August 8, 2011
1. Eat or snack close to bedtime.
Going to bed on a full stomach may help you fall asleep faster, but once you’re asleep, you’re more likely to have reflux into the throat, leading to more frequent breathing obstructions and arousals, leading to inefficient sleep.
Most modern humans have dental crowding and smaller jaws. Since soft tissues such as the tongue and nasal septum grow to their genetically predetermined size, the airway gets crowded. This leads to more frequent obstructions when on your back (due to gravity) and especially when in deep sleep (due to muscle relaxation). The more juices you have in your stomach when you go to bed, the more likely it’ll come up when you stop breathing.
Your stomach juices include not only acid, but also bile, digestive enzymes, and even bacteria. These substances can cause even more inflammation and swelling in your throat, leading more more obstructions and arousals.
If you want to gain weight, continue eating late. Lack of sleep quantity or sleep quality has been shown to promote weight gain, which leads to more narrowing in your throat.
2. Drink a night cap before bedtime
Alcohol may help you to fall asleep better and faster, but it causes your throat muscles to relax and you’ll stop breathing much more often, preventing you from achieving continuous deep and REM sleep. Not sleeping deeply can increase stress levels, making it difficult to shut down your brain when you’re trying to fall asleep. Drinking alcohol before bedtime can help you to go to sleep, but you end up aggravating this vicious cycle. Alcohol also irritate the stomach, creating more acid production.
3. Sleep on your back
Modern humans, due to smaller than normal jaws, are unable to breathe well during sleep when supine due to the tongue falling back (due to gravity) and especially in deep sleep (muscles relax). The more crowded your mouth is (if you needed braces), the more likely you’re going to be a natural side or stomach sleeper. Anything that prevents you from your normal preferred position will increase the number of obstructions and arousals, leading to less efficient sleep. One way to make sure that you sleep on your back is to get injured or undergo surgery—this will definitely lower your sleep quality.
4. Undergo rhinoplasty
Whenever the surgeon narrows the tip, cartilage in your nostrils are weakened, and years later, are more likely to cave in whenever your inhale. If you have a deviated nasal septum, or allergies, the weakened nostrils are more likely to collapse inwards, leading to a vacuum effect in the throat, with more frequent tongue collapses (especially if you have small jaws, eat late or drink late). Look for a surgeon that doesn’t take the steps needed to prevent this from happening if you want to have more breathing problems later in life.
5. Bottle-feed as an Infant
Dentists have shown that the physical act of bottle-feeding changes your bite and dental structures, leading to a higher incidence of malocclusion. This leads to crowded teeth and narrow dental arches, which can increase your chances of developing obstructive sleep apnea later in life. If you want to make things worse, use pacifiers whenever possible and encourage thumb-sucking for as long as possible.
6. Undergo jaw surgery
Jaw operations are commonly performed to correct bite or occlusion problems, but one thing that surgeons frequently don’t address is the fact that any time the upper or lower jaw is pushed back, the airway can become more compromised. As a result, your smile and your bite can improve, but your ability to breathe properly at night will go downhill. Not sleeping efficiently can significantly increase your rate of aging.
7. Don’t treat your sleep apnea
Obstructive sleep apnea is a common condition that becomes more common as we all get older. People with sleep apnea stop breathing repeatedly at night, without even realizing it. This causes a major physiologic stress response that wreaks havoc on your body. Even growth hormone levels are diminished. In fact, about 1/4 of men and 1/10 of women are thought to have unrelated obstructive sleep apnea. After age 60 to 70, some studies show that the vast majority have obstructive sleep apnea, especially if you have chronic medical conditions or are institutionalized.
Efficient sleep (quantity and quality) is essential for healing, regeneration, and rejuvenation. Ignoring your breathing problems while sleeping is a surefire way to age faster. If you really want to have more facial wrinkles, wait until you’re much older to address any underlying sleep-breathing issues you may have.
