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Is Your Throat Sore Just Before Your Period?

Here's an interesting observation by more than a handful of my female patients: Their throats are sore for a few days just before their monthly periods. It doesn't go on to a cold or other more severe symptoms. Just a transient sore throat. Then it goes away.

If you've been following my blogs, articles, and especially if you read my book, Sleep, Interrupted, there's a simple explanation. During your monthly cycles, progesterone levels increase with ovulation, but drops when there's no egg fertilization. One relatively unknown property of progesterone is that it's an upper airway muscle dilator. It literally tenses your tongue muscles. When in deep sleep, your muscles (as well as your tongue and other throat muscles) tend to relax to various degrees depending on your sleep stage. If you have less progesterone on board, then it's more likely to fall back, obstructing your breathing, leading to a temporary vacuum effect in the throat, suctioning up small amounts of normal stomach juices. All this causes a temporary deep sleep deficiency. If you eat a late meal, more of these juices will come up. But once progesterone levels begin to increase again, the tongue tenses, and sleep quality improves as well.

 

Sometimes, the inflammation in the throat increases to the point of significant deep sleep deprivation, leading to some of the more severe symptoms as pre-menstrual headaches, fatigue, irritability, and weight gain.

 

For you women out there, do you experience sore throats just before your periods? Please enter your responses in the comments box below.

Health Consequences of Routine Medical Procedures

The New York Times recently ran an exposé on the lack of quality control systems that have lead to a surprisingly high number of radiation overdoses, in some cases leading to death. This reminded me of what they used to do in the 1950s to 60s, where they used x-rays to treat everything from pimples to large tonsils to ringworm. Many women's ovaries were irradiated for depression. What they did in the past may seem barbaric by today's standards, but I'm confident that many of the things we do today may seem barbaric to future generations.

 

There are two procedures that are still being routinely performed that have negative consequences years, if not decades later, and these are rhinoplasty, and dental extractions for orthodontic work. I see at least 4-5 patients a week that come to see me for routine problems, only to find that their "routine" procedure 10 to 25 years ago probably aggravated their current condition.

 

During routine rhinoplasty, especially when you're trying to narrow a wide tip, surgeons by definition have to weaken or remove a portion of the support structures (or cartilages) that keep the nostrils open. Current surgical methods take this into consideration to compensate for this fact, but many surgeons are still weakening the lower lateral cartilages without strengthening the remaining structures. This leads to flimsy nostrils that cave in with every inspiration.

 

As a result of this weakening, patients will have stuffy noses, unrelieved by allergy medications or decongestants. Medicines won't work for structural problems. Sometimes, someone with this condition accidentally tries a Breathe Rite nasal dilator strip, and swears by how wonderful it is.

 

Dental extractions are still being performed as part of routine orthodontic treatment. If there's too little space for the teeth, then it's logical that removing a few teeth can create enough space for the remaining teeth, right? What's missed entirely is that the jaw's too small. The teeth, especially the molars, act as support structures for the soft tissues of the throat. Once removed, the space behind the tongue collapses, leading to significantly lessened quality of sleep. Even simple orthodontic adjustments can have a major impact on sleep quality, since the space that that the tongue is contained in can change dramatically.

 

Fortunately, forward-thinking dentists are recognizing the fact that the position of your teeth and size of your jaws have a major impact on your breathing, and your health. Some of these dentists have leapfrogged ahead of the medical profession in terms of understanding the holistic implications of proper facial form and function.

 

Did you have rhinoplasty years ago, only to have continued nasal congestion, or did you undergo dental extractions before undergoing braces? If so, please describe your experience below.

Ask Dr. Park Your Question About Sleep Apnea Surgery

Please join me as I host another Ask Dr. Park teletraining program on "What You MUST Know About Sleep Apnea Surgery." I get inundated with questions about surgery all the time, and I thought it was time I spoke my mind about this controversial subject. To ask me your question and to register for this event, click here.

 

 

 

Topic:  "What You MUST Know About Sleep Apnea Surgery"

Date:    Tuesday,  February 9th, 2010

Time:   8PM Eastern

 

Click here to register and receive the call-in details.

Tongue Scalloping: A Simple Marker for Sleep Apnea?

Besides the typical descriptions of physical features for someone at risk for obstructive sleep apnea (such as male, overweight, obnoxious snoring, and a big neck), one physical finding that's rarely mentioned is tongue scalloping (click here for picture). This is when you have impressions or ridges on the sides of your tongue where it sits against your molars. One past study showed that having tongue scalloping can positively predict the presence of apneas or hypopneas and oxygen desaturation in 89% of cases. Overall, having scalloping is about 70 sensitive in picking up obstructive sleep apnea. 

