In a recent article in the New York Times, various experts describe his medical ailments that lead up to his massive stroke and death at the age of 53. His cerebral arteries were found to be almost completely clogged. He supposedly had major sleep problems and had chronic headaches. He also had a strong family history of cardiovascular diseases, with his father dying of a cerebral hemorrhage at age 54, and siblings dying of a heart attack and stroke.

Lastly, notice that he had a mustache and a goatee. Many men with weak chins grow facial hair to make their chins more prominent. It’s not surprising that he also had narrow, triangular facial features. Take a look at his picture in the New York Times. It seems like he had a fat neck as well. 

What do you think about my theory?

Some of the questions I get asked include:

• How did you become interested in sleep apnea surgery?
• As a busy surgeon, how do you have time to do run your website and do your programs?
• How do you decide who can benefit from surgery?
• Why do modern humans have more sleep apnea?
• How do I find the right surgeon to treat sleep apnea?
• Any advice for people who are considering surgery for sleep apnea?

They also note that nearly 60% of women of childbearing age in the US is overweight and about 1/3 are obese. Obesity rates are rapidly climbing. Autism rates are also climbing, with the latest report showing 1/88 children having one of the autism spectrum disorders.

The authors mentioned every possible explanation (diabetes, high blood pressure, fluctuating glucose levels, lack of oxygen) expect for obstructive sleep apnea. I’ve written numerous times in the past about complications of obstructive sleep apnea during pregnancy. If you’re overweight or obese, you’re much more likely to have obstructive sleep apnea. One of the hallmarks of sleep apnea is hypoxia and major physiologic stress on the mother’s body. I wonder what the effect is on the developing baby’s brain? It would make sense to routinely screen for sleep apnea in all women, especially if you’re overweight or heavier.

If you were overweight during pregnancy, did your doctor screen you for obstructive sleep apnea? 

There’s nothing more public about his health status besides his cancer, but one of his hallmark features was his raspy voice. If  he had upper airway resistance syndrome, it’s likely he also had laryngopharyngeal reflux disease. Besides aggravating hoarseness, reflux can also cause chronic oral cavity, nasal and lung inflammation, potentially leading to a multitude of health problems. It’s also very likely that he didn’t like to sleep on his back, and had unrefreshing sleep. Studies are beginning to show that lack of good sleep may also be a risk factor for cancer. 

All this is speculation, but celebrities are also modern humans, being susceptible to craniofacial features that can lead to sleep-related breathing disorders. Do you know of other celebrities that have small jaws or facial features?

A new study done at UCSF showed that women with migraine were 2.6 times more likely to have babies with colic.  They suggested that colic might be a manifestation of early migraine and that the predisposition to migraine may include a hypersensitive nervous system which manifests as colic in the infant.  They mention earlier studies which showed that children with migraine were more likely to have had colic as infants.

What does this have to do with sleep disordered breathing (SDB)?

Well, we know that people with UARS tend to have migraine, and that morning headache is a typical sign of OSA.  We know that people with UARS have a heightened nervous system and tend to be hypersensitive to light, noise, and sometimes odor.  (If you are spending 1/3 of your life suffocating in your sleep, then of course you will be constantly “en garde” and all your senses will be turned up in order to deal with the threat.)  Therefore it may be that many women with migraine actually have undiagnosed sleep disordered breathing.  If this is the case, we know that there is a 50% chance that they will pass their narrowed upper airway anatomy down to their child, which may manifest as SDB in the child. 

Infants are born with what we call the palate-epiglottis lockup.  There is a good picture in Dr. Steven Park’s book, Sleep Interrupted which shows this.  Because of the overlap of the soft palate and the epiglottis, the infant is an obligate nose-breather; they cannot breath through their mouths unless they open very wide or cry.  If they are having difficulty breathing through their noses, due to nasal congestion or an inherited nasal narrowing, they might spend quite a bit of time crying.  Especially, when they are supposed to be sleeping.  If they cannot breathe in their sleep, they might end up crying instead; babies with colic cry at night when they are supposed to be sleeping.  Any sleep disordered breathing will increase GE reflux, something very common in infants, which will only compound the crying, as well as the nasal congestion as stomach contents get suctioned into the nose and cause inflammation.  Many colicky infants are diagnosed with GE reflux and treated with acid blockers.  I am suggesting that the GE reflux might be only a consequence of the underlying problem in colic, and the acid blockers only a bandaid.  Alternatively, with how common GE reflux is in infants such that we consider it to be a normal physiologic state, it may be that the nasal inflammation which results from GE reflux is the cause of the very common nasal congestion we see in neonates, which will then trigger the breathing problem which I am suggesting may cause colic.  This infant nasal congestion resolves between 2-3 months of age.   Colic resolves by 3 months of age.  The palate-epiglottis lockup opens between 2-3 months of age.  Does anyone else see the connection here?  Until the lockup opens and a baby can mouth breathe to compensate for a narrowed nose, they may cry a lot just in order to breathe: hence, colic.