July 22, 2011
Michelle Bachmann’s recent revelation that she suffers from migraines brings up an important point that most doctors and the lay public don’t appreciate: the importance of proper breathing at night. It’s commonly known that sleep deprivation can cause or aggravate migraines, but what’s usually assumed is that migraine sufferers are breathing well at night. If you’ve read my articles or listened to my teleseminars, I can make a convincing argument that migraine sufferers all have some variation of a sleep-breathing disorder, of which only a small fraction have obstructive sleep apnea.
Not Your Normal Migraines
The classic migraine headache is described as a one-sided, debilitating, pounding, intense headaches that’s associated with nausea, vomiting, light or sound sensitivity. Notice that classically, migraines get better with sleep. Recently, neurologists have expanded the definition of a migraine attack. Any time the nerves in any part of your body becomes oversensitive or overly excitable, then you’ll experience symptoms that are specific to that part of the body.
For example, if the nerve endings in your sinuses are suddenly extra sensitive, then you’ll feel pain, pressure, nasal congestion, and post-nasal drip. In fact, it’s been shown that the vast majority of chronic sinus headache and pain sufferers actually have a variation of a migraine, with normal CAT scans. Many people are placed on oral antibiotics empirically, when there’s no bacterial infection.
You can also have migraines in your stomach. This can present as nausea, vomiting, diarrhea, constipation, or bloating. It’s been suggested that children who suffer from chronic abdominal pain actually suffer from migraines.
If you have a migraine attack in your inner ears, you’ll feel dizzy, lightheaded, feel fullness, or have hearing loss or ringing. This is called vestibular variant of migraine.
Problems Due to Your Tongue?
One anatomic feature that I see all migraineurs have in common is the very small nature of their upper airways, especially in the space behind the tongue and in the nose. I talk about how most modern humans have smaller jaws and facial skeletons due to a radical change in our diets and lifestyles. This leads to dental crowding, which narrows the space behind your tongue, especially if you lay flat on your back. When you go into deep sleep, since your muscles will relax, you’ll stop breathing and wake up to turn over to your side or stomach. This is why most people with this type of anatomy can’t sleep on their backs.
You Are A What?
These breathing pauses usually aren’t long enough to be called apneas (at least 10 second pauses), and usually don’t lead to lowered oxygen levels. However, it does lead to more frequent arousals and sleep fragmentation. Essentially, you can’t stay in deep sleep. In most cases, you won’t even realize that you’re waking up. What you will feel is not feeling refreshed when you wake up in the morning, or feeling like you only slept for 2-3 hours.
In the early 1990s, a new type of sleep-breathing problem called upper airway resistance syndrome (UARS) was described. Young women and men who didn’t meet the official criteria for obstructive sleep apnea were recruited and underwent esophageal pressure monitoring. What they showed was gradually increasing negative inspiratory pressures leading to an arousal, but not severe or long enough to be called apneas or hypopneas. Officially, apneas require at least 10 second breathing pauses, whereas hypopneas require 30 to 50% drop in airflow, along with arousals or oxygen level drops. However, if you don’t reach the 10 second threshold for apneas or hypopneas, then they’re not scored at all. So in theory, you can stop breathing 20 to 30 times every hour and not officially have obstructive sleep apnea.
Not being able to get deep, refreshing sleep can lead to a physiologic state of stress, where your entire nervous system can become heightened and hypersensitive, even carrying over into the daytime. Poor sleep quality also cause muscle tension and tightening, which can predispose to headaches, TMJ, neck spasms or backaches. Even your senses can become overly sensitive, especially to weather changes, chemical, scents or odors. In this particular situation, even your creativity or intuition can be heightened.
Notice how many of the features of a migraine attack are very similar to suffering from a hangover: nausea, vomiting, brain fog, and sensitivity to bright lights and loud noises. This is your involuntary nervous system over-reacting to something that’s not normally bothersome.
Simple Steps to Take
So if you suffer from any of these migraine types, what can you do besides take prescription medications? Here are 5 basic steps for better sleep and less headaches:
1. Don’t eat anything within 3-4 hours of bedtime. Having juices in your stomach can promote reflex into your throat, causing more arousals and less efficient sleep.
