and a relatively low-sitting tongue, and you’re not very overweight, then you’ll have about an 80% chance of surgical "success." Unfortunately, not too many people fit into this category.

 

ENT surgeons tend to overly focus on the soft palate, mainly because that’s where the snoring is coming from, and it’s the traditional operation that we do for snoring and sleep apnea. Now we know that the soft palate is only a small part of the condition that causes sleep apnea. Once you address the entire upper airway (from the tip of the nose to the voice box), then surgical success rates can go as high as 80%. If you make the jaws much larger (the maxilla-mandibular advancement, or the MMA), success rates are well above 90%. The thinner you are, the better these procedures will work.

 

One study that I recall showed that even the 40% success rate was better in the long term than CPAP. Patients were recruited from a VA hospital with newly diagnosed sleep apnea and two groups were followed: CPAP users and UPPP patients. What why found a few years later was that you had a higher chance of being alive if you underwent a UPPP than if you were assigned to the CPAP group. Even though the overall success rate for UPPP is only 40%, these 40% stayed "successful", at least for the first few years. CPAP users, on the other hand, probably began to drop off in using their CPAP machines, at after a few years, compliance was poor. Based on research that shows that your overall risk of dying from cardiovascular disease in much higher if your have untreated sleep apnea, these results make sense.

 

Of course there’s still a lot more we as physicians can do for sleep apnea patients before they even consider surgery (counseling for CPAP, oral appliances, etc.), but once they run out of all other options, it’s important to know the facts and see the big picture. With good patient selection, intensive counseling, and setting realistic long-term goals, surgery can be a good option for some people. Usually, a UPPP alone is never the answer.

 

How many of you have undergone a UPPP operation and it didn’t help? How much counseling, follow-up and support did you receive with CPAP or oral appliances? Was multi-level surgery offered besides just a UPPP? Please enter your response in the text area below.

Sleep Apnea Success: What Does It Mean?

If you have sleep apnea, success has many meanings. In the ideal situation, it means that you feel great, you don’t have to use any gadget or device when you go to bed, and your sleep apnea score (AHI) is 0. 

 

Unfortunately, the definition of success in the sleep apnea research fields keeps changing depending on who’s reporting it. In general, the surgical definition of success is a drop in the final AHI (apnea hypopnea index) of greater than 50%, and the final number is less than 20. Some use an AI (apnea index) being less than 10. Rarely, some people use 5. Some studies report two or three definitions simultaneously. Studies report anything from 40% to 95%, depending on different types and combinations of procedures.

 

For CPAP users, there are multiple definitions of success. One common definition is when CPAP is used at least 50% of each night for at least 4 out of 7 nights. Actually, this is a measure of compliance, meaning, how well did the patient stick to using the machine? Reported compliance rates using different criteria range widely from 20% to 90%.  

 

Surgical success and CPAP compliance doesn’t measure the effectiveness of the form of therapy. In other words, do you actually feel much better? Is it lowering your blood pressure, or are you feeling less depressed? You can be using CPAP 100% of the time 7 days a week, or your AHI after surgery can drop from 45 to 3, and you may not feel any better. These same concepts apply to oral appliances as well. 

 

What you may find is that although you’re using CPAP every night, your "effective" AHI each night is still relatively high, and not anywhere near the near 0 levels that were obtained during the CPAP titration study. Since the vast majority of CPAP machines that are prescribed will only measure "compliance" data, you’ll never actually know how effective the treatment is when you’re actually using it. Some of the more advanced models are able to tell you what the effective AHI is every night. For only a few hundred dollars more, it’s probably worth giving every patient models with these features.

 

Even if you’re "successful" in the beginning, how will you feel 20 to 30 years from now? Will you still be using your CPAP machine 100% of the time, or will your AHI remain at the same levels just after surgery? Probably not. 

 

As I’ve describe with my sleep-breathing paradigm, all modern humans are susceptible to sleep-breathing problems to various degrees. It’s a normal part of being human, mainly due to our ability to talk. So thinking of any of these treatment options as a cure is a mistake, since the forces that create collapses in your throat will only get worse as you get older. (Find out more about these important concepts in my book, Sleep, Interrupted.)

 

Just like any chronic condition, managing sleep apnea has to be considered a life-long process of constant adjusting and fine-tuning, rather than thinking of these treatments as a one time "cure."

 

Are you a successful sleep apnea patent? How has your mindset changed regarding "success" since you first started treatment? Please enter your responses below in the comments box.

Tongue Retaining Device for Obstructive Sleep Apnea: Does It Work?

There are many variations of oral appliances to treat snoring and obstructive sleep apnea, but one variation that you may not have heard of is the tongue retaining device (TRD). There are also different variations of TRDs, from suction bulbs to hybrid mandibular advancement device-TRDs. Here’s one example and here’s another. Here’s a good review of the science behind tongue retaining devices.

 

In this month’s issue to Journal of Clinical Sleep Medicine, French researchers reported complete or partial responses in 71% of cases, with the mean AHI dropping from 38 to 14. Snoring dropped by 68%, and subjective sleepiness dropped significantly as well.

 

What I had in mind when I saw the paper’s title was the suction cup-like device that sits between your teeth and lips, with a bulb protruding out your mouth. Your tongue sits inside the suction cup, keeping it from falling back. A simple and novel idea. However, when I looked more closely at the study it turns out that what they call a tongue retaining device is actually a hybrid mandibular advancement device and TRD. We know that mandibular advancement devices, by pushing your jaw forward can significantly push your tongue base forward, improves the space behind your tongue. The researchers set the mandibular protrusion at 50 to 75% of maximal protrusion, which can definitely improve your sleep quality.

 

Although my experience is limited, I’ve had mixed results in people who have tried tongue retaining devices. In general, they’re not as expensive as the formal mandibular advancement devices, so there’s less of a barrier for people to try it out. 

 

Just out of curiosity, I have patients stick out their tongue whenever I examine the space behind the tongue while they’re lying flat on their backs. This is a rough estimate, but only in about one out of 4 times, do I see any significant improvement in the posterior airway space. This may explain why many patients don’t see any benefits. Drooling, discomfort and an inability to swallow are some of the more common complaints.

 

Have you tried tongue retaining devices and if so, what’s been your experience? Please enter your responses below.

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