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Sleep Apnea Is A Craniofacial Problem

As a resident during otolaryngology training, I rotated in the medical center’s craniofacial clinic, seeing various disorders that lead to underdeveloped or malformed facial or skull structures. These syndromic children clearly had severely asymmetric faces or underformed jaws. In many cases they had breathing problems requiring surgery.

One of the more common conditions you’ll see in such a clinic is Pierre Robin sequence, where due to improper maturation of the lower jaw, the lower chin is recessed severely. You’ll see milder variations of this all the time, but if severe enough, these people can’t breathe, especially at night.

Treating Only The Extremes

One of the problems with modern medicine is that we name and treat only the extreme end of a continuum, or only when significant problems result. Having a slightly recessed chin may be thought of a the person’s normal facial feature, and his or her ability to breathe is never even considered.

The entire basis for my sleep-breathing paradigm is that all modern humans have constricted facial structures, not due to a congenital or genetic problem, but due to our eating and lifestyle habits. Genetically, we’re all programmed to have relatively wide jaws, with room for all your wisdom teeth. Now, that rarely ever happens. This is why obstructive sleep apnea can be described as a mild craniofacial condition that can significantly affect your upper breathing passageways.

Small Jaws, Small Airway

It seems that almost everyone these days will need braces to fix crooked teeth or narrow dental arches. Dental crowding by definition means that your upper and lower jaws are underdeveloped. This creates less total volume inside your mouth, leading to overcrowding of your tongue. Your tongue can then fall back easier when on your back, and when in deep sleep, due to muscle relaxation, you’ll stop breathing more often at night.

Even your nose can be affected by this problem. Since your nasal sidewalls follow your upper molars, the side to side distance in your nose will be more narrow, and as the roof of your mouth (nasal floor) gets pushed up, it’ll also cause your septum to buckle.

If you add additional inflammation and swelling in your nose (due to colds, allergies or nonallergic rhinitis), your nose will become stuffier faster, and even worse, your nostrils will cave in easier.

Having underdeveloped upper jaws prevents proper cheekbone fullness, giving your mid-face a sinked-in look. This type of facial appearance is so common these days that it’s almost accepted as normal. I remember reading in the New York Times a few years back where they reported that women’s preferences for male actors has changed from the classic square-faced, angular facial features, to softer, more feminine, rounded faces.

Despite having some good first line options such as CPAP or oral appliances, these approaches don’t really address the root cause. If your child’s jaw was severely underdeveloped and your choice was either lifetime CPAP or jaw enlargement, which would you choose? What if, rather than cutting the jaws and pulling it forward, you can apply distraction plates that can be pulled slowly, little by little, to normalize the jaws and improve the airway significantly? What about advanced dental appliances that can expand your upper and lower jaws in three dimensions, making more room for your tongue? With current technology, we can modify your jaws significantly. But for adults with obstructive sleep apnea, any kind of surgical or dental modification of the jaws is only considered as a last resort.

I describe obstructive sleep apnea as the end extreme of a continuum of sleep-breathing disorders. Similarly, if you look at obstructive sleep apnea as being a craniofacial problem, everyone will have various degrees of jaw underdevelopment. If you have impacted molars, or had to have your wisdom teeth taken out, then your breathing passageways are compromised.

Not only are your jaws more narrow, but the soft tissues that line your breathing passageways will be much more likely to become inflamed and cause even further obstruction. Frequent obstructions can cause a vacuum effect in your throat which literally suctions up your normal stomach juices into your throat, promoting more inflammation and swelling. These juices (which include acid, bile, digestive enzymes and bacteria) can then also reach your nose, sinuses, ears and even your lungs, causing additional inflammation and swelling. If your nose is stuffy, then a vacuum effect is created downstream in your throat and the tongue can fall back much easier, whenever you’re in deep sleep (due to muscle relaxation).

Our Airways Are Like Plumbing

In the medical community, craniofacial problems are generally treated surgically. Even with plumbing, if you only open up one area of multiple clogged areas, the pipes will still be clogged (like doing a UPPP). Sometimes you can put in drano to soften the clogging and open up the passageways (like allergy medications), but after years of buildup and accumulation, you have to physically open up all the blocked areas. You can also use a plunger to force the water down the drain (like CPAP), but you know that sooner or later, it’ll get clogged again. The older the pipes, the worse it becomes (old age).

CPAP and oral appliances are both important and necessary tools to treat the vast majority of people with sleep apnea, but we also need to open our minds to the idea that we shouldn’t have to sleep with gadgets or devices for the rest of our lives.

A Modern, Western Dilemma

It’s commonly known that our brains are getting bigger over time. As modern human’s mid and lower faces get smaller and smaller, I predict that in a few hundred to a few thousand years, everyone will be tethered to a hose while sleeping, like in the science fiction movies. Maybe vocal speech and communication will not be needed anymore, and we’ll be able to communicate with mental telepathy. We’ll all begin to look like that alien in the old Star Trek episode with the huge brain and a tiny face.

Sadly, it’s already started. If you look at the younger generations, you’ll see how narrow their dental arches are, along with flat cheekbones and narrow nasal widths. Recently, I happened to see an Amish chorus singing songs in the Grand Central subway station. I was amazed how most had very prominent cheekbones, well-formed jaws, and good looking smiles. It’s not surprising that cultures that eat organically and off the land will have more fully developed jaws.

So the next time you’re sitting in an auditorium and a public place with lots of people, think about that classic first day of college speech by the dean or president:

“Look to your left…and look to your right. At the end of this year, one of the two that you see will not be here with you.”

Similarly, every other person sitting next to you will most likely have smallish jaws, and have an undiagnosed sleep-breathing problem. From a craniofacial standpoint, they won’t be able to sleep well due to narrowed breathing passageways. If you end up befriending or marrying one of these people, now you’ll understand what makes them tick, or sick.

ADHD & Sleep Apnea: The Controversial Connection

As the new school year begins, it’s only natural that there’s more awareness about learning and behavior issues. One of the most controversial topics that came up frequently is ADHD, or Attention Deficit Hyperactivity Disorder. It’s thought that 2-4% of children have this condition, and a shocking 50% of children with this condition are on some form of prescription medication. Not only is it seen in children, but adults can have it as well. Symptoms include inability to focus or pay attention, being easily distracted, and various behavioral problems in the classroom.

