Another Possible Explanation for Chronic Fatigue Syndrome

Almost every week, I see young patients that come in who complain of severe fatigue, poor concentration and various aches and pains, despite 10 to 12 hours of sleep. In many cases they’ve undergone extensive testing, and even with sleep studies showing that they don’t have obstructive sleep apnea. However, in many of these patients, I see that their airway is extremely narrowed, leading to frequent obstructions and arousals during deep sleep that prevents them from being able to stay in deep sleep. I suspect that many people with this condition may have upper airway resistance syndrome.

Here’a news piece from the BBC that reports on a study that estimated that about 1 in 100 high school students in England may have chronic fatigue syndrome (CFS), or myalgic encephalomyelitis (ME). What caught my eye was the picture of the teenage girl in the video lower down in the article. Notice that she’s mildly overweight and she has a very recessed jaw. I’m willing to bet that she can’t ever sleep on her back, and she has severe dental crowding and upper airway narrowing from her nose to behind her tongue base. Sleeping on the back causes the tongue to fall back even further, and will often obstruct breathing completely when in deep sleep, due to muscle relaxation. Most people compensate by sleep in on their sides or stomach, but this is usually not good enough.

The vast majority of younger people with this condition will have one or two parents that snore heavily. However, these patients may or may not snore. The reason for this is that when they obstruct, they’ll wake up from deep to light sleep immediately. They won’t go into the intermediate state of snoring, with partial obstruction and vibration of the soft palate. Sleep apnea patients will pause for long periods after having an obstruction, leading to low oxygen levels. Patients with upper airway resistance syndrome will wake up too quickly, never reaching the threshold for an apnea or a hypopnea. This is why on sleep studies, despite not having very many apneas, they’ll have lots of arousals, movements, and sleep fragmentation. This leads to a chronic state of sympathetic nervous system overload, causing you to be overly sensitive to essentially everything.

In my experience, some patients with this condition will have large lingual tonsils (lymphoid tissues behind the tongue base). After surgery, these patients usually will feel much better. However, even surgery won’t cure them completely, since there’s usually some complement of brain dysfunction. This brings up an obvious question: Does sleep-disordered breathing lead to brain dysfunction, or does brain dysfunction lead to sleep-diordered breathing? I answered this partially in my last post about dementia.

 

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12 thoughts on “Another Possible Explanation for Chronic Fatigue Syndrome

  1. I had my tonsils out at age 16 I didn’t get sick till I was 33 now 57, my jaw is perfect , so your theory doesn’t cut it

  2. Blair,

    There are many explanations for chronic fatigue syndrome, of which this is only one. I mentioned that some people have large lingual tonsils, which is deep behind the tongue base. What you underwent was most likely a palatine tonsillectomy in the throat. Also, having large jaws does not preclude you from having crowding of your airway due to tongue collapse, which can become symptomatic at various stages of life.

  3. The diagnosis of sleep apnea and the use of CPAP had no effect on my chronic fatigue syndrome whatsoever. This article only serves to trivialize and insult patients with a very serious and debilitating illness.

  4. Dave,

    My article points out my observations whenever I see the airways of people with chronic fatigue syndrome. In fact, what I describe legitimizes this condition as a real problem. There are numerous explanations by various experts with the consensus that there’s a multi-factorial origin. My obstructed airway theory only adds to the discussion, rather than exclude other explanations.

    In many cases the extremely narrowed airways causes frequent obstructions at night with quick arousals, preventing progressing into apneas. This can lead to chronic deep sleep deprivation, which is critical for proper brain functioning.

    Even with obstructive sleep apnea, CPAP doesn’t help everyone. In fact, it can make some people feel worse, despite optimal usage. Just because it didn’t cure your fatigue doesn’t exclude it as an aggravating factor in your condition. If you go along with the obstructive sleep apnea theory, there’s lots of evidence that chronic hypoxia can damage various areas of the brain, especially parts that are involved in energy, metabolism, and memory. So even if the apneas are completely treated, there will be variable responses with brain healing.

  5. Doc how would you explain the absolute sudden onset of symptoms that occurs in most cases of CFS which was the case with me. Perfectly healthy 50 year old runner, weight lifter,ideal weight, diet etc. It seem to me that sleep apnea would be a more gradual onset of symptoms. It just does not seem logical to be highly functioning all of your life with a very high energy level then wake up one day feeling like the worst case of the flu that’s lasted 8 years at this point. It makes sense that apnea treatment would help with chronic fatigue but not Chronic Fatigue Syndrome. Also something toconsider

  6. Doc how would you explain the absolute sudden onset of symptoms that occurs in most cases of CFS which was the case with me. Perfectly healthy 50 year old runner, weight lifter,ideal weight, diet etc. It seem to me that sleep apnea would be a more gradual onset of symptoms. It just does not seem logical to be highly functioning all of your life with a very high energy level then wake up one day feeling like the worst case of the flu that’s lasted 8 years at this point. It makes sense that apnea treatment would help with chronic fatigue but not Chronic Fatigue Syndrome. Also something to consider when looking at the weight of a CFS patient is that it may have been normal at the onset of the illness such as in my case. Also note that I’ve snored like a bear since I was a kid including the interrupted breathing.

