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Sleep Apnea Lessons From Africa

Here's a great example of how our diets literally affect the way you breathe and sleep at night. A patient who happened to have grown up in Rwanda told that there are three major ethnic groups in his home country: The Tutsi, the Hutus, and the Twa. The Tutsis are generally tall, pastoralists, and eat mainly soft foods, usually milk products, beans and sweet potatoes. It's also known that the Tutsi have severe cavities, dental crowding and crooked teeth. The Hutus are generally agrarians, but hunt occasionally. The Twas are pygmies, and are true hunter-gatherers, eating nuts, fruits, meat, roots, and grains. They also have the reputation of having great looking teeth. 

 

This what Dr. Weston Price described in his classic book, Nutrition and Physical Degeneration: What you eat leads to certain predictable jaw and dental structures. This phenomenon is seen across all cultures throughout the world. Smaller jaws and crooked teeth means smaller airways behind the tongue, with more frequent arousals and less sleep efficiency. It's not surprising that my patient, who happens to be a Tutsi, has obstructive sleep apnea. 

 

What type of foods do you eat? Do you eat like an agrarian farmer, or a hunter-gatherer? Please answer in the comments box below.

 

pictures?

An Insider’s Guide to Septoplasty

The septoplasty operation is one of the most misunderstood surgical procedures that lay people, and even many physicians have. Some people even equate septoplasty with having a nose job, which is not true. Although, some people use having a crooked septum as 

an excuse to undergo a rhinoplasty, septoplasty, done correctly, can help patients breathe better, and more importantly, sleep better.

Understanding the Anatomy

In order to fully appreciate if septoplasty is the right procedure for you, you must understand the anatomy of how it’s done.

The nasal septum is the midline cartilaginous structure that divides the two halves of your nasal cavity. The part in the back of the septum is made of bone. Whenever the septum is crooked to a significant degree, your nose can be stuffy, and a septoplasty can be offered if medical therapy doesn't work.

However, having a crooked septum doesn't mean that you'll have a stuffy nose, or that you'll need a septoplasty. No one has a perfectly straight septum. There are other parts of your nasal anatomy that contributes to your ability to breathe, which includes your nasal turbinates and your nostrils. The turbinates are wing-like structures that jut in from the side-walls of your nose that look like wings. They normally warm, filter, smooth and humidify the air that you breathe. Inside this structure is the bone and the outside is a mucous membrane lining. The middle part is made of very vascular tissues that can swell tremendously when filled with blood. This is regulated by your involuntary nervous system. This nervous system normally swells and shrinks the turbinates, alternating from side to side, every few hours (called the nasal cycle).

Do You Have Flimsy Nostrils?

The other structure that is often overlooked is your nostrils. For most people, breathing in causes a mild vacuum effect that causes a mild collapse and a constriction of the nostrils. But in some people with either flimsy or weakened nostrils (from a prior rhinoplasty), they collapse very easily, even with a slight bit of inspiration. If you are one of these people, you may benefit from nasal dilator strips (Breathe-rite is one brand). Sometimes these strips are not strong enough, or it can irritate the skin. Another option is to use internal nasal dilators which work much better. Some of the more common brands are Breathewitheez, Nasal Cones, and Nozovent.

What's Involved with Septal Surgery? 

The septoplasty procedure can be done in conjunction with a turbinate procedure. There are many ways to perform a septoplasty, but the most important point is that it should be done well. The septum is covered on both sides by a mucous membrane. After an incision is made inside the nose on the mucous membrane, this layer is peeled away from the septal cartilage. The other side is also entered, which creates two tunnels on either side of the septal cartilage. The crooked part of the septal cartilage is next removed. Some surgeons either soften the cartilage or flatten it out and place it back, and others leave it out completely. In many cases, a small portion of bony spur that juts out at the base of the septal cartilage is also removed. The last part of the operation is where different surgeons use different techniques. Traditionally, thin plastic sheets with or without soft sponge-like packs are placed against the septum on both sides to keep the mucous membrane together for proper healing. If a large clot of blood forms between the two mucous membrane layers, the remaining cartilage may lose it's blood supply and literally melt away. 

Because the entire procedure in done inside the nose (or endoscopically), there is no swelling, bruising or changes to the outside of the nose or face (unless a rhinoplasty is done simultaneously).

What to Expect After Surgery

Nasal packing, if placed, are removed anywhere from 1-3 days after the procedure. Many patients report that this is one of the most uncomfortable parts of undergoing this procedure. Some surgeons, like myself, don't use any packs or splints using the following method: compressing the two mucous membrane layers by sewing the two layers together using an absorbable suture, like a quilting stitch. This way, nothing needs to be removed, and you're breathing much better right after the surgery. It's expected with this procedure that your nose will get clogged up after a day or two with accumulation of blood, mucous and debris.