There are a number of proposed explanations for why ADHD occurs, including brain biochemical imbalances, environmental and dietary toxins, and allergic conditions. One possible explanation that never receives very much attention is from lack of deep quality sleep.

Poor Sleep Can Ruin Your Child’s Brain Health

It may be coincidence, but it’s estimated that about 2-4% of all children have obstructive sleep apnea. And we know from numerous studies that poor sleep, whether not enough sleep, or poor quality sleep, can adversely affect the brain in a number of different ways.

For one thing, lack of oxygen to the brain has been shown to cause lowered blood flow and metabolism in critical areas of the brain, including parts that involve memory and executive function.

There’s no doubt that hypoxia can cause significant alterations in the levels of neurotransmitters that regulate memory, focus, concentration, and other cognitive skills. If you pick any one out of dozens or hundreds of biochemical markers, you’ll find that there will be a deficiency or an elevation. Whether it’s dopamine, acetylcholine, or serotonin, if you look for abnormalities, you’ll find it. Not too surprisingly, the same can be said for depression, anxiety, and other mood disorders.

Admittedly, ADHD is a multifaceted condition. Sometimes, it’s mainly due to one condition, and in other cases, from a combination of different causes. Not breathing well at night while sleeping can present with the same clinical symptoms as toxic contamination such as lead poisoning. So it’s important to have the pediatrician or other health care professional to look at all possibilities before considering psychotherapy or prescription medications. Only after every treatable condition has been ruled out should the diagnosis of ADHD be given, since ultimately, it’s a diagnosis of exclusion.

First Check For Sleep Apnea, Then ADHD

One recent study found that 28% of children scheduled to undergo routine tonsillectomy had official ADHD. Once their tonsils were removed, the rate of ADHD dropped by about 50%. Since these children were selected from a pool of patients that are already predisposed to sleep-breathing problem, it’s only natural that sleep apnea is so common. In another contrasting study, there was no difference in the rate of obstructive sleep apnea between controls and children with ADHD.

One thing that’s for certain, many children with ADHD, even if they don’t officially have sleep apnea, will have major sleep breathing or sleep hygiene issues. This situation is similar to patients who don’t have obstructive sleep apnea but have upper airway resistance syndrome, where they still stop breathing multiple times during the night.

During the initial evaluation process, one of the first things to always consider is the possibility of a sleep-breathing problem. Snoring or breathing problems at night are always a good thing to look for, but you don’t have to snore to have significant obstructive sleep apnea. If your child has very large tonsils, or has frequent throat infections, then consider seeing an ENT surgeon. Chronic nasal congestion or a runny nose can suggest a problem with the upper breathing passageways as well. If one or both parents snore, then even more reason to suspect a possible sleep-breathing problem.

But before you take your child to see a sleep doctor or an ENT surgeon, first try these simple steps to improve their sleep quality.

1.  Take care of any allergies, whether food related or environmental. Allergies can cause inflammation of the upper air passageways that can cause swelling and further narrowing, leading to more obstructions and arousals. If conservative options fail, then see an allergist.

2.  Don’t eat or snack within 3-4 hours of bedtime. Eating close to bedtime allows more stomach juices to be suctioned up into the throat when you stop breathing.

3.  Deal with any nasal congestion. Having a stuffy nose for any reason causes a vacuum effect that allows your tongue to fall back easier when in deep sleep.

4.  Set a regular bedtime routine, with no media (TV, computers or phones) within one hour of going to bed.

5.  Make sure the bedroom is completely dark. Many bedroom appliances, clocks or other devices have exceptionally bright LED bulbs that can prevent proper sleep onset.

If you suspect that your child may have ADHD, the first thing to consider is to consider poor sleep quality as a major aggravator, if not the cause. Yes, you still need to address all the other issues that can aggravate ADHD, such as diet, stimulus control or allergies, but sleep should never be excluded from the list. Even if sleeping better doesn’t’ help with the ADHD, it can definitely help with various other health issues, such as obesity prevention, or lower incidence of asthma, depression, and anxiety. It could even help your child raise his or her test scores.

What Everyone Should Know About Mold

I was recently watching an HGTV program where a prospective home buyer was shown a house with obvious mold in the basement after flooding. The discussion that took place between the host and the guest was similar to talking about the black plague. Similarly, even in my practice, many patients are at their wits’ end trying to rid their houses or apartments of mold.

But as I look at it, molds, yeasts and fungal infestation or infection, although harmful, may not be as pernicious as the press and the media would like to have you believe. Here’s why.

Why Mold Is Not Our Enemy

Molds, funguses and yeasts, called collectively as fungi, are different from bacteria, plants or animals. They are widely present throughout the world, and are an important part of our earth’s ecosystem. However, just like bacteria, pollens, dust, gluten, or milk, modern humans have developed sensitivities to normal substances in our environment. There are a number of different explanations for this phenomenon, including living in relatively more sterile environments, or having toxic infiltration of chemicals into our food and water supply. Children growing up in farms or third world countries, for example, are found to have less allergies.

Our modern times have been called the “age of anxiety,” and this includes our body’s over-reaction to normal substances, situations or environments. To understand why this is so, it’s helpful to go over what happens in a stressful event. Robert Sapolsky, in his classic book, Why Zebras Don’t Get Ulcers, explains that when a zebra is running away from a lion, every aspect of the zebras’ physiology is being geared up to avoid being eaten by the lion.

This means that the nervous system and the immune system are extremely heightened thereby increasing reflexes and stimulating the immune system. This short burst of intense sympathetic activity, lasting seconds to minutes, is what’s called the “fight or flight response” by endocrinologist Hans Selye. You hear about mothers lifting cars to save their children, and other amazing stories. But what if this beneficial response is happening all the time, but at lower levels?

This is exactly what Sapolsky describes—that modern societies, with its’ constant and incessant little stresses, is what’s killing us—literally. Some examples include the honk behind you as soon as the traffic light turns green, the rude cashier at the store, deadlines, crisis management at home, and various other issues at work.

During a major stressful event, your cortisol levels (your stress hormone) and your sympathetic nervous system increases greatly, but once the stressful event is over, your hormonal and nervous system responses return back to normal levels. Actually, with the immune system, as it drops back to normal levels, it dips below normal for a short period of time before going back to normal levels. This may be one explanation why people get sick only after a major stressful event.