The traditional explanation is that the tongue is too big, but for sleep apnea patients, the jaw is too small for the normal sized tongue. If you add additional inflammation due to chronic reflux from the stomach with each obstruction, the swelling of the tongue will only aggravate the dental impressions on the tongue. Along with the small jaws and scalloping, you'll also have a high-arched hard palate, and the tongue sits very high in the mouth, preventing you from seeing the back of the throat more fully.

 

This condition is also described in hypothyroid patients, but as I've stated before sleep apnea can cause hypothyroidism.

 

Take a look at your tongue in the mirror right now. Do you have scalloping? Do any of your family members or friends have it? Please enter your responses below in the comments box.

Overcoming Physical Adversity to Achieve Athletic Greatness

There are many stories of athletes that overcome physical adversity to reach elite levels. One such amazing story is about Diane Van Deren, a 49 year old ultra-distance runner that underwent brain surgery to recover from lifelong recurrent seizures. Any time she felt a seizure coming on, she would go out and run intensely, which usually prevented the attacks from progressing. During her third pregnancy, she suffered a severe grand mal seizure, which prompted her to eventually undergo removal of a small portion of her temporal lobe, which eventually controlled her problem. In the dozen or so years since she underwent her surgery, she's become one of the the top endurance runners in the world, winning the 300 mile Yukon Arctic Ultra two years ago, and recently being the first woman to finish the 430 mile version last year.

 

Similar stories come to mind, including Bruce Jenner, the 1976 Olympics decathlon winner, who as a child ran home from school as quickly as possible to take down the bed sheet his mother draped outside his window because he still wet his bed. Wilma Rudolph, another olympic champion, suffered from polio and couldn't walk normally until age 12. 

 

I've stated in past blogs that poor sleep quality, due to narrowed jaws, poor breathing and inefficient sleep at night, is a common condition in many elite athletes. As a way to compensate for feeling tired all day long, they train intensely and regularly for years or decades, eventually reaching their elite levels. Anecdotally, many long distance runners that I know prefer not to sleep on their backs, and is typically tired when they wake up in the morning, no matter how long they sleep. I'm not suggesting that Ms. Van Deren has this particular problem (although she could have it, since we know that untreated obstructive sleep apnea can aggravate seizures, and pregnancy can aggravate sleep apnea). But I do bring up her story as an example of someone who has overcome so many odds to achieve success.

 

We know that all modern humans, due to our smaller jaws and crowded teeth, are susceptible to various degrees of sleep-breathing problems. All of us are on a sleep-breathing continuum, where obstructive sleep apnea is only the extreme end. Since elite athletes are humans as well, they'll be susceptible to these same issues, if not more so than normal. 

 

Come to think of it, untreated sleep apnea is a major cause of bedwetting in young children….

 

What are your thoughts on this? Do you or someone you know very good at a physical activity to potentially compensate for poor quality sleep? Please enter your comments in the text box below.

Did NFL Defensive End Gaines Adams Have Sleep Apnea?

Sadly, the Chicago Bears defensive end Gaines Adams died of a cardiac arrest during sleep early this morning. Preliminary reports state that he had an enlarged heart. He was only 26 years old. There are many reasons for an enlarged heart but one major risk factor Adams had was his build. He was 6' 5" and 260 pounds which gives him a BMI of 30.8, which is in the obese range. Furthermore, just like many NFL players, he had large neck muscles that probably pressed on his upper airway.

 

A study of NFL players in 2003 showed that about 14% overall and 34% of all linemen had obstructive sleep apnea. Reggie White, the Hall of Fame Linebacker, was thought to have died from complications of untreated obstructive sleep apnea.

 

There are certain sports that are probably at higher risk for sleep apnea, including football, body building, and weight lifting. All three involve bulky neck muscles, created intentionally, or indirectly. The human upper airway is unprotected in the throat area, so any enlargement of soft tissues, whether fat or muscle, can press on the airway and make the passageways smaller. One way to compensate for the fatigue that develops is to work out harder, eat better and train smarter. Over time, however, the soft tissues stay collapsed, and no amount of weight loss will completely cure the problem.