This operation is usually performed as an outpatient procedure, so you'll go home a few hours after surgery. It's usually performed under general anesthesia, but can also de done under local anesthesia with sedation for certain situations. Most people can go back to work after a day or two. Heavy straining or lifting should be restricted for about one week. In my practice, I see the patients about 2 days after the surgery, when the nose is cleaned of all the accumulated debris. Some people need a second cleaning 1-2 weeks later.

Typically, it may take a few weeks to months to feel the full benefits of this operation. During the first few weeks, crusts will build up and fall out as wounds heal. This is also the time when the swelling from the surgery goes away. Afterwards, scarring and tightening of the soft tissues can take weeks to months. You may have your ups and downs in the first few weeks, but you should see consistent improvement by 3-4 weeks. 

Most people don't use any pain medications, but one is prescribed just in case. You'll probably be more bothered by the sore throat from having a breathing tube placed during intubation.

What Are The Risks?

Complications are rare, but with any surgical procedure, there is a small chance of infection or bleeding. There is also a small risk any time someone undergoes general anesthesia, which includes, allergic or medication reactions or airway problems. In terms of overall risk, it's riskier when you cross the street. Other very rare complications such as smell loss or a hole in your septum have been reported. 

A septoplasty, if done properly, is one of the most gratifying procedures for both the patient and the surgeon. Success rates are very high. However, there are a few percent of patients where nasal congestion still persists, or it comes back after a few weeks to months. In this situation, there are two main possible reasons: there is persistent turbinate swelling due to inflammation, or you have flimsy nostrils. There are treatment options for both theses conditions.

What You Can Do About Your Stuffy Nose

Although many people assume that big nosed people naturally breathe better, there's nothing further from the truth.  The shape and size of your nose is mostly cosmetic. How well you breathe actually depends on what your internal breathing passageways look like. And for many sleep apnea sufferers, a stuffy nose can make or break their treatment therapy.

Yet, opening up the nose through medical therapy or even surgery has been found to “cure” sleep apnea in only 10% of people. Patients will definitely feel and breathe better, but it’s unlikely that their sleep apnea is addressed definitively. However, I have seen many of the people in the “10%” group derive significant benefits from clearing up their nasal congestion. Besides breathing better for the first time in years, opening up the nose can allow the person to tolerate and benefit from other treatment options for OSA besides CPAP.

 

Why Is My Nose Stuffy?

Problem #1:  Deviated Nasal Septum

One of the more common reasons for a stuffy nose is due to a deviated nasal septum. A “septum” is a term that describes a structure that acts as a wall or separator between two cavities. Your heart has one too. No one has a perfectly flat or straight septum.

All septums, by definition, have slight irregularities or curvatures. A major reason for a crooked septum, unbeknownst to many people, even other doctors, is because your jaw never developed fully. Most people with sleep apnea have narrow upper jaws, which pushes up the roof of your mouth into your nasal cavity, which causes your septum to buckle.

If medical options don't help you to breathe better through your nose, then you may be a candidate for a septoplasty. To get a much more detailed explanation about this procedure see the accompanying article, Myth and Truths About Septoplasty.

Problem #2. Flimsy Nostrils

In some people, the space between the nasal septum and the soft part of both nostrils is either too narrow to begin with, or they collapse partially or completely during inspiration. In many cases, this can be seen years after reduction rhinoplasty, where the nose was made smaller or narrowed for cosmetic reasons. Occasionally, people can have naturally thin and floppy nostrils.

Another common reason for flimsy nostrils is due to a narrow upper jaw. The width of your nose follows the width of your jaw. If the angle between the midline septum and the nostril sidewall is more narrow than normal, then it’s more likely to collapse with any degree of internal nasal congestion. It’s not surprising that people with sleep-breathing disorders will typically have narrower jaws, and thus more susceptible to nostril collapse. Certain ethnicities are also more prone to this phenomenon than others.

One way that you can easily tell if you have this problem is to perform the Cottle maneuver: Place both index fingers on your face just beside your nostrils. While pressing firmly against your face and simultaneously pulling the skin next to the nostril apart towards the outer corners of your eyes, breathe in quickly. Then let go and breathe in again. If there is a major improvement in your quality of breathing while performing this maneuver, then you have what’s called nasal valve collapse.