But if you have multiple small stressful events throughout the day, you don’t have time to recover, and your baseline stress levels remain constantly elevated.

If you add to this any form of sleep deprivation, than you’ll be adding to this chronic stress state even more. Moreover, if you have obstructive sleep apnea, it’s a given that you’ll have more physiologic stress, proven by numerous studies. Add any additional sources of emotional, psychological or physical stress, and it can make your internal stress levels even worse.

Coming back to the mold example, if you have an underlying sleep-breathing problem such as obstructive sleep apnea, you’ll be extra sensitive to molds compared with someone without sleep apnea. However, if you add to this the anxiety of media driven shows that multiply fears about the dangers of any kind of mold, then your baseline response to molds will be further increased.

Can Mold Cause Sinusitis?

One recent theory about the origin of chronic sinusitis is related to molds—that your nasal cavity is filled with normal mold spores that come in from your natural environment. Once it settles into your mucous membrane layer, it eventually gets slowly passed into your throat by the mucous blanket that gets pushed back into your throat. However, if you are overly sensitive to molds, then white blood cells are recruited from the surrounding blood vessels that eventually reach the mucous membrane layer, releasing toxic chemicals that end up destroying the molds. Phagocytic cells then come in to clean up the mess.

However, as a result of the release of toxic chemical, the underlying mucous membrane is damaged, and becomes “leaky”, allowing normal bacteria that live in your nose and other toxic substances to leak into the tissues of the nose and sinuses. This same concept has been used to describe food sensitivities that can lead to a “leaky gut” with its’ various gut-related symptoms.

I’m not discounting the legitimacy of mold hypersensitivites, but I do want to emphasize the fact that any kind of allergic reaction or hypersensitivity (pollen allergies, certain foods, weather, etc.) can be aggravated by an underlying sleep-breathing problem. If you do have a known sensitivity to molds, you have to either remove the mold, or remove yourself from the moldy environment. But at the same time, this should be a signal for you to investigate if there isn’t another stressor, like a sleep breathing condition, that’s aggravating your mold allergies even more.

As such, mold problems, like any other health problem, don’t occur in isolation. Just as a migraines is caused by a number of different triggers that can add up until you have your headache, your mold problem will worsen if you have a number of other factors that stimulate your nervous system, such as whether changes, allergies, sleep quality, emotional stress, nasal congestion, etc.

There’s no doubt that millions of people are suffering from mold or yeast related health problems unnecessarily. But at the same time, there are also many people who are taken advantage of by industries playing to their fears and anxieties about the dangers of mold. Whether or not you have potential mold problem, it’s important to evaluate your sleep quality. Knowing that a significant proportion of Americans have undiagnosed obstructive sleep apnea, treating this condition will not only improve your mold-related health problems, but improve numerous other aspects of your health as well.

Central Sleep Apnea—A Simple Explanation

In sleep disorders, obstructive sleep apnea is the most common condition that’s seen, but a significant number of people with obstructive sleep apnea will also have central sleep apnea. Central sleep apnea is thought to be a condition that’s associated with a number of different neurologic problems, as well as heart or kidney failure. During the night, people with central sleep apnea stop breathing when signals in the brain that tells the body to breathe don’t work properly. No effort is even made to inhale. In contrast, with obstructive sleep apnea, an effort is made to breathe in, but because of collapse in the upper airways, air can’t get into the lungs.

One of the hallmarks of central sleep apnea is Cheyne-Stokes breathing, where after a long pause, due to gradually increasing levels of carbon dioxide (CO2), shallow breathing is triggered which gradually becomes deeper and deeper, and then once CO2 reaches a safer level, the breathing becomes more shallow again.

Unfortunately, treating central sleep apnea is more of a challenge than treating obstructive sleep apnea, and the best way of treating this condition is to use a variation of CPAP as a respirator. This is a servo-ventilator feature that’s found in machines that can treat this condition. When it senses that you’re not breathing, it literally breathes for you, rather than applying constant positive pressure for obstructive events. Some people will have a combination of obstructive and central events, which is called mixed or complex sleep apnea.

A number of different neurologic conditions can cause central sleep apnea, but here’s a simpler explanation:

We know that a HUGE number of people have undiagnosed obstructive sleep apnea. Up to 1/4 of all men and 1/10 of all women have it, and by the time you’re 60 or 70, the vast majority will have at least some degree of sleep apnea. If you’re human, and you can talk, then you’re susceptible to breathing problems at night, even if you don’t suffer from any apneas. The reason is that complex speech and language development unprotected our upper airways, and everyone’s tongue can fall back and obstruct your breathing at night, especially when you’re in deep sleep, due to muscle relaxation.

I’ve also talked about how modern humans’ jaws are shrinking, due to a radical change in our diets and the addition of bottle-feeding. This had lead to increased rates of dental crowding, with more and more people needing braces. The smaller the jaws, the less space there is for the tongue, which can take up too much space, ultimately crowding the airway.

We also know that there’s a linear correlation to complications of apneas, even in the very low range, where having an AHI of 4 is significantly worse than having an AHI of 2, although officially, you won’t have obstructive sleep apnea, since you come in below 5. Sleep apnea patients are also known to have thick or viscous blood that tends to clot easier when there are areas of low blood flow or small vessel constriction. People with obstructive sleep apnea by definition have smaller vessels and low blood flow simply due to the massive stress response that naturally constricts blood vessels and causes hypertension.

Numerous imaging studies also show that people with obstructive sleep apnea have much higher numbers of lacunar infarcts, which are small areas of dead brain tissue that’s normally seen in routine CT scans of the brain. Other studies reveal lower blood flow, metabolism and brain tissue density in certain critical parts of the brain that control memory, executive function, and autonomic function. Areas of the brain that address hearing, including the high frequency sound perceiving areas of the inner ear, are also extremely sensitive to instances of low blood flow or stagnation. One recent study showed that people with sleep apnea had lowered auditory brainstem reflexes, but after treatment with CPAP, or after thinning patients’ blood concentrations, these auditory reflexes improved.