This recent paper showed that infant colic is associated with emotional and behavioral disorders in the toddler, such as sleep disorders, feeding problems, temper tantrums, chronic fussiness and excessive clinginess.  Specifically, the authors say: “Dysfunctional sleep-wake organization is typically associated with excessive crying in the first 3 months (95.5% of age group). At around the sixth month of life, diurnal problems of sleep-wake organization give way to nighttime sleep disorders, which are the most frequent diagnoses in all age cohorts.”

Doesn’t all this suggest that babies with colic actually have sleep disordered breathing?  And that the risk for migraine that is associated with colic is actually secondary to the sleep disordered breathing, NOT that colic itself is early migraine?

The American Heart Association recently reviewed 537 articles on this subject and published a review, stating that there’s no scientific evidence that gum disease causes heart disease, heart attacks, or stroke. Past studies were mainly observational, and not based on prospective studies. They also state that there’s no evidence that treating periodontal disease can prevent heart disease.

What’s the missing link? You guessed it: Obstructive sleep apnea. We know that obstructive sleep apnea can cause reflux and inflammation in the mouth. Mouth breathing due to craniofacial narrowing and inflammation also dries out saliva, which helps to protect your mouth from pathogens. If you’re missing teeth, then your mouth gets smaller, narrowing your airway even further. We also know that obstructive sleep apnea significant increases your risk of heart disease, heart attack, stroke, and death.

So it makes sense that if you treat sleep apnea, you’ll have less gum disease, and less heart disease. Obviously a prospective, randomized, placebo-controlled, double-blinded study is needed to prove this point.

I was taught to perform chin implants during the plastic surgery portion of my residency training. It’s a simple procedure with dramatic results. I still remember how we were taught to do facial analysis showing how many people with weak chins also had humped noses and droopy tips. Not once did any of my teachers mention why this happened in some people and how it also involves an narrowed airway. 

Having a weak chin implies that your jaws are underdeveloped, which can lead to less space behind the tongue for breathing. Typically, your upper jaw will be recessed and narrow as well, leading to a high-arched hard palate, dental crowding, and a deviated nasal septum. Underdeveloped upper jaws can also lead to flat cheekbones, flimsy nostrils, and a droopy nose. Certain anatomists have said the humans should not have nasal humps. 

Surgeons will typically perform a rhinoplasty and chin implant together, with some incredible results. However, these same people are now showing up in my practice years later with major sleep-breathing issues, namely obstructive sleep apnea or upper airway resistance syndrome. 

You’ll also see that most people with weak chins can’t (or prefer not to) sleep on their backs. This is because when supine, your tongue falls back due to gravity. When you add deep sleep and muscle relaxation, you’ll stop breathing, wake up, and turn over to your side or stomach. If you stop breathing at least 5 times per hour for 10 seconds or longer (and you’re tired), you have obstructive sleep apnea. But you can stop breathing 25 times per hour and not have any sleep apnea if your pauses are less than 10 seconds long.

A better way to improve your jaw line is to undergo a sliding genioplasty or mandibular osteotomy with genioglossus advancement, both of which pulls your tongue attachment forward. A more definitive procedure involves maxillo-mandibular advancement, where surgeons pull both the upper and lower jaws forward. Other less invasive options include functional dental appliances.

Have you ever undergone chin implant surgery or rhinoplasty, only to have breathing problems surface later in life?

AJ Jacobs, a senior editor for Esquire Magazine, interviewed me last year while working on his latest book project, Drop Dead Healthy: One Man’s Humble Quest for Bodily Perfection. The book is now out and was favorably reviewed by the New York Times. We talked extensively about his snoring and sleep apnea, and he underwent the entire diagnosis and treatment protocol, including CPAP. I just read sections of his book (including parts with me in it) and it’s hilarious! 

If you’re not already familiar with Mr. Jacobs, he’s also the author of The Know-It-All: One Man’s Humble Quest to Become the Smartest Person in the World and The Year of Living Biblically: One Man’s Humble Quest to Follow the Bible as Literally as Possible. His current book, Drop Dead Healthy, is already #31 on Amazon’s best-seller list. 

His book was endorsed by Dr. Mehmet Oz, and Timothy Ferriss (author of The 4-Hour Body). I strongly recommend that you read Mr. Jacobs’ book. But don’t stay up too late reading it—sleep deprivation can lead to premature aging.