The simplest way of correcting nasal valve collapse is by using nasal dilator strips, or Breathe-Rite® strips. If you do the Cottle maneuver and there is no significant difference in your breathing, don’t waste money buying these strips. If you perceive an improvement in your breathing, you can continue using the strips at night while you sleep. For some people, these “strips” are not strong enough to hold up the nostrils, or may cause irritation to the skin.

There are also many other “internal” options available over the counter, including metal springs or plastic cones that are placed inside the nostrils. People tolerate these particular devices differently, so the only way to know if you’ll like them is to try them. Three examples are Breathe With EEZ, Nozovent, and Sinus Cones.

To find out if your nasal valve collapse is from weak or flimsy cartilages or is aggravated by internal nasal congestion, you can spray nasal saline (which is a mild decongestant) into your nose. If your nostrils doesn’t collapse as much, then you need to address your internal nasal congestion first. A stronger over-the-counter medication that you can use is oxymetazoline, which is a topical spray decongestant. There are many brand name and generic versions that are sold that contain this ingredient. It’s very important that you don’t use this medication for more than two to three days—otherwise, you may get addicted to it.

If you want a permanent solution to this problem without having to use dilator strips or internal devices, the only option is surgery. The traditional way of dealing with this issue is to perform a kind of reconstructive rhinoplasty surgery, usually by taking small portions of your nasal septal cartilage or ear cartilage and placing in underneath the weakened portions of your nostril walls. A newer, simpler way of addressing this problem is by attaching a permanent suture just underneath the eye socket and tunneling the suture under the skin and looping it around the weakened area to suspend the nostril to prevent collapse.

Problem #3: Wings in Your Nose

Another common source of nasal congestion is from swelling of your nasal turbinates, which are the wing-like structures on the side-walls of the nasal cavity opposite the septum. Turbinates are comprised of bone on the inside and mucous membrane on the out- side. The area just underneath the mucous membrane is filled with blood vessels which can swell significantly. As the turbinates swell due to allergies, colds, or weather changes, the air passageways narrow further, especially if you have a mildly deviated nasal septum, and particularly if you have nasal valve collapse.

One of the most common misunderstandings that I see by both doctors and patients alike is that they think that swollen turbinates are polyps. The nasal turbinates can swell so much that you can sometimes see the reddish-pink, fleshy grape-like mass through your nostrils. Once decongested, they shrink dramatically and the air passageways open up again.

If conservative treatment including prescription allergy medications don’t work, various surgical options are available from very conservative 5 minute in-office procedures to more aggressive procedures that are performed in the operating room. These procedures are usually performed alongside a septoplasty to improve nasal breathing.

 Problem #4: Sinusitis

If you suffer from sinusitis, this can cause nasal congestion and inflammation combined with post-nasal drip, sinus pressure, and pain. Put simply, pure misery. Sinus infections typically follow either a routine cold or allergy attack; they cause both swelling and blockage of the sinus passageways, leading to negative pressure initially and, if allowed to progress, can turn into a full-blown sinus infection, with yellow-green discharge, fever and severe facial pain. Your teeth can also hurt since the roots of the upper molars jut up into the floor of the maxillary sinuses. Similarly, dental pain can sometimes feel like sinus pain.

Fortunately, most cases of sinus congestion will eventually go away. The body has a remarkable ability to take care of these issues without any intervention. Sometimes bacterial infections occur, and with proper conservative treatment using saline and decongestants, the infection gradually resolves. Rarely, you may need an antibiotic to control stubborn bacterial infections.

Problem #5: Poor Sleep

As you can see from the above discussion, there are a number of various reasons for having a stuffy nose. But the most common reason for nasal congestion that I see routinely is due to inefficient breathing and poor sleep. This is why sleep apnea sufferers, more often than not, suffer relentlessly from nasal congestion. 

Without a doubt, structural reasons like allergies or nasal polyps can definitely block your nose and these issues must be dealt with appropriately. But in general, it’s the inflammation that’s created by a combination of your hypersensitive nasal nervous system and possible stomach acid regurgitation into the nose from multiple obstructions and arousals, that causes nasal congestion. Without addressing this underlying source of inflammation, correcting a deviated nasal septum or treating for nasal allergies will only provide a temporary solution.

Are Your Children Sleeping In Bed With You?

It's surprising to me how often I see parents sleeping with their young children. They know that it's disruptive to their sleep, but can't seem to break the habit. It's much easier for children to fall asleep with you, rather than all the crying and stress of trying to teach your child to sleep separately. You'll see a lot of strong opinions on this issue, but my recommendation is that children (starting as infants) should sleep in separate beds, in separate rooms. 