One finding that’s fascinating is that parts of the brain that control breathing are also affected preferentially by these events. Knowing that even mild levels of sleep-breathing problems can aggravate various levels of clotting and vessel blockages, if you happen to clot off a small vessel that leads to this area, then your neurologic breathing patterns can be affected. These same areas also control autonomic function, which includes heart rate, temperature, digestion, sweating, and vascular reflexes. Damaging even a small part of the brain in this area can wreak havoc on your breathing patterns, as well as other regulatory functions that control your body’s organs.

Since we know that obstructive sleep apnea is strongly associated with heart disease, it makes sense that central sleep apnea is commonly seen in patients with heart disease. Not only can obstructive sleep apnea cause heart disease, by applying this model it can also cause central sleep apnea. Poor involuntary nervous system control, especially of the heart, can wreak havoc on heart function. It can also cause problems with digestion and even your hormones.

Although we have a way of treating central sleep apnea, the results are not as satisfying compared with treating obstructive sleep apnea. Ultimately sleep doctors don’t have very good answers to why this happens, or how to treat it effectively. Think of it as a permanent neurologic condition, where rather than having weakness of your lower legs, you have weakness of the nerves that control your breathing patterns. Treating the obstructive component probably won’t cure the central sleep apneas, but at least it could prevent it from getting worse.

7 Common Procedures That Can Worsen Sleep Apnea

Millions of surgical operations are performed every year to improve your health, beauty, and even your smile, but there’s a hidden danger in some of the most common procedures that can aggravate if not actually cause obstructive sleep apnea. Sleep apnea happens when your jaws are too narrow, which constricts the internal soft tissue layer that lines your upper breathing passageways, from your nose to your throat. More than a few times a week, I see patients that underwent procedures in the past that clearly was detrimental to the quality of their sleep. Here are 7 common and uncommon procedures that can affect the way you breathe and sleep.

1. Rhinoplasty

One of the most common procedures that’s performed today is your routine nose job, or rhinoplasty. In most cases a hump is taken down, or the tip is made more narrow. In the process, certain support structures are weakened, with flimsy nostrils resulting many years later. In the 1950, the Goldman tip was one of the more popular styles, where the tip of the nose was made very narrow and lifted up slightly. With any procedure that narrows the tip, a portion of the lower lateral cartilages have to be either removed or weakened. This cartilage is one of the main support structures that keeps your nostril from collapsing inwards.

Initially after the procedure, patients can breathe well, but years or decades later, with constant inspiration and vacuum forces from routine breathing, the nostrils slowly cave inwards, worsening nasal congestion.

We know that nasal congestion can aggravate or cause obstructive sleep apnea. This is why nasal packing after any surgery is a miserable experience, and why you’ll toss and turn whenever you have a cold (from a stuffy nose). If your jaws are already narrowed, you’re more likely to have a nasal hump and narrowed nasal cavity, so worsening nasal congestion can only aggravate breathing problems downstream. Underdevelopment of the midface pulls the upper lip and the lower cartilaginous nose down, creating the classic nasal hump.

Even with contemporary rhinoplasty techniques, it’s important to prevent this from happening using proper technique and by minimizing removal of excessive cartilage.

2. Orthodontics / Headgear

I’m sure you’ve seen children wear headgear in past years, with a brace around the head and wires pushing or pulling teeth. Children with overjets (overbite) were managed by pushing the upper teeth back, thus creating the illusion of a proper bite. The fact is that in these children, the lower jaw is underformed, and the best thing to do is to pull the lower jaw or teeth forward to match the upper teeth.

Additionally, some orthodontists still extract teeth to make room for the remaining teeth. Your smile may be nice, but in the process, your jaw just became smaller. Any amount of narrowing of your jaws creates less room for your tongue, and with muscle relaxation in deep sleep, you’ll stop breathing much more often. It’s bad enough that modern human’s jaws are shrinking more and more (due to a radical change in our diets and with bottle-feeding), but when you start to extract multiple teeth, you’re definitely going to have problems breathing. The back molars also act to support the soft tissues of your throat. So removing your molars can destabilize the soft palate, aggravating more soft tissue collapse, especially later in life.

3. Jaw Surgery

Once in a while, I’ll see patients that underwent lower jaw surgery to push back a prominent lower jaw. In this situation, the upper jaw should  have be pulled forward. Since the base of your tongue attaches to you back of your mandible, any backward movement of your jaw can push your tongue back, aggravating breathing problems while you sleep.

4. Thyroglossal Duct Cyst

The thyroid gland starts at the back of your tongue and migrates down your neck in front of your voice box, and then divides into your right and left thyroid lobes with a small connection between the two over the top of the windpipe. Sometimes, a remnant of that tract from your tongue to the voice box can remain, with cysts or tracts or even thyroid tissue along this pathway. When a cyst develops, you’ll have a midline ball or swelling that won’t go away. The treatment for this condition, called thyroglossal duct cyst, it surgical removal.

The procedure is classically called the Sistrunk procedure, named after the surgeon that originally described it. The critical part of this procedure involves removed the midline 1/3 of the hyoid bone, which is a c-shaped bone that sits on top of your voice box. Unfortunately, you’re also weakening and destabilizing the attachments to the tongue and voice box. Upon questioning the handful of patients that have undergone this procedure in past years (some by me and some by other surgeons), most have said that their sleep quality worsened. If you’re ever going to undergo this procedure, it’s important to reattached or reconstruct the tissues that help to support your tongue and voice box.

5. Hysterectomy

Total hysterectomy with or without removal of the ovaries is a common procedure for many women. We know that especially when the ovaries are removed, this creates a state of surgical menopause. I’ve described in past articles that as progesterone naturally drops in normal menopause, sleep quality can diminish, mainly due to the effects of progesterone on tongue and upper airway muscle tone. As the tongue muscle tone slowly drops, obstructions and arousals become more frequent, and you won’t sleep well.

This is also one of the main reasons why hormone replacement therapy (HRT) helps many women sleep better. However, with the recent finding that HRT can increase rates of cancer, it’s not generally recommended anymore. If you’re thinking about undergoing a hysterectomy, be prepared not to sleep as well.

6. Breast Implants

If you’re a woman and like to sleep on your stomach, then getting breast implants can definitely worsen your sleep quality. For a few weeks after this procedure, most surgeons will ask you to sleep on your back. The problem is that when on your back, your tongue will fall back more often, leading to more frequent breathing obstructions and arousals. Until you’re able to go back to stomach sleeping, be prepared to lose a lot of sleep. Unfortunately, some women are never able to sleep on their stomachs again, being forced to sleep on their sides or back.