  7. Dave,

    Here’s one hypothetical possibility: OSA can significantly increase your chances of stroke. This can happen to various degrees in any blood vessel in your brain. If you clot a small vessel in your brainstem or midbrain that modulates energy, metabolism or hormones, then you can have very sudden severe fatigue. The same explanation can be given for sudden sensorineural hearing loss, where you can clot a small vessel leading to your inner ear. OSA patients are also known to have highly viscous blood, which can clot more easily.

    Any type of viral infection can also suddenly aggravate or bring to light already underlying sleep-breathing problems due to upper airway swelling.

    You can be young, thin, fit, and not snore, and still have significant sleep-breathing problems. If you can’t sleep on your back, then there’s more reason to suspect a sleep-breathing disorder. It’s also likely that one or both your parents snore heavily. If you don’t fit any of these situations, then your condition is more likely to be from one of the other causes, rather than from a sleep-breathing problem.

    Thanks for your comments.

  8. Dear Dave;
    see my guest blog a few months ago (on this site) regarding intracranial hypertension. there is some evidence that people with intracranial hypertension will not tolerate CPAP as it can raise intracranial pressure. I have this and using CPAP at the level they titrated me to made me very sick. however I am doing OK on a BiPAP machine, something that has been helpful for some UARS patients. any degree of hypoventilation will raise intracranial pressure, therefore even mild sleep apnea can be a big problem in the setting of intracranial hypertension. there are many things which can start the process of intracranial hypertension, and viral infections are one possibility. certainly a significant viral infection can obstruct your nose and swell your tonsils and push you over the edge, suddenly, into more significant sleep apnea. this becomes perpetuated by laryngopharyngeal reflux.

    what needs to be considered is that the true frequency of sleep disordered breathing is much higher than has been reported, if proper hypopnea criteria are used. even if there are other explanations for your condition, sleep apnea makes everything worse. I believe it will make the difference between another condition becoming clinically significant or not. and just statistically, it is quite likely that all chronically ill people have sleep apnea.

    the other thing I have noticed is that most doctors do not consider intracranial hypertension and are loathe to order a spinal tap, as are patients loathe to get them. but in the absence of papilledema, you cannot diagnose this condition without a spinal tap. but it can explain all the symptoms of chronic fatigue syndrome, and should be ruled out. and it will be worsened by the amount of hypoventilation that most sleep docs think is “within normal”.

    Dr. Deb

  9. Very interesting site. I like how you explain backgrounds and connections and don’t oversimplify. I wonder if you can tell more about reflex mechanisms that must exist in connection with completely stuffed up nose and sneezing attacks at night. I’m 58 years old male and never had allergies for airborne pollen and other things, and would hope that this hasn’t changed. Recently I have almost every night this problem that I wake up around 4 am with a totally blocked nose. However, I don’t have a real cold. Anti-histamines have essentially no effects on this, and during the day I have no problems. So for perhaps the last two weeks I have to get up after a few hours of sleep and I can’t get back to sleep. I then use salt water to open the nose up, which then is followed by an hour of sneezing and blowing my nose which seems to produce mucus like crazy for some time, and sometimes it blocks up again a few times. I found that it also helps to artificially bring myself out of breath by jumping around or running and dancing like I having a fit. It essentially forces the nose to open, but usually doesn’t last long when I calm down. In most cases, the whole problem simply goes away within one or two hours and I can go back to sleep. But usually I simply don’t get enough sleep like this. The reason I’m asking about reflexes is because I notice how rapidly the state of this system can change. It can go from a clear nose to totally blocked within a minute, and it may go back to normal in a minute. Then of course I would like to know how to influence these reflexes, if that is at all possible. I also tried the experiment with flimsy nostrils – there is a small effect but doesn’t seem to be significant. I’m ready for more experiments, because there is a 1-2 hours period every night where I do nothing but trying to get back to breathing normally.

    Thank you for any leads here, Doctor

  10. Reiner,

    What you’re describing is most consistent with an over-reactivity of your nasal nervous system. It’s a variation of chronic or nonallergic rhinitis. Various factors can trigger attacks, such as weather changes, chemicals, and odors. This is why allergy meds don’t help. Even apneas can trigger it due to rapid pressure fluctuations, especially in the early morning hours when you go into prolonged periods of REM sleep (when your muscles are most relaxed). There are a few nasal sprays that can sometimes help (such as ipratropiunm), but the best way of treating this condition is to take care of your breathing problems downstream (palate and tongue). This is assuming you prefer to sleep on your side or stomach. Rarely, nasal surgery can also help. You may consider seeing an otolaryngologist about your nasal problems. Good luck.

  11. Reiner;
    when you jump around you are stimulating the sympathetic nervous system, which stimulates the nose to decongest. this is exactly the mechanism used in decongestants; they are sympathomimetic drugs.