My youngest son, Brennan (who's one year old), has always been a great sleeper, usually sleeping through the night since around 4 months. About two weeks ago, he caught a bad cold with fever to 104. During this episode, he kept waking up, and refused to go to sleep. He would cry for hours and eventually fall asleep only after exhausting himself. He would stop crying if you picked him up, but started crying and jumping up and down as soon as you placed him in back in his crib. In the morning, he would wake up extra early, severely depriving me and my wife of much needed sleep. 

One night, I gave in and held him on the rocking chair for the first half of the night, not sleeping at all. I ended up paying the price. The next few nights, he expected to be held all night long. Fortunately, after a few days of Ferberization, he's now back to his routine sleep cycle (keeping our fingers crossed). 

I understand a parent's need to comfort their child and to find the easiest way to get some sleep, but sometimes you just have to bite the bullet and do the right thing. I see the same situation with people and their pets.

Did you or do you sleep in the same bed as your young children? If so, how long have/did you do it for and how will/did you stop it? Please enter your experiences in the comments box below.

Does Having Sleep Apnea Prolong Life in the Elderly?

Here's a twist to the typical story about sleep apnea you don't see every day. A prominent sleep researcher in Israel discovered that elderly people with mild to moderate obstructive sleep apnea where less likely to die than their counterparts who didn't have sleep apnea. Their explanation is that years of hypoxia promoted increased collateral blood supply, meaning that the heart developed blood vessels that bypassed blockages. This explanation was supported by a recent German study which found similar results.

 

On first thought, it makes sense. When younger, since you don't have time to develop collateral blood vessels, you're more likely to die if you suffer a heart attack. The incidence of sleep apnea may increase as you get older, but the rate of death could go down as one gets older.

 

I wonder if chronic hypoxia in the brain causes similar protective effects. Since we know that hypoxia causes plaques that are similar to what we see in Alzheimer's, the answer is probably no. If you live long enough to beat obstructive sleep apnea, then is it more more likely you'll develop dementia?

 

What do you think about this study?

Why Women Prefer Johnny Depp Over Sean Connery

Thanks to Van for pointing out this article that explains why modern women might prefer Johnny Depp to Sean Connery when it comes to choosing mates. In a University of Aberdeen study that studied the preferences of 4500 women in 30 different countries, the quality of healthcare was directly related to preferences of certain physical male features. One prominent male facial feature cited was having a square jaw, which is linked to superior genes that produce stronger and healthier children. Women who lived in countries that had better quality health care systems tended to prefer men with more feminine features. Their explanation was that women with good quality health care systems didn't have to worry about the health of their future offspring.

I won't get into all the social and ethical implications of this study, but one thing that I wanted to point out is that there's a direct correlation between jaw size and the size of your upper airway. Modern humans in general have much smaller jaws, with dental crowding, which leads to constricted upper airways, from your nose to the space behind your tongue. This leads to breathing problems at night, with the extreme end of this spectrum called obstructive sleep apnea. This is what leads to or aggravate depression, high blood pressure, heart disease and obesity. What I describe in my book, Sleep, Interrupted, is a sleep-breathing continuum, where all modern humans are on a spectrum. 

The next time you're in a public metropolitan area, take a look at recent immigrants' faces, particularly from less developed nations in South America or Eastern Europe. Notice how in general the parents' faces are nice and broad, whereas their children's faces are narrow and long, due to eating mainly Western, modern diets. (Thanks to Anna for pointing this out). After many generations, the facial structures get more and more narrow.

One comment, however, about women's choices in this study. Is it possible that women with narrow faces prefer men who look similar to themselves, like what their parents have, rather than thinking that their children's health issues can be solved after the fact?

What do you think about this study? Do you prefer to look at people with wide, square jaws, or narrow, soft features? 

My Magic Sleep Sofa-Pillow

Due to various reasons (my father visiting, and my 1 year old son sleeping in a Pack-And-Play crib in the living room), I ended up sleeping on our old leather sofa the other night. Although I only slept for 5 hours, I woke up much more refreshed than my usual night's sleep. I do remember that I had a similar experience a few months ago when I had a bad cold with severe cough, and I  felt better sleeping on the same sofa. Now I realize that it wasn't a coincidence. The curvature of the armrest is a low gentle slope, with my feet resting on the other side's armrest (preventing me from sliding down). 

What I realized was that due to the armrest lifting up my upper back/shoulders and tilting back my head slightly, my airway must have opened up. This is a normal situation for almost everyone. Whenever you tilt your head forward slightly, the space behind your tongue narrows, whereas tilting the head back opens the airway. This is also why in many cases, "Contour" pillows have this same effect: By lifting up your neck and cocking your head back slightly, you're opening up your airway. Most contour pillows, however, don't function the way they're meant to work, since as you slide down, the the lower part of the pillow that's raised ends up tilting your head slightly forward. 