7. Any Type of Surgery

No matter what type of surgical procedure you undergo, if you’re forced to sleep on your back, then your sleep apnea will be worse. If you never had sleep apnea or sleep-breathing problems, then being on your back may bring on your first experience, especially if you’re a natural side or stomach sleeper.

As you can see, millions of people undergo these procedures every year. Sometimes, the effect on sleep occurs immediately, whereas in others, it can take months or years to surface. If you’re planning any of the above procedures, or if you’ve undergone any in the past, think about how it can potentially affect your quality of sleep. It’s something you should definitely sleep on.

The Biggest Throat Problem for Sleep Apnea Sufferers

If you wake up every morning needing to hack up lots of thick mucous, or have throat pain, hoarseness, or a chronic cough, you’re not alone. You may think it’s the beginning of a cold, but a cold doesn’t continue for weeks to months without progressing into the full-blown viral symptoms.

Instead, these symptoms are the beginnings of the most common throat problem sleep apnea sufferers face. And as I explain below, without understanding why this occurs, it can be one of the hardest problems to treat.

Beware of the “Vacuum Effect”

People with obstructive sleep apnea are more prone to breathing problems at night due to partial or total collapse of one or more areas of the entire upper airway, from the nose to the tongue. It’s usually worse when on your back, since the tongue can fall back more in this position. During deep sleep, your muscles naturally relax and you’ll be more susceptible to breathing stoppages.

Pressure sensors placed inside sleep apnea patients reveal that every time an apnea occurs, a tremendous vacuum effect is created inside the chest and throat, which literally suctions up your normal stomach juices into your esophagus and throat. This can happen occasionally, even for normal people, but if you happen to have a late meal or a snack just before bedtime, there will be even more stomach juices lingering in your stomach to come up into the throat. If you happened to drink a nightcap, the situation is even worse since alcohol is a strong muscle relaxant.

What comes up into your throat is not only acid, but also bile, digestive enzymes, and even bacteria. Washings of lung, sinus and ear contents have shown H. pylori, a common stomach bacteria, and pepsin, a major stomach digestive enzyme. So what comes up can cause severe irritation in your throat, provoking the mucous secreting glands of your throat to try to dilute these substances.

Although people generally attribute throat mucous to post-nasal drip, in most cases there’s nothing dripping down the back of the throat. It’s actually coming from your stomach. However, in some cases, since your stomach juices can reach your nose, it can cause nasal congestion and inflammation, which can aggravate tongue and soft palate collapse by creating a vacuum effect downstream. Ultimately, it’s a vicious cycle.

Chronic acid and other irritating substances lingering in your throat can have other detrimental effects. One recent study showed that chronic acid exposure can numb or deaden the protective chemoreceptors in your throat. These are sensors that detect any acid in the throat to prevent aspiration of your stomach contents into your lungs. If these chemoreceptors sense any acid in your throat, a feedback signal is sent to the brain, causing you to wake up so that you can swallow. This is what’s called a reflux arousal.

Treating Reflux For Good

So besides not eating late and avoiding alcohol close to bedtime, what else can you do?

I’m assuming that many of you that are reading this article are already being treated for obstructive sleep apnea, via either CPAP, oral appliances, or even with surgery. The problem is that no matter which option you choose, there will always be some degree of reflux. Taking acid reflux medications can help sometimes, but for the most part, these reflux medications don’t really do anything for reflux. All they do is to lower the acid content content before it comes up into your throat.

Other options include stimulating your stomach via natural remedies or prescription medications to empty your stomach much faster. One fascinating study showed that using a combination of pseudoephedrine (Sudafed) and a pro-motility agent (domperidone) eliminated snoring in most people. Unfortunately, we don’t have the equivalent of domperidone here in the US. Other similar medications are available, but have more serious side effects.

This is why eating early at least 3-4 hours of bedtime is so important whether or not you have obstructive sleep apnea. The same also applies to alcohol. If your nose is stuffy, talk with your doctor to find a way to breathe better through your nose. Make sure you’re sleeping in your preferred or optimal sleep position. Lastly, work with your sleep physician to fully optimize your sleep apnea treatment, no matter which option you choose.

UARS: The Hidden Sleep Condition

You’ve gained some weight over the years and you’re just not sleeping well. Your husband says you’ve begun snoring. You know that your father has obstructive sleep apnea and is doing well with CPAP. You mention this to your doctor and she orders a sleep study. The sleep study comes back completely normal. Now what?

The Real Reason for Your Chronic Fatigue

Before you begin searching for other reasons for your chronic fatigue, don’t rule out a sleep-breathing problem too quickly, even if you don’t have obstructive sleep apnea. In fact, a sleep-breathing problem can cause if not aggravate conditions such as hypothyroidism, chronic fatigue syndrome, depression, insomnia, and even irritable bowel syndrome.

Sleep doctors have defined obstructive sleep apnea as having at least 5 apneas or hypopneas every hour on average. An apnea means you stop breathing completely for 10 seconds or longer. Hypopneas are similar 10 second or longer pauses but with restricted airflow. But what what happens if you stop breathing 25 times every hour but each episode lasts only a few seconds?

In the early 1990s, Dr. Christian Guilleminault of Stanford University looked at young, thin men and women who were tired all the time, no matter how long they slept. These people were found not to have obstructive sleep apnea after undergoing formal sleep studies. However when they placed thin pressure catheters in their chest and throat, they found the they had frequent episodes of partial obstruction which led to subtle, but significant limitation of nasal airflow, along with very negative vacuum pressures in the throat. Most of these minor episodes were not apneas or hypopneas, but still lead to an arousal—from deep to light sleep. What was happening was multiple partial obstructions and arousals that were not severe enough to be called apneas or hypopneas, but enough to wreak havoc on deep sleep quality.

It’s been shown that even very subtle levels of restricted breathing can lead to deep brain stimulation and arousals that prevents your ability to stay in deep sleep. These reflex signals to the brain can be so weak that it doesn’t even reach the outer layers of the brain where standard scalp electrodes can pick up these disturbances.

Blame It On Your Parents (And Your Jaws)

The fundamental problem in UARS is due to smaller upper airway anatomy, caused by having smaller jaws and dental crowding. The smaller the space behind the tongue, the more likely you’ll obstruct while breathing when on your back (due to gravity, the tongue can fall back), and when in deeper levels of sleep (when your muscles relax). This is why most people with UARS can’t, or prefer not to sleep on their backs. The problem is that you can still have breathing problems despite sleeping on your side or stomach, just not as bad as being on your back.

Lack of sleep and especially lack of deep sleep has been found to cause a whole host of physiologic changes. In general this happens due to chronic overstimulation of your sympathetic nervous system. This is the fight-or-flight half of your involuntary nervous system. Since your body thinks it’s under attack, it heightens your nervous system, making you en garde, edgy, hypersensitive or overreact to normal situations. This also leads to diversion of blood flow, energy and resources away from less essential body parts and organs, such as your digestive system, reproductive organs, skin, hands, feet, and other “end organs.”

Due to this “hypersensitivity,” the nose and sinuses can be overly sensitive, reacting to stimulants such as weather changes, chemicals, scents, and even allergies. Chronic stress that results from sleep deprivation also can heighten your immune system.

Is It Hormones or Your Breathing?

A number of other studies point out that UARS patients are more prone to have cold hands or feet, hypothyroidism, irritable bowel syndrome, depression, chronic fatigue, and various other “somatic” syndromes. I see this all the time in my practice. In fact, a recent study even showed that chronic long-term sleep deprivation caused significant lowering of the TSH and T4 levels, with women being much more susceptible to this effect compared with men.

With time, as people age, and especially as they gain weight, most people will progress into true obstructive sleep apnea. You’ll find that most younger, thinner people with UARS will have one or two parents with significant obstructive sleep apnea.

Now that you’re convinced that you may have this condition, what can you do about it? For the most part, it’s treated just like obstructive sleep apnea. You should start with all the conservative options first, such as weight loss (if you’re overweight), diet, exercise, improving your nasal breathing, and not eating late. If these options don’t work, then all the formal options for treating obstructive sleep apnea are possible including CPAP, oral appliances, and even surgery.

Unfortunately, if you don’t officially have a sleep apnea diagnosis based on a sleep study, then insurances generally won’t cover any of the treatments. The irony is that our health care system won’t treat or prevent diseases in the early stages, and would rather wait until it’s much more severe before covering for medical services.

If you think you may have upper airway resistance syndrome, you may be disappointed to find that the medical community in general will not be responsive to your queries. With a few exceptions, many sleep doctors are not convinced that UARS is even a legitimate condition, and would rather lump it into the spectrum of snoring to obstructive sleep apnea. Time after time, whenever I see patients who are told they don’t have obstructive sleep apnea and I treat the upper airway narrowing and inflammation, patients almost always feel better. Your best option is to continue to educate yourself and be persistent. Your first priority should be to be able to breathe better so that you can sleep better.

Don’t Let Poor Sleep Ruin Your Vacation

There are many resources available regarding tips for travel while on vacation, but one thing that can definitely ruin your vacation is poor sleep. You may never think that you will suffer from sleeping problem until it happens, and by then, it’s too late. Besides the various stresses of travel, including delayed flights, misplaced luggage, or traveling with children, the last thing you need is to lay down in your hotel bed, and start tossing and turning, unable to sleep.

On the other hand, you can go to sleep with no problems, but wake up feeling like you slept for only 3 hours. This can happen due to worrying about your lost luggage, persistent ear pain and hearing loss since getting off the plane, or an uncomfortable mattress or pillow. If you are a poor sleeper to begin with and especially if you normally can’t sleep on your back, then the following travel tips could prevent your vacation from turning into a disaster.

Tip #1. Keep your nose clear.

If you have a history of ear or sinus discomfort while flying, or if you have any degree of nasal congestion due to allergies or colds, then take preventive measures to open up your nasal breathing passageways to prevent ear, nose or sinus problems which can keep you up at night. Your ears and sinuses are connected to your nose through very narrow passageways. If you have any form of nasal congestion or inflammation, these passageways can become more narrow, and the rapid pressure changes during your flight (usually when descending) can aggravate more swelling and a partial blockage of your sinuses or ears. The middle ears are connected to the nose by the Eustachian tubes, which acts to equalize pressure between your nose and your ears every time you swallow. But when there’s swelling (due to colds, allergies, migraines, or acid reflux) around the Eustachian tubes in the back of the nose, this tube doesn’t work properly and your ears won’t equalize. Not breathing well through your nose can also prevent proper breathing at night, leading to poor sleep.

The simplest way of preventing ear, nose and sinus problems while flying is to decongest your nose using generous amounts of nasal saline (which is a mild decongestant), or over-the-counter decongestants, such as Sudafed tablets or Afrin nasal spray. If you have high blood pressure or are sensitive to Sudafed, it’s not a good idea to take. Afrin, on the hand, can only be used for 2-3 days if you have persistent ear fullness after the flight. For most people, taking a decongestant in the middle of the flight (before descending), should be enough. There are various ear “plugs” marketed for flying. They can be helpful for some people; if it works, keep using them.

Now that you've made it safely off the plane without any problems, you finally make it to your hotel at 9 PM and check in. You're really hungry and stop by the restaurant to grab a sandwich.

Bad move.

Tip #2: Don’t eat before bedtime.

Eating late before bedtime, while on vacation or at home, is the single most common habit that could potentially ruin a good night's sleep. On vacation, it’s tempting to eat later or binge at a great restaurant, but you’ll pay for it that night. For many people, if you have food in your stomach when you lay down, some of the stomach juices can regurgitate up into your throat, causing irritation and inflammation. This can wake you up more often, diminishing deep sleep quality. For people who snore or prefer to sleep on their sides or stomachs, they may actively suck up stomach juices into their throats while sleeping, worsening an already tenuous sleep situation. The general rule of thumb is to eat your last meal about 3-4 hours before bedtime. This also means no snacks before bedtime.

Tip #3. Avoid the Night Cap.

You've stopped your late night snacks, and so far so good. You make arrangements to meet your long-time friend at the hotel bar, but the earliest he can meet is at 10 PM. The two of you meet and decide to have a glass of wine. As you take your first sip, you remember the newspaper article that reported that red wine has an ingredient that could keep you young. Afterwards, you to back to your room to rejoin your wife, and you go to bed. The next morning, for some reason, you feel like you only slept for 3-4 hours. What happened?

There are numerous studies that tout red wines' beneficial health effects. But one aspect of red wine, and all other forms of alcohol, that could be detrimental to your health is its' relaxing effects on your throat muscles. If you already have a slightly narrowed upper airway passageways (like most people), sleeping on your back can cause mild collapse of your tongue backwards. But when you add deep sleep, since all your body's muscles relax the most, adding alcohol can tip you over the edge and cause you to stop breathing. You may wake up subconsciously, or completely awake. This is one of the main components of alcohol that promotes hangovers in some people.

The bottom line is that you should avoid drinking alcohol 3-4 hours before bedtime.

Tip #4. Take Your Own Pillow.

You've stopped your late night eating and drinking alcohol, and you are ready to go to sleep. You lie down to sleep, but something doesn't feel right. After a few minutes of tossing and turning and fluffing the pillow, you realize what the problem is: you miss your own pillow. Yours is much firmer, and the hotel's pillow is too soft. Thinking about your pillow is not something that most people consider before taking trips. You can't bring your own mattress, but you can bring your own pillow, if space allows. On car trips, I always bring my own memory foam, contoured pillow. A soft down pillow could easily fit into a decent sized suitcase.

Don't wait until you are ready to go to bed to find that the hotel's pillow isn't "just right." When you first arrive in your room, after you unpack, test drive your pillow. If it doesn't feel right, ask the concierge for a different type of pillow. Some may even have the memory foam contoured pillow that I like, and some Asian travelers may prefer a roll-like buckwheat-filled pillow.

If you like to sleep on your back, and feel less than refreshed in the morning, try sleeping on your side. If that's not possible, experiment with the roll-like pillow that I mentioned previously, or roll up a towel to just the right thickness. The reason this may help you sleep is that when your head is cocked back slightly when sleeping (unlike softer, down pillows that end up bending your head forward), the space behind the tongue opens up significantly, preventing frequent awakenings at night.

Tip #5. Don't Sleep In.

When you're on vacation, it's tempting to stay up late and sleep in in the morning. RESIST THE URGE. I've already covered in the past few lessons why it's important not to eat late, and why you must go to bed at a reasonable time to allot for your normal sleep duration. If you go to bed late and wake up later in the morning, you've shifted your sleep clock, which will make you want to go to bed later. Once you're back home, along with the clock shift from changing time zones, you'll be doubly affected: time zone shift and a sleep clock shift. This is why it's so hard to get anything done when you get back to work.

To make the most of your vacation, plan your sleep times accordingly so that you can maximize your fun during your waking hours. Spend time outside in the sun, walk, jog, cycle, swim, and relax! If possible, remember to give yourself a day or two to wind down after you come back before you go back to work.

Even if you don't suffer from any problems during your trip, many ear and sinus problems occur AFTER your return trip, usually aggravated by the return flight. You've had a great vacation, but now you're paying for it when you come home. If you had followed my advice during your vacation, you wouldn't have to see a doctor about your ear problem.

Tips for Traveling with Your CPAP Machine

One of the most common excuses for not wanting to use CPAP is that "I travel a lot." Even after I explain that many people travel just fine with their CPAP machines, some people are stll reluctant. With advances in technology and increased awareness by the lay public, government officials and medical professionals about the importance of using CPAP for obstructive sleep apnea, traveling with CPAP, although initially a challenge, can be done with relative ease. People use CPAP on planes, and even go camping with it. With the FAA's recent ruling and instructions on carrying and using CPAP on airlines, it's become even easier to travel with CPAP machine. I know there are various types of PAP devices, but for the sake of simplicity, I'll call these devices the generic name, CPAP.

Flying with Your CPAP

The Federal Aviation Administration (FAA) recently ruled that airline passengers must be allowed to use respiratory assistive devices, such as a CPAP machine (Nondiscrimination on the Basis of Disability in Air Travel – May 13, 2009). However, don't think that you'll just breeze by security checkpoints at the airport. Here are some common tips that are recommended when you fly with your CPAP machine:

1. Never check your CPAP machine.

2. Always have with you a prescription for your CPAP machine and your latest sleep study. You never know if your unit gets lost or stolen, or breaks down.

3. Attach a medical equipment tag, identifying the contents as such.

4. Let the TSA security agent know that you have a CPAP machine. Remove it from the back and have it scanned separately.

5. Request that security agents change gloves and wipe down the table before inspecting your machine. Wrap your device in a clear bag while being scanned to prevent contamination with germs and other chemicals.

6. Keep a record of the model and serial number in hand, just in case.

7. If you're going to use your CPAP machine in-flight, check beforehand if there's an outlet next to your seat, and if you have the right adaptor.

8. If the flight attendant says something about your CPAP being another carry-on, let him or her know that it's a CPAP machine and under the Americans with Disability Act, it's not counted as an added carry-on.

9. Consider having your doctor give you a letter describing the need for your CPAP machine.

10. Most CPAP units will automatically convert to the correct local voltage. Check with your instruction manual or manufacturer to confirm this. You may, however, need a plug adaptor, as well as an extension cord, in case your outlet is far away.

Tips On Water

Many people are so focused on the logistics of their machines, that sometimes they forget about distilled water. Make sure you have plenty of distilled water available if you're going to use it on the plane, or at your final destination.

If you're not going to use your CPAP device on the plane, then make sure you empty and dry the water chamber before flying. If you're planning on using your CPAP device on-board, there are two options to be able to pass large amounts of fluids past TSA security checkpoints: Have your doctor prescribe distilled water in a pharmaceutical grade bottle. A 500 mL bottle should hold about 16 oz. Another option is to purchase papFLASK, which is designed to pass through security checkpoints with ease.

For whatever reason you don't have distilled water available, using bottled or even tap water is OK, but try to find distilled water as soon as reasonably possible. Mineral deposits in tap water can build up within the PAP machine and can cause damage if it continues long-term.

Camping or Backing Up with CPAP

For travel to areas that don't have electricity, or in case you have a blackout, there are numerous battery options available. Each manufacturer will usually have a back up battery recommendations and adaptors.

For more extended periods, various people have written about using a 12 volt deep cycle marine battery with a sine wave inverter. There are numerous other battery options so do your research. Different manufacturers have different voltage needs, so also check with your manufacturer. Since a humidifier uses a lot of energy, most people recommend not using the humidifier if you're only camping for a few days. There's lots more information about batteries in CPAP support sites such as sleepguide.com, cpaptalk.com, talkaboutsleep.com, or apneasupport.com.

Have A Back Up Plan

Some patients carry around their oral appliances with them whenever they travel, either using it in place of their CPAP machines or just in case the device breaks. Some people use both the oral appliance and their CPAP machines simultaneously. If you've never tried an oral appliance and you're interested in an alternative option, it may be worth giving it a try now before you need to travel for long extended periods.

No More Excuses

With advances in technology and more acceptance by the medical community as well as the lay public, there's basically no reason (unless it's psychological) you can't travel with a CPAP machine. With knowledge and some flexibility and creativity, anyone can travel with CPAP, even in the more remote areas of the world. There have even been descriptions of solar power being used to recharge batteries used for CPAP. If you travel frequently to the same location, consider purchasing a second unit. Prices for middle of the road CPAP models are in the $300 to $700 range.

The first major challenge is in finding a way to make CPAP work for you. The second major challenge is in un-tethering your machine from your bedroom. Many people are living vibrant and normal lives, despite having to use their CPAP machines while traveling. Or is it because they are using their CPAP machines regularly while traveling? You decide.

The Biggest Ear Problems for Sleep Apnea Sufferers

If you have obstructive sleep apnea, chances are, you’re likely to have some sort of an ear problem. There are a number of reasons why you’re going to be prone to various ear problems, but in many cases, the problem is not actually coming from the ear. To better manage your ear issues, you first have to understand your ear anatomy, and the different types of inflammation caused by sleep apnea. In the last part of this article, I’ll go over some tips to help you solve many of your ear-related issues.

What You Must Know About Ear Anatomy

The ear drum is a thin membrane that separates the middle ear cavity from the outer ear canal. Sounds waves vibrate the ear drum, which connects via a sophisticated lever and piston amplifier system that transmits sound waves to the inner ear. Normally, the middle ear cavity should have the same pressure as the outer ear canal. This is made possible by the function of the eustachian tube, which connects your middle ear cavity to the back of your nose. Whenever you swallow or yawn, your palatal and throat muscles open up the eustachian tube temporarily, equalizing pressure between the middle ear and the nose. You can think of the middle ear as a sinus—an out-pouching from the nose into an adjacent pocket of bone or soft tissue.

Whenever you go up an elevator or descend during a flight, the atmospheric pressure either goes up or down, and this creates either positive or negative pressure in your middle ear. With very slight pressure changes, you’ll feels a bit of fullness and hearing loss, but with severe pressure changes, you may even have pain and discomfort. If you keep swallowing, then you’ll keep popping open your ears. As a result, you’ll feel anything from fullness, hearing loss, popping, clicking, buzzing, or even ringing. This is why it’s recommended that you chew gum during descents in flights, or give the baby a bottle to feed.

Causes Of Inflammation

However, if you have any degree of inflammation in your nose, then additional swelling can prevent proper equilibration of air between your middle ear and nose. A number of different causes can aggravate swelling, including viral colds, allergies, weather changes, and even acid reflux.

You’re probably very familiar with the effects that a simple cold or allergy can have on your nose and ears. In most cases, you’ll have a few days of discomfort. But in certain situations, your cold or allergy may go away, but your ears will continue to be stuffed for days or weeks. Sometimes, the vacuum pressures that are created can cause fluid to accumulate, giving you what’s called serous otitis media. Rarely, this fluid can get infected and turn into the classic bacterial infection or otitis media. Fortunately, not too many people have true bacterial infections—most never make it past the vacuum pressure or clear fluid stages.

A Vicious Cycle

If you don’t have obstructive sleep apnea, the entire process can come and go within a few days to weeks. However, if you have sleep apnea, due to the additional inflammation that’s created, a simple ear or sinus problems can linger for weeks, and sometimes even months for the following reason: Any additional inflammation in the nose or throat causes swelling which can aggravate more frequent obstructions, leading to stomach juices to come up into the throat and nose, including in the area of the eustachian tubes. Furthermore, frequent obstructions and arousals leads to an imbalance of your involuntary nervous system, where your nose is going to be overly sensitive, especially to weather changes (pressure, temperature, and humidity changes). This is called chronic or non-allergic rhinitis.

For some people using a CPAP machine can blow air into the middle ears, through positive pressure. This can be a frustrating issue that’s difficult to cure completely.

Solutions For Your Ear Problems

So if you have obstructive sleep apnea and are prone to ear problems, what can you do? The first thing to make sure of is that you’re treating your sleep apnea condition optimally. If your CPAP pressure is too low, or your dental device is undercalibrated, or your UPPP procedure was only partially effective, then you’ll still have residual obstructive sleep apnea and are still feeling the effects of intermittent obstructions and arousals.

Second, make sure that your nasal breathing is optimal. By definition, your nasal passageways will be either narrowed, inflamed, or both. Having a chronically stuffy nose can create more of a vacuum effect downstream, which allows the tongue to fall back more often when in deep sleep, due to muscle relaxation. If you’re using CPAP, then it’s likely that your pressures may be too high, which can make it uncomfortable, and even blow air into your ears. Whether through vigorous saline irrigation, allergy avoidance, medications, or surgery, it’s important to make sure you’re able to breathe well through your nose.

Lastly, it’s important to lower inflammation in your throat by making sure you’re not eating within 3-4 hours of bedtime. Having even 2-3 apnea or hypopnea episodes per hour, although acceptable, can still suction up juices into your throat. Since you’re going to suction up normal stomach juices anyway, it’s important to keep the acidity and juice volume as low as possible. The same rule applies to alcohol, since not only does it produce more stomach acid, it also relaxes your tongue and throat muscles, causing you to stop breathing more often.

Ear problems are an inevitable part of having obstructive sleep apnea. By knowing what can cause ear problems and how you can deal with it, you can minimize the discomfort to a point where it’s tolerable or minimal.

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Copyright © 2012 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent