Ask Dr. Park Teleseminar (7/12/11)

June 28, 2011

In this month’s Ask Dr. Park Teleseminar (7/12/11), I answer the following questions:

• Can having a stuffy nose prevent CPAP use?

• What kind of surgical procedures for the nose can help me breathe better?

• Can Viagra make me sleep better if I have sleep apnea?

• What’s the best non-CPAP treatment for severe sleep apnea?

• Is the laser procedure for snoring or sleep apnea effective?

• How does the TAP oral appliance compare with CPAP?

• Can oral appliances be used to treat UARS?

• Is CPAP a commitment for life? Is it ever reversible without surgery?

• What’s the success rate for tongue reduction surgery?

• What can I do about my dry mouth when using CPAP?

• Can wearing a cervical collar help sleep apnea?

• How can air in the stomach due to CPAP be prevented?

• What’s the Pillar procedure?

• Plus many more questions….

Download the 60 minute MP3 recording ($17).

Written by Steven Park · Filed Under Expert Interviews | 2 Comments

Why Doctors Are The Worst Sleep Apnea Patients

June 27, 2011

It’s estimated that about 25% of men and 10% of women have obstructive sleep apnea. Since doctors are human beings as well, it’s expected that you’ll find the same proportion of sleep apnea within the physician population. In general, people respond well to sleep apnea treatment, but one thing I’ve noticed is that for the most part, doctors are reluctant to even acknowledge that they may have sleep apnea, and even if diagnosed, refuse to get it treated properly.

I see the same proportion of high blood pressure, asthma, high cholesterol, depression and heart disease in doctors, and they take the typical medications that are given for these medical conditions. But when it comes to sleep apnea, I’ve noticed 3 common features:

1. Doctors are very reluctant to use the various machines, appliances or even consider surgical options for sleep apnea. Perhaps they’ve been exposed to these options in their career and don’t like the idea of having to do something other than to take a pill.

2. The first thing that they think about when I mention sleep apnea is either a tracheotomy or the stereotypical picture of the morbidly obese man with a CPAP mask and hose attached to a machine. Maybe it reminds them too much of being on a respirator.

3. Just like many non-physicians who may have sleep apnea, not having an official diagnosis means that they can put off having to try the different treatment options. Frequently, they’ll refuse to undergo a sleep study.

Ultimately, it sounds like denial to me. But one requirement that all doctors should experience is to undergo the various treatment options that they prescribe to their own patients. All sleep doctors should undergo a sleep study and experience a CPAP machine. Gastroenterologists should undergo a colonoscopy before starting practice. Undergoing surgery is more difficult, but when needed, can be a valuable experience for experiencing what it’s like to be on the other side of the curtain. Maybe even oncologists should undergo chemotherapy at least once in their lifetime.

Unfortunately (and fortunately), I’ve had the opportunity to be a patient a handful of times, and each one was a valuable learning experience. After undergoing emergency surgery a few years back, I’ve noticed that my demeanor and attitude to patients during and after surgery has improved for the better. A doctor with sleep apnea should set an example for the patient and practice what he or she preaches.

Do you have any doctors that may have undiagnosed sleep apnea?

Written by Steven Park · Filed Under Blog | 1 Comment

Shocking Revelations About Strep Throat

June 24, 2011

This is a bit off the topic of sleep apnea, but definitely relevant for everyone. I just finished reading Dr. David Newman’s book, Hippocrates’ Shadow:What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach. It was an eye-opening book, confirming my suspicions that many of the routine forms of therapy that we as doctors prescribe are more based on tradition or flawed logic than real science.

One shocking example is our obsession with treating Strep throat with oral antibiotics. The main reason why treatment is recommended is to prevent rheumatic fever. In the 1940s on an army base, there was an epidemic of streptococcal infections and rheumatic fever, which can lead to heart disease. By treating with antibiotics, they were able to lower the incidence of rheumatic fever from 2% to 1%. Calculations showed that they had to treat 50-60 soldiers to prevent one case of rheumatic fever.

Now that rheumatic fever is almost nonexistent, it’s estimated that you need to treat 1 million people with strep throat to prevent one case of rheumatic fever. What most doctors don’t realize is that every time you give antibiotics, you have a 10% chance of developing a rash, 10% chance of having diarrhea, and 10% of of suffering from a yeast infection. That’s potentially 300,000 complications. Furthermore, 0.24% of people will suffer a potentially life-threatening allergic reaction, and of these, about 1 out of every 10 will die (240 people). What’s worse, only about 1/3 of people with rheumatic fever will develop long-term heart disease. So you’ll have to treat 3 million people with antibiotics to prevent one case of heart disease. That means 900,000 people will suffer complications and about 720 people may die. Ten million antibiotics are prescribed in this country every year for throat infections.

Does this mean that we should shop prescribing antibiotics? Absolutely not. In selected situations, it would be inappropriate to withhold antibiotics. But in most cases, antibiotics are prescribed for a sore throat, viral infections, or a slight suspicion of a bacterial infection. In many instances, tonsils can become huge and obstruct your breathing, aggravating sleep apnea temporarily. Sometimes it can even lead to an abscess.

I still remember the one time I had Strep throat when I was a senior in high school. I was spiking fevers, sweating profusely, and was weak, dizzy and lightheaded. I was miserable. Despite this I played my bass clarinet solo in our annual symphonic band concert. After the performance, my father took me to the local ER, where they saw huge, inflamed tonsils. I was tested positive for Strep, and was given a penicillin shot. The next day, I felt 95% better. The point of this story is that we should try to avoid using antibiotics inappropriately, especially when there’s no absolute need.

Here’s a related short discussion on this topic.

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The Link Between Allergies, Nasal Congestion, & Sleep Problems

June 22, 2011

Allergies are commonly blamed for poor sleep. But does it really? Researchers from Japan found that allergies alone are not enough to cause sleep disturbances, but a combination of allergies and nasal congestion lead to increased reports of sleep difficulty.

This finding isn’t surprising, since any degree of nasal congestion can aggravate your soft palate or tongue to fall back more easily when you’re in deep sleep. Even if you’re completely normal, you’re more likely to toss and turn when your nose is stuffed up from a cold.

This also implies that the more narrow your jaws, the more susceptible you’ll be to any form of irritation or inflammation in the nose which can lead to nasal congestion. The more narrow the space between your upper molars, the less space there will be in your nasal cavity, and the more likely your septum will buckle (deviated nasal septum). Plus, the angle between your nasal septum and your nostrils will be more narrow, which makes it easier to cave in with even a little bit of internal nasal congestion.

If you suffer from allergies, and you have nasal congestion, it’s important to treat the congestion as well. Simple steps you can take include using Breathe Rite strips, nasal saline irrigation, and avoiding eating or drinking alcohol close to bedtime. If you must take an over-the-counter antihistamine, make sure that it includes the letter ” -D”, which stands for decongestant. Usually, it’ll have a variation of pseudoephedrine (the generic name for Sudafed). If pseudoephedrine makes you hyper or jittery, you can always use oxymetazoline (Afrin) very sparingly (not more than 3 days).

If these conservative options are not enough, then prescription medications can be used. As a last resort, surgery can sometimes help.

Do allergies cause you to sleep poorly?

Written by Steven Park · Filed Under Blog | 6 Comments

How Sleep Position Can Affect Stillbirth Risk

June 19, 2011

Researchers from New Zealand discovered that women who did not sleep on their left side the last night before delivering their babies had twice the rate of stillbirth compared with those that slept on their left side. It’s commonly recommended for pregnant women to sleep on their left side, especially later in pregnancy. There are various explanations for why this is preferred, from placing less pressure on the mother’s major blood vessels to worsening the mother’s snoring.

I’ve mentioned before that a woman’s risk of developing obstructive sleep apnea increases as she gains weight during pregnancy, but progesterone counteracts this effect neuromuscularly, by tensing the throat muscles and increasing the drive to breathe. However, back sleeping is a known aggravator of breathing pauses during sleep due to gravity’s effects on the tongue. Whether or not this leads to apneas (10 seconds or longer pauses), the mother will still stop breathing and wake up more often during the night. This can place a major stress not only on the mother’s body, but on the baby as well.

This study was an observational study, so more prospective studies are needed. But it only goes to show that any additional situation that can aggravate sleep-breathing problems during pregnancy can raise your risk of complications, which also includes gestational diabetes and preeclampsia.

I wonder if the researchers asked the women what their preferred pre-pregnancy sleep position was. I suspect that women who can’t sleep on their backs may have more complications during pregnancy due to narrowed upper airway anatomy.

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Expert Interview: Anthropologist Dr. Robert Corruccini on Why We Have Crooked Teeth (And How This Relates To Sleep Apnea)

June 14, 2011

In this program, I interview Dr. Robert Corruccini, anthroplologist and author of How Anthropology Informs the Orthodontic Diagnosis of Malocclusion’s Causes (Edwin Mellen Press). We’re going to talk about why modern humans have crooked teeth, and how this relates to smaller jaw sizes and smaller upper airways. In particular, you’ll learn:

- When did humans begin to experience a lot of occlusal problems?

- What kind of genetic and environmental factors can cause malocclusion?

- How does Dr. Corruccini’s work compare and contrast to Dr. Weston Price’s work?

- Is it true that even a few hundred years ago, humans didn’t have as many impacted wisdom teeth?

- What are some of the health consequences of crooked teeth?

- Has modern dentistry helped or hurt our teeth and our health?

- For those of use with dental crowding already, what can we do? What can we do for our children?

Please enter your information below to receive your free MP3 link:

Written by Steven Park · Filed Under Expert Interviews | 5 Comments

Septoplasty Without Packings Or Splints

June 12, 2011

One of the most uncomfortable things you can do to another person is to place nasal packs in their nose after nasal surgery. What’s even worse is when you have to take it out. I know what it feels like, as I had nasal packs after I broke my nose when I was six. I still remember waking up after surgery, with my nose completely stuffed up, and my sleep was terrible.

Unfortunately, ENT surgeons still routinely use nasal packing after nasal surgery, especially during septoplasty. The reason why packing is used is due to a combination of of the nature of the surgery and tradition: The mucous membrane layer on both sides of the midline cartilaginous septum is peeled off, and the deviated portion of the cartilage or bone is removed. Next, the mucous membrane layers are placed back together in the midline. Packs (either long gauge strips or an expandable absorbent sponge are placed on either side of the septum, to compress the mucous membrane layers together. Since cartilage doesn’t have blood vessels for nutrition, it has to receive its’ nutrient supply from diffusion and osmosis from the inner walls of the mucous membrane layers. If you have a blood clot that separates the two mucous membrane layers, nutrient flow to the remaining cartilage will be shut off, and the cartilage will die off, leading to a drooping of your nasal tip.

So if you don’t use nasal packs, what else can you do? Some surgeons place two plastic or silastic sheets in the nose next to the septum, and then tie the two splints together in the front through the nasal septum. You still have to put something in your nose to press the silastic sheets together. Some use rolled up Telfa pads (the nonstick surface that you see on Band Aids), and others place packing around the splints. Most surgeons take out the splints or packing after 2-3 days, but some leave it in up to 7 days.

Many years ago, I came across a paper showing that if you plug healthy college students’ noses and put them through a sleep study, you’ll see apneas. Another study showed that in patients without sleep apnea who undergo nasal packing for nasal or sinus surgery, the AHI increased from 11 to 37, and for patients with sleep apnea, 14 to 39. It’s interesting to note that patients without sleep apnea who need to undergo nasal surgery have mild underlying obstructive sleep apnea. This is in line with a study I performed many years ago showing that up to 80% of people who undergo nasal or sinus surgery and have recurrent or persistent symptoms have significant obstructive sleep apnea.

As I began to realize how important nasal breathing is to the quality of your sleep, I came to the conclusion that nasal packing was sure to cause apneas. If your septum is deviated, by definition, you’re going to be at a much higher risk of having jaw structures that predispose to obstructive sleep apnea. Total nasal congestion can only make things worse. This is also why even if you’re “normal”, having a stuffy nose from a cold or allergies makes you toss and turn more at night—it’s because you stop breathing more often. These obstructions don’t even have to be apneas or hypopneas—they can be short periods of obstruction that still wake you up multiple times per hour.

You’re probably wondering by now how I get away with not using any nasal packs or splints. It’s very simple: After removing the deviated cartilage or bone, I use a little 1/2 inch needle with a dissolvable chromic suture (stitch) and perform a quilting suture, back and forth from one side of the nose to the other, in a zig-zag manner, until all the areas of separated mucous membranes are closed together. In most cases, I do a very conservative shrinking procedures on the nasal turbinates, so there’s little to no risk of scar tissue connecting the raw surfaces of the septum and the turbinates. Some people also need their flimsy nostrils stiffened as well.

When you wake up from anesthesia, you’re breathing really well. But after a few days, it’s expected to get stuffy again, since all the blood, mucous and secretions will block your nose. You’ll go home a few hours after surgery. Two to three days later, I’ll see patients in the office for a 2 minute “cleaning”, after which you can breathe much better again. Most people can go back to work after 2-3 days, and about 2/3 of patients don’t even take any prescription pain medications.

Contrary to conventional perceptions of the misery of undergoing a septoplasty procedure, there are now ways of minimizing pain and discomfort. Surgery is never a walk in the park, but well worth the ability to breathe clearly through your nose again.

Written by Steven Park · Filed Under Articles | 8 Comments

Ask Dr. Park: Anything About Obstructive Sleep Apnea (6/14/11)

June 9, 2011

This month, I answer the following questions (6/14/11):

- Are there travel-sized CPAP machines available?

- What are the surgical options for sleep apnea and what are their success rates?

- What are the benefits of acupuncture for sleep apnea?

- Is it customary for surgeons to perform turbinate surgery along with septum surgery?

- Are there places to check out all the different CPAP masks and machine and read user reviews?

- If someone can’t breathe through their nose, is it dangerous to use a nasal mask and chin straps?

- How commonly is tracheotomy used to treat sleep apnea after exhausting all other options?

- Are there any new developments in sleep apnea treatment that will be available within the next 5 years?

- What can be done about bloating with CPAP use?

- Do over-the-counter boil-and-bite devices for snoring and sleep apnea work?

- Can you design a bed or a pillow to sleep with your face down to prevent your tongue from falling back? Does sleep apnea disappear for astronauts since there’s no gravity?

- And many more questions from the live audience.

Please click here to order the 60 minute MP3 recording.

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The Connection Between MS And Fatigue

June 8, 2011

It’s a given that if you have multiple sclerosis (MS), you’ll be tired all the time. It’s thought to be a normal part of having this condition, just like many other chronic medical conditions. But here’s an interesting study that suggests that fatigue can precede MS by up to 3 years. The researchers found that many MS patients complained of fatigue to their doctors months or even years before the first clinical signs of MS.

Here’s my take on this: I’ve written in the past about how the vast majority of people with MS that I see in my office have small jaws and narrowed upper airway anatomy. In an informal poll I conducted on Medhelp.com’s MS forum, a very high number of people had an excessive number of dental extractions, couldn’t sleep on their backs, and many of their parents snored heavily. Having excessive dental extractions causes the oral cavity to become much smaller, making the tongue take up too much space.

I’m not discounting current thinking about the origins of MS, but it’s extremely interesting that most patients with MS have very narrowed upper airway breathing anatomy which prevents achieving deep sleep. Lack of quality deep sleep can lead to various neurologic, hormonal, metabolic and digestive problems. Many patients with MS also have obstructive sleep apnea, but most will most likely have upper airway resistance syndrome, which I’ve described extensively here and in my book.

For those of you who happen to have MS:

What’s your favorite sleep position (back, side or stomach)?
Did you have any teeth removed besides your wisdom teeth, and if so, which ones and how many?
Do either of your parents snore heavily?

Written by Steven Park · Filed Under Blog | 1 Comment

Why Sleep Apnea is More Dangerous For Women

June 5, 2011

I’ve mentioned before a study showing that going to the bathroom (nocturia) two or more times per night can significantly increase your chance of dying. In going through the data again, I noticed something interesting: Women aged 50 to 64 with nocturia had a 94% increased risk of mortality compared with men of the same age, at 60%. This age group also had much higher mortality rates than younger or much older ages.

So why are middle-aged women at a much higher risk of dying, if they have to urinate in the middle of the night? To summarize, most of these people probably have undiagnosed obstructive sleep apnea. With sleep apnea, every time you stop breathing, the vacuum pressures in your chest prevents blood from reaching your heart. Once you start breathing again, blood rushes back into your heart, causing your heart chambers to dilate. Your body thinks you’re fluid overloaded, and produces a hormone called atrial natriuretic peptide, which makes your kidneys make more urine.

Another past study showed that people who wake up to go to the bathroom do so not because they make too much urine, but because they stopped breathing, and think they have to go. Typically, people don’t usually have a full bladder. They also tend to wake up every 90 to 120 minutes, which is one sleep cycle. So every time you go into deeper levels of sleep when your muscles relax, you’ll stop breathing and wake up.

Having untreated obstructive sleep apnea has been shown to significantly increase your risk of developing heart disease, heart attack or stroke. Your risk of getting into a motor vehicle accident increases 4 to 7 times overall. Having all these risk factors can definitely increase your chances of dying.

If you look at the data from the study, you’ll also see that young men who have this problem are also at higher risk for dying, but not so for young women. But in the years after menopause, the risks for women spike significantly. One possible explanation for this finding is that estrogen and progesterone is protective for women against obstructive sleep apnea during their reproductive years, but once they go through menopause, women who develop sleep apnea do so at much more accelerated rates. With men, on the other hand, may develop sleep apnea gradually at a much earlier age, so the body has time to adjust and compensate to some degree.

This theory also is supported by studies showing that women are more likely to die after suffering from a heart attack or a stroke.

It’s disappointing that doctors aren’t taking nocturia more seriously. Instead, people are told to avoid drinking water before bedtime, or put on medications for overactive bladders or enlarged prostates. My feeling that anyone with significant nocturia should be screened for obstructive sleep apnea. Once treated for obstructive sleep apnea, not only will you go to the bathroom much less often, but you’ll sleep better and have a much lower chance of dying.

If you go to the bathroom more than 2 times per night, what are you doing about it? Please enter your answers in the text box below.

Written by Steven Park · Filed Under Blog | 3 Comments