As a result of this experience, since I like to sleep on my back, I added a bit of support using a rolled up towel, just below my Contour Pillow, slightly lifting up my shoulders. Not too surprisingly, I did seem to sleep better. Next, I'm going to add one more thing: Breathe Right strips. By artificially opening up my nasal passageways by using these nasal dilator strips, perhaps I can finally sleep more deeply and wake up much more refreshed in the morning.

Does sleeping in strange environment or bed make you sleep better or much worse than your normal nights' sleep? Please enter your answers in the comments box below.

Flu Shots, Hutterites, and Sleep Apnea

It seems that even in very closed communities, flu vaccinations can help to lower the rate of influenza infections. A recent NY Times article described a study that revealed that widespread flu vaccinations in Hutterite schoolchildren resulted in lower rates of infection throughout the community, including adults. The population that received the vaccine had about a 5% rate of infection, whereas the placebo group had a 10% rate of infection. 

 

Regardless of the implications of this study, what caught my eye were the pictures. In the article, the two children and woman's faces were nice and wide. I went on to google other pictures of Hutterites, and by a wide margin, most of the adults and children have very wide jaws and facial structures. This is in contrast to regular urban people (especially younger adults and children) with more narrow faces and small jaws. Small jaws means less room to breathe at night due to narrowing of the space behind the tongue.

 

This makes sense since secluded communities like the Hutterites tend to eat off the land and breastfeed for extended periods of time. It's expected that they'll have proper dental development, and as a result, will be more immune to the effects of any viral infection, even the influenza virus. 

 

Any degree of inflammation in the upper airways can aggravate further narrowing, leading to more frequent pauses in breathing, leading to aspiration of stomach juices into the lungs and nose, aggravating a vicious cycle into more obstructions. This is why people with sleep-breathing problems suffer more complications such as pneumonia, sinus and ear infections.

 

We know that some people who catch the flu experience it just like a common cold, whereas for others, it can be deadly. It's one thing to show that giving immunizations can prevent infections, but what's the rate of complications in Hutterites that do contract the flu? I'm willing to bet it's much lower than normal. With this in mind, it it even worth vaccinating this particular population?

 

What's your opinion about my theory? 

Aliens, The Future, And Sleep Apnea

As I watched the Pixar Movie Wall-E this past weekend, I was struck by how prophetic the movie was in predicting the state of mankind in the not too distant future. People are so sedentary that everyone becomes morbidly obese, and use roving hover chairs with remotes for everything. Everyone is so fat that they can't even walk. The planet earth is a vast wasteland, and everyone has to live in a mega-shopping mall space station. Consumption and advertising is taken to a new extreme.

 

One thing that struck me was the fact that if they were all morbidly obese, then they most likely had obstructive sleep apnea. However, I don't recall seeing any CPAP masks or machines in the movie.

 

If you also recall some of the older sci-fi movies, notice how all the aliens have huge brains and very tiny faces. If you think about what's happening to our jaws (getting smaller) and our brains (getting larger), it's conceivable that in a few million years, we'll all begin to look like aliens. By then vocal communication will be gone, since complex vocal speech is detrimental to breathing and swallowing. We'll have evolved to the point of communicating only through mental telepathy, and everyone will be hooked up to positive airway pressure machines while sleeping at night. By then they may have the technology to turn on a switch that bypasses the upper airways directly at night to function like a tracheotomy, except that no surgery is needed. Will they have developed a way to function without sleep?

 

Pure speculation, but not too far fetched. What do you think?

Conflicting Reports About Napping

Should we adopt the siesta? A study was recently presented at the American Association for the Advancement of Science showing the benefits of napping on memory. People who napped for 90 minutes after lunch raised their memory recall scores by 10%. However another study just published the the Journal Sleep showed that nappers had a higher chance of having type 2 diabetes.

 

These studies may sound contradictory, but the results are not surprising. There's no doubt about the benefits of napping on memory and cognitive functioning. The fact that you prefer to nap probably means that you're not able to get deep, efficient sleep at night. This causes hormonal changes that elevate glucose levels and also cause insulin resistance. Poor sleep also causes weight gain, which can aggravate sleep apnea. I'm sure that if you tested these nappers with a higher rate of diabetes, their memory scores will be improved compared to those who are not able to take a nap.

 

Do you routinely take naps? Please enter your answer in the comments box below.

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