 

I've always stated that all football players, serious weight lifters and bodybuilders should be screened for obstructive sleep apnea. Once diagnosed and treated, who knows how much better they will be able to perform? What do you think about this issue? Should certain athletes and professions (long distance truck drivers, pilots, etc.) be routinely screened? Please enter your opinion in the comments box below.

Do You Really Grow Out Of Your Tonsils? The Possible Link Between Sleep Apnea and Autism

In the 1950s to 1970s, it used to be a rite of passage for young children to get their tonsils taken out. These days, we're a lot more conservative with tonsillectomy, and frequently, parents are told that their child will grow out of their tonsils. While this is true in some cases, there's a consequence to the watching and waiting option. 

 

Your tonsils are lymphoid tissue that's part of Waldeyer's ring, which is a ring of lymphoid tissue made of the palatine tonsils (your typical tonsils), the adenoids (in the back of the nose), and the lingual tonsils (at the base of the tongue in the midline). In some children with overdeveloped lymphoid tissues, you'll see a communication between all four of these glands, forming a complete circle. These tissues are normally involved in educating your immune system, since everything you breathe or swallow has to go through this ring. As a result, it's expected that the tonsils (and adenoids) will be enlarged during the ages of 3-5. 

 

However, with the shrinking size of modern human jaws, now there's less room for the normal-sized tonsils, which takes up relatively more space. This aggravates more frequent obstructions and arousals, leading to more inflammation from refluxed stomach contents and more swelling of the tonsils. The chronic negative pressure created from this process can prevent proper jaw enlargement, similar to what can occur with bottle-feeding. In many children, their snoring and sleep problems will prompt the parents to see an ENT for tonsillectomy. For children with mild to moderately enlarged tonsils that are not causing any symptoms, or those that are symptomatic but are told that they'll outgrow it, there can be permanent long-term consequences.

 

In children with huge tonsils, one of the reasons why they look so big is that the space that the tonsils sit in is too narrow. Taking out the tonsils can make a dramatic difference is most children, but there are some children that won't respond to tonsillectomy or only partially. One recent meta-analysis showed that adenotonsillectomy was helpful in about 2/3 of all children. But the remaining 1/3 still had residual symptoms or signs of obstructive sleep apnea. These are the children that have smaller jaws than the children who responded to the procedure.

 

In a recent Stanford University study, children who were scheduled for tonsillectomy were divided into two groups. One group underwent standard tonsillectomy, and the other under went rapid maxillary palatal expansion. The results were equivalent for both groups. When children in both groups were crossed over and given the other procedure, the overall results were additive. This just goes to show that one reason why you can have large tonsils that that your jaw is too small. Of course, everyone is on a continuum, and as usual in modern medicine, you're treated only if you are at the extreme end of the continuum. 

 

This is pure speculation, but I wonder if the significant increase in the rate of ADHD in the 1980s and 1990s could be related to the dramatic decline in the rate of tonsillectomies. Furthermore, since the peak incidence of autism is around ages 3-4, it's interesting that this is also the time that the tonsils become enlarged in most children. If you have enlarged tonsils to begin with, any simple cold or infection (even vaccines!) can cause swelling which starts a vicious cycle, leading to a sudden increase in breathing problems and poor sleep. Sleep apnea by definition causes systemic inflammation and an increased susceptibility to form microscopic clots in the brain. 

 

This is also the time (around age 4) when the voice box reaches its' final position below then tongue as it descends from its' original position behind the tongue. A space is created behind the tongue and between the soft palate and the epiglottis called the oropharynx, which exist only in humans, and allows for complex speech.

 

One last interesting phenomenon to point out is that in the early 1990s, parents were recommended to place infants on their backs, to prevent SIDs. We know that back sleeping lowers your time spent in deep sleep and leads to more frequent arousals. 

 

All these factors taken together may be what's developed into the "perfect storm," leading to the dramatic rise in ADHD and autism in our current times. Obviously, there are many other dominant theories for ADHD and autism, but from a sleep-breathing standpoint, what I propose is something that definitely needs to be proven in clinical studies. 

 

What do you think about all this? Please enter your responses in the comments box below.

Hair Loss and Sleep Apnea?

This is what I posted to the NY Times Blog for an article on hair loss in women:

 

Hair loss in women is a serious condition with lots of conventional explanations. One area that's never mentioned is the connection to poor sleep quality, especially due to breathing problems at night. A significant percentage of men and women have undiagnosed sleep-breathing problems, with the end extreme being called obstructive sleep apnea. 