2. Don’t drink any alcohol within 3-4 hours of bedtime. Alcohol relaxes your throat muscles, causing more frequent obstructions and arousals.
3. Keep your nose clear. If your nose is stuffy for whatever reason, do everything possible to keep it open. Having a stuffy nose creates a vacuum effect downstream in the throat which causes your tongue to fall back more often. Use nasal saline irrigation systems, nasal dilator strips, allergy medications, decongestants and even surgery if the former options don’t work that well.
4. Don’t sleep on your back. Back sleeping promotes tongue collapse due to gravity.
5. Do more yoga, tai chi, or deep breathing exercises to calm your nervous system. Take 4-5 slow deep breaths anytime you have 15 to 30 seconds, such as while standing in line, in-between major activities, on hold one the phone, or walking to another room. This helps to activate your parasympathetic nervous system, which helps to calm and relax your body. Acupuncture can also help.
Other Steps to Take
Once you’ve tried these conservative options, and you wish to take it to the next level, consider undergoing a thorough ear, nose and throat evaluation to see of you have any narrowing in your breathing passageways. In particular, your doctor should focus on your nasal septum and turbinates, your nostrils (to see if they collapse), tonsils, adenoids, lingual tonsils, soft palate and tongue base areas.
Many people with migraines will have either UARS or sleep apnea. Standard treatment options can help to alleviate migraines significantly. Dental appliances and specialized orthodontics are also an excellent option—these options are more important if you have any significant dental crowding, bite issues, or if you have a very small mouth. Dentists can also help with TMJ, which can overlap significantly with migraines and various other facial pain syndromes.
Botox can also be used for migraines, but just like using prescription migraine medications, are only covering up the causes, rather than treating it.
To a certain extent, OTC medications, and natural herbs or supplement (like feverfew), while they do work to various degrees, doesn’t help everyone. But it’s worth trying, if you’re interested.
Avoiding migraine triggering foods: red wine, aged cheeses, chocolate, and MSG.
I don’t usually recommend surgery, but it can be a viable option if the more conservative options don’t help. There are a number of different options, depending on where the narrowing occurs in your breathing passageways.
Hope for Migraine Sufferers
One of the most gratifying experiences is to have patients tell me that their migraines (or even cluster headaches) went away after various forms of surgery. It even happens sometimes with some of the non-surgical, conservative options.
It’s a given in our culture that migraines must be treated with a pill, and I want to dispel that stereotype. I believe that trying to achieve the best possible sleep (by breathing better) is a better way of improving migraines. It’s important to combine the various conservative steps along with techniques to help you breathe better and sleep better. Rather than focusing on the migraine only, it’s more important to re-evaluate your entire life situation, and be willing to make the lifestyle changes that can not only improve your migraines, but also significantly improve your overall quality of life.
July 9, 2011
Recurrent sinus infections, throat pain, ear fullness and chronic cough are some of the most common conditions that I see every day. You may think that I typically diagnose and treat for routine bacterial infections in these situations, but in most cases, they’re not really infections at all. What I do find, however, is that if you probe and look back at the patients’ history, there’s always some major life change or recent event that acted as a trigger for their symptoms, especially if their upper airway anatomy is already narrowed or predisposed. Here are 5 common examples:
Sleepless nights from a newborn child
The birth of a child is always a joyous event, but everyone knows that your life will change drastically all of a sudden. Your normal routines, eating habits, exercise regimens, and especially the timing for all these events will change. The sleep deprivation, lack of exercise, and bad eating habits can promote weight gain, which can narrow your throat even further. This leads to more problems breathing at night, leading to less efficient sleep, leading to more weight gain. This applies to both the mother and the father.
It’s also a common phenomenon where a woman is never able to lose her pregnancy weight, despite extreme dieting or exercise. This leads to less effective sleep, increased fatigue, and various other health-related conditions.
Newfound independence, more depression
The freshman 15 is more than just an observation—there’s a good reason why college students gain weight all of a sudden during their freshman year. Dorm meals and cafeteria food tends to be starchy and very high in calories, and because of the buffet-style format, there can be problems with portion control. Home-cooked meals by parents, eaten at relatively normal times (5 to 7 PM), turns into eating later in the night: more episodes of pizza, take out food, and late night snacks while pulling all-nighters for exams.
Having stomach juices when you go to sleep will allow more acid and other stomach materials to regurgitate into your throat, leading to more frequent arousals and less efficient sleep. This leads to a cascade of metabolic, hormonal, and cardiovascular consequences that promotes weight gain. Drinking alcohol at night relaxes the throat even further, leading to more frequent breathing pauses.
This relative sudden change in your eating and sleep routines can definitely affect your mood and mental health. It’s not surprising that depression and anxiety peaks during the college years. This is also the time when the larynx (voice box) descends in the neck to its’ lowest position during maturation into adulthood. The lower your voice-box, the more the tongue can fall back, leading to more frequent breathing problems.
A new job or a promotion
It’s great to start a new job, or get that promotion that you’ve wanted. But just like any other major change in your life, your routines will change. You’ll stay later to impress your boss, skip meals, come home later and go to bed later. As a result, you’ll gain a few pounds. Some people can eventually adjust their schedules to accommodate a healthy sleep schedule, diet and exercise regimen, but others can’t. This is when things begin to go downhill.
Injury or surgery
Most people with sleep-breathing problems prefer to sleep on their sides or stomach. Any kind of injury or undergoing surgery can force you to sleep on your back, which causes more tongue collapse (due to gravity) and more obstructions and arousals (due to muscle relaxation in deep sleep). In fact, many patients have told me that their lack of sleep, physical activity and subsequent weight gain is what triggered a vicious cycle.
This applies mainly to women, but hormonal changes can affect men too. Loss of estrogen and progesterone can diminish their protective effects on the upper airway. In particular, progesterone is an upper airway muscle stimulant/dilator. As it begins to diminish in the early 40s, the tongue begins to relax more and more over the years, leading to less efficient sleep, and the typical vasomotor symptoms begin which includes hot flashes, night sweats, weight gain, mood swings, and irritability. Believe it or not, these symptoms can happen in young men, too. These are your body’s nervous system reaction to the changes with your sleep-breathing status.
As you can see, all of us will go through some or all of these events at some point in our lives. It’s natural as modern humans to be susceptible to these sleep-breathing related conditions. It may sound a bit depressing, but the good news is that now you’re aware of it, you can take preventive measures once it starts.
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.
March 22, 2011
Ponce de Leon is well known as the Spanish explorer that searched for the fountain of youth in the early 1500s. Even today, that search continues through the multi-billion dollar cosmetics industry, plastic surgery procedures, and nutritional products. Anti-aging medicine even has a certifying organization for doctors. Some experts are even claiming that they can reverse the aging process.
Knowing what we know about the importance of sleep and the havoc it can cause on your body, I can confidently say that the best way to slow down aging is to optimize your sleep quality. Sleep is known to be vital in tissue healing and regeneration, hormone regulation, as well as in helping to consolidate memories and thought processes. For example, non-REM deep sleep is important for tissue repair, growth hormone release, and other regenerative processes. REM sleep is needed for memory consolidation and creativity.
When most people read or hear about better sleep, they think about going to bed earlier or sleeping longer. People with insomnia are also inundated with “warm milk” recommendations, such as valerian, green tea, turkey, melatonin, meditation, and probably dozens of other vitamins, supplements, or relaxation techniques that help to calm or numb the mind to allow for faster sleep onset. Many of these options can work to various degrees, but won’t be helpful at all if you stop breathing at night. Once your breathing passageways obstruct while sleeping, you have to wake up. You can either wake up violently in a state of panic with sweating and your heart racing, or just get taken out of deep sleep into a lighter stage of sleep.
About 1-2 times per month, I see women who complain of various ear, nose or throat symptoms, let’s say for about 6 weeks. They also usually complains of increased fatigue, headaches, and poor sleep. They usually see their medical doctors and have tried multiple courses of antibiotics or allergy medications. They will typically say that they sleep on their backs when questioned about their preferred sleep position. Looking at their oral cavity exam, I don’t believe them. When questioned further, they all admit that they used to be stomach sleepers, but changed to back sleeping after reading an articles on various magazines, usually by a dermatologist (or sometimes a chiropractor) that recommends avoiding stomach sleeping since it can cause facial wrinkles. Almost every time, their health problems began just after they made the switch in their sleep position. Once they go back to their normal sleep position, their health problems usually resolve.
The cosmetics industry’s fight against facial wrinkles is a classic example our quest to delay aging. In the above example, the reason why some people have to sleep on their stomachs is so that they can breathe properly. Being on their backs causes the tongue to fall back due to gravity, and when in deep sleep, it relaxes completely, leading to obstruction and arousal. Having smaller jaws and dental crowding can aggravate this problem even more. Not getting sufficient amounts of deep sleep causes a generalized state of physiologic stress and adrenaline production, which tends to constrict blood vessels that supply certain parts of the body that are considered “unessential” when you’re under stress. This includes your digestive system, your reproductive organs, as well as your skin. Not receiving proper circulation deprives the tissues of oxygen, preventing proper nutrition and not allowing for healing, regeneration, and waste removal. Hypoxia also creates an environment that’s toxic to the local tissues, leading to further damage and accelerated aging. The bottom line is that not getting good sleep accelerates your aging process.
Another important concept that has profound implications is the fact that underdevelopment of the bony midface and jaw structures leads to wrinkles earlier in life. Having smaller facial bony structures does not stretch the facial skin over the bones as much compared to larger facial structures. Since elastic properties of facial skin tend to degrade over time, having smaller facial bones allows wrinkles to show up earlier, with the same degree of environmental, dietary, or genetic factors.
Two common habits that are thought to accelerate aging and even wrinkles are sun tanning and smoking. Sun tanning may make you look “healthy” temporarily, but sun damage takes a toll on your skin, especially if you’re susceptible to the sleep-breathing problems that I describe. Imagine if you already have diminished circulation to the skin, with diminished levels of oxygen. By definition, you’ll have more levels of oxidative stress, where free-radical oxygen molecules are formed, which can damage DNA. Add ionizing radiation, and it’s a double whammy.
Nicotine is a known stimulant which also has been proven to constrict blood vessels, especially in the skin. It also has a calming effect the way Ritalin helps to calm children with ADHD: Stimulants help to counteract the effects of sleep deprivation from not breathing well at night. It’s also been shown that it takes nicotine about 45 seconds to reach the brain once you inhale smoke into your lungs. This doesn’t make any sense, since most smokers will tell you that they feel more relaxed after the first one or two breaths. What’s making smokes relaxed is the relaxing properties of deep breathing, along with the stimulating effects of nicotine. But by relaxing more using deep breathing techniques to inhale a stimulant, you’re cutting off blood flow to your skin, which if already sun damaged, is more likely to suffer from wrinkles.
The basic thesis of my sleep-breathing paradigm states that all modern humans stop breathing once is a while. But as we get older, not only do we sag on the outside, but also on the inside. If you think about it, the rate at which we age is directly proportional to how narrow your upper airway gets. Add to this additional gravity and the typical weight gain that tends to occur during middle age, it’s no wonder so many people have sleep-breathing problems as we all get older. We’ll never run out of more pills, gadgets, devices and diets that tout their anti-aging properties, but without addressing how well you breathe while sleeping, you’ll continue to suffer from accelerated aging.
Struggling with an addiction? Check into a Long term drug rehab facility and get the help you deserve!
February 10, 2011
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.
October 27, 2010
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.
October 27, 2010
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.
October 25, 2010
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.
October 25, 2010
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.
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.
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.