 

It's estimated that about 1/4 of all men and 1/10 of all women have at lease mild sleep apnea, and 90% are not diagnosed. However, there's a variation of sleep apnea called upper airway resistance syndrome (UARS), where you'll stop breathing while sleeping, but not long enough to be called obstructive sleep apnea. 

 

Typically these people (more typically thin women) will have colds hands or feet, prefer not to sleep on their backs, feel tired all the time, no matter how long they sleep, and will usually have at least one parent that snores heavily.

 

These multiple arousals lead to a chronic low-grade physiologic stress response which heightens the nervous system (and immune system). During times of stress, blood is shunted away from low-priority organs like the GI  system, reproductive organs, the distant extremities and the skin. Chronic lack of blood flow can lead to a number detrimental effects, including hair loss.

 

It's also been shown that chronic physiologic stress also raises your cortisol levels, lowers your thyroid levels, and alters your estrogen/progesterone/testosterone balance. 

 

There are also anecdotal reports of people who report hair regrowth after starting sleep apnea treatment.

 

If you have any of the symptoms mentioned above, you should get checked for UARS. In many cases, UARS progresses into obstructive sleep apnea, especially after menopause. Even if it doesn't help your hair loss, being diagnosed may prevent complications of sleep apnea, including hypertension, diabetes, weight gain, anxiety, depression, and heart disease.

Why Humans Choke and Die: A Link to Sleep Apnea

It may be a surprise to you that of all the mammals in the world, only humans can choke and die. I'm sure there may be rare exceptions to this fact, but nearly 2800 people die every year in this country from choking. Far greater numbers of choking without dying are seen in ERs every year. 

Evolutionary biologists and comparative anatomists have stated that speech and language development was ultimately detrimental to humans. It makes sense: If you have a common conduit that serves three functions (talking, swallowing, and breathing), and one overdevelops, then the other two have to suffer. 

 

Take a look at this picture. Notice that in the chimpanzee, the voice box is behind the tongue, whereas in man, it's below the tongue. Only humans have a true space behind the tongue called the oropharynx. This is a space created behind the tongue when the epiglottis (the top part of the voice box) separated away from the soft palate. In human infants and animals, the soft palate stays overlapped with the epiglottis, allowing suckling and breathing at the same time. 

 

This process begins at 3 months and reaches its' final position at 4 years. Adolescent boys have a second descent which lowers the voice even further. Notice also that the peak incidence of SIDS is around 2-4 months.

 

Furthermore, this process allows the tongue to fall back into the oropharynx, obstructing your breathing and causing frequent arousals. Terrance Davidson has a great article that I reference in my book, Sleep, Interrupted, on this topic. Here's another interesting reference on this topic from a speech development perspective.

 

I think the implications of these findings are enormous. What do you think? Please enter your comments below in the text box.

Provent Nose Plugs for Sleep Apnea

I have to admit, the idea that you could treat sleep apnea with nose plugs was very interesting. Ventus Medical's Provent is a totally different type of sleep apnea treatment using adhesive plugs that works by making breathing out slightly more difficult through your nose. When you inhale, your breathing is normal, but as you exhale, a slight bit of resistance is created, creating a gentle amount of positive pressure downstream in the throat, preventing the tongue and soft palate from collapsing.

The scientific explanation is a little complicated (even for me), but the gist of it is that at the end of exhalation, that's when your throat muscles are most prone to collapse. So by slightly increasing the pressure, a stent-like effect is created, just like with CPAP.

Their study involved 28 people who used the device over 3 nights in the lab. On average, the AHI dropped about 50% (19.1 to 8.2) and after 30 days at home, it stayed low at 10.6. Other studies have also shown an average drop of about 50%. As expected, patents with severe sleep apnea didn't respond as well. You can find out more about the results at the companies' website.

Another study showed that 94% of patients continued using the device for a significant number of hours on a regular nightly basis.

Without a doubt, Provent does work to various degrees in various people. But just like every other new sleep apnea treatment option, it's not a "magic bullet" that cures sleep apnea for 100% of patients. Looking at the numbers, It seems like it's no better than other minimally invasive options (except that it's not invasive).

Practically speaking, I've had limited experience using this device in a handful of patients with mixed results. Some patients like it and others can't use it at all.

It's not covered by insurance yet, and it'll cost about $135 per month. They also have a rebate program for a 50% discount for the first few months. If you're interested in trying out Provent, an examination in the office is needed to make sure that you're a right candidate.

To learn more about Provent Therapy, click here.

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Copyright © 2008 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent