Sleep Apnea Causes Brain Damage

A new study in the journal Sleep revealed that using special MRI imaging techniques, untreated sleep apnea patients have significantly decreased concentrations of gray matter in certain predictable areas of the brain. This means that the density of neurons is much lower than normal. The average AHI was 52, and on initial inspection of the MRI, there were no obvious structural abnormalities, with no differences in the total volume. However, gray matter density was significantly lower for sleep apnea patients in various areas of the brain that serves important functions such as memory, breathing, cardiovascular function, and autonomic function.

This study complements a prior study that showed that OSA patients have multiple dysfunctional areas of the brain.

I think the implications of this study along with various other similar studies are profound. What this means is that if you have obstructive sleep apnea, you can literally kill off certain parts of  your brain, that preferentially control your memory, executive function, your breathing patterns, and even your your heart rate. Could this be an alternate explanation for central sleep apnea? Maybe this is also why not all patients that use CPAP feel significantly better—perhaps the damage is irreversible. What's frightening is that you can suffer permanent brain damage long before your sleep apnea is even picked up and treated. 

Take a look at the abstract and read the paper if possible. What do you think about these findings? Please enter your opinions in the text box below.

Sleep Apnea and the Reason for Facial Wrinkles

One of the main reasons why sleep apnea is so common these days is that modern human's facial skeleton and jaws are much smaller than what they used to be hundreds of years ago. Dentists are saying that people didn't get impacted molars hundreds of years ago, since they had much more room inside their mouths. Dr. Weston Price, in his classic book, Nutrition and Physical Degeneration, describes how due to a radical change in our diets from natural, organic foods to highly processed and sugary foods, our jaws are getting smaller and smaller. 

 

Think about your facial skeleton as the walls of a house. The soft tissues are the furniture. As you move the walls inward, there's less space for the furniture and less space for you to walk through the room. To improve the situation, you either have to widen the walls or remove some furniture. This is what's done with the various sleep apnea treatment options that involve surgery. With CPAP, picture yourself navigating through the crowded furniture a bit faster to get to the other side.

 

A very important concept that many forward-thinking physicians and dentists point out is that the soft tissues (your facial skin, and internal structures like your tongue or septal cartilage) grow to its' genetically predetermined size. If you have smaller jaws, then you'll have crowding in your mouth, with partial obstruction of the breathing passageways behind the tongue. This is why many modern humans can't sleep on our backs. With gravity, the tongue falls back, and when you add deep sleep with additional muscle relaxation, you'll stop breathing and keep waking up.

 

The same process applies with the nasal septum. If your jaws are more narrow, the roof of your mouth gets pushed up into your nasal cavity. Then one of two things can occur: the septum (which sits on the floor of your nose, which is also the roof of your mouth), buckles to one side or the other, of the septum stays in place, but causes the maxillary bone underneath to splay apart, leading to the symmetric right and left maxillary bone spurs that you'll often see. Sometimes, due to the constant stimulation of the septum on the roof of your mouth, a midline bony bulge can occur in your mouth (called a torus palatini). 

 

If you upper jaw is underdeveloped from a front and back perspective, then your upper lip and lower nose will be pulled down and in, leading to the appearance of a nasal hump. This is one of the most common reasons for a traditional rhinoplasty. Furthermore, underdevelopment of the lower jaw creates the classic weak chin, which is traditionally treated with chin implants. Cheek bones are also underdeveloped, leading to a lowering of the lower eyelid and flattening of the face under the eyes. Since the facial skeleton is smaller, the skin that drapes the bony structures are more lax, and with aging, tends to sag and wrinkle easier. An excellent, more thorough review of these concepts can be found here.

 

When I first read about this process, my eyes were opened as to why there's so many sinus problems, nasal congestion, headaches, TMJ, and various sleep-breathing problems. This is also why when one specialty treats one particular problem (ENTs treating the sinus problem, dentists treating the TMJ problem, the neurologist treating the headache, and the dermatologist treating the wrinkles, etc.), these problems always tend to come back.

 

What do you think about what I'm describing? Is it academic hype, or should we be afraid of our very future? Please enter your comments in the comments box below.

Ask Dr. Park Your Question About Sleep Apnea Surgery

Please join me as I host another Ask Dr. Park teletraining program on "What You MUST Know About Sleep Apnea Surgery." 

Topic:  "What You MUST Know About Sleep Apnea Surgery" 
Date:    Tuesday,  February 9th, 2010 
Time:   8PM Eastern 

I get inundated with questions about surgery all the time, and I thought it was time I spoke my mind about this controversial subject and often misunderstood topic. To ask me your question and to register for this event, please go to the link below: 

http://doctorstevenpark.com/ask-dr-park 

Sleep Apnea and Scarring

In the medical world, the word scarring has negative implications. Other similar words include growth, tumor, and lump, all of which are words used to describe certain anatomic features without any prognostic value. Whenever a doctor uses words "scar tissue," it evokes an image of a complication or adverse effect. However, with sleep apnea and snoring procedures, scarring is usually a good thing. 

Many of the procedures that are performed in the upper airway rely on fibrosis and scarring, not only to shrink the soft tissues, but also to tighten floppy structures and prevent either vibrations or obstruction. For example, many of the various soft palatal snoring procedures are dependent on significant scarring for good results. Whether it's using one of the minimally invasive procedures without any cutting (injection snoreplasty, radiofreqeuncy stiffening, or the Pillar implants), or the ones that involve cutting or tissue vaporizing (laser procedures and the UPPP), the appropriate level of scarring in the right place will determine whether or not the procedure is successful. Of course, sometimes, you'll have scarring in the wrong places, which can be complication.

 

In the nose, many of the turbinate procedures involve irritating, burning, or destroying the blood vessels and soft tissues underneath the mucous membranes. With time, scarring occurs inside the turbinates, with tightening and shrinkage, leading to better nasal breathing.

 

The challenge with many of the more "minimally invasive" snoring and sleep apnea procedures is that you'll tend to get minimal results. Most will work very well initially, but in my experience, there's a significant degree of recurrence years later. One of the main reasons for this is that these minimally invasive procedures usually only address one area. Obstructive sleep apnea, by definition, means that you have some degree of narrowing in multiple levels of your entire upper airway, from the tip of your nose to your voice box. Stiffening your soft palate when you have nasal congestion or tongue base collapse is not going to treat the problem definitively. In carefully selected patients, these minimal procedures can be useful, but many will need more aggressive, multi-level procedures later on.

 

Did you undergo one of the soft palatal stiffening procedures? Did it work for you? Please describe your experiences below in the comments box.

Sleep Apnea, Concussions and Dementia in the NFL

There's been a lot of media coverage recently about the high incidence of dementia in retired NFL pros. One report using a phone survey of retired NFL players revealed that the incidence of dementia or memory-related problems was 19 times higher than normal for men ages 30 to 49. Repeated head trauma is thought to create conditions that significantly increases the chances of developing dementia. A number of states are even enacting legislation that sets certain criteria for removing high school football players after any head injury with prompt and proper medical evaluation.

While these concerns are legitimate, I think the NFL officials are missing a very important piece of the puzzle, and that's the very high incidence of obstructive sleep apnea in current and retired pro football players. One recent Mayo Clinic study showed that 60% of all retired linemen and 46% of all other positions were found to have significant obstructive sleep apnea. Amongst active players in 2003, the overall numbers were 14% and 34% with linemen.

 

If you look at what happens to the brain with repeated episodes of hypoxia during apneas, then you'll see that the implications are profound. Untreated patients with sleep apnea are found to have multiple areas of dead or non-functioning brain tissues. Another similar study showed multiple areas of microscopic strokes, called lacunar infarcts. Chronic hypoxia in mice resulted in brain biopsy studies revealing amyloid plaques (similar to what we see with Alzheimer's disease). 

 

So with this logic, it makes sense that repeated concussions in someone with untreated obstructive sleep apnea is more likely to suffer from the cumulative effects of head trauma compared with someone without sleep apnea. As with everything else in medicine, diseases never exist alone in a vacuum. It would be interesting if they did a study looking at the incidence of obstructive sleep apnea in these ex-players with dementia. I'm willing to bet a very high percentage will have undiagnosed obstructive sleep apnea. Another, more costly and ambitious study would be to screen all current NFL players for sleep apnea and follow them for years (or decades) while undergoing proper treatment, measuring their rate of progression to developing dementia. 

 

What do you think about this issue? Should be continue treating medical conditions in isolation, or look at other co-morbid conditions that can aggravate the original diagnosis? Please enter your comments in the text area below.

Is Your Throat Sore Just Before Your Period?

Here's an interesting observation by more than a handful of my female patients: Their throats are sore for a few days just before their monthly periods. It doesn't go on to a cold or other more severe symptoms. Just a transient sore throat. Then it goes away.

If you've been following my blogs, articles, and especially if you read my book, Sleep, Interrupted, there's a simple explanation. During your monthly cycles, progesterone levels increase with ovulation, but drops when there's no egg fertilization. One relatively unknown property of progesterone is that it's an upper airway muscle dilator. It literally tenses your tongue muscles. When in deep sleep, your muscles (as well as your tongue and other throat muscles) tend to relax to various degrees depending on your sleep stage. If you have less progesterone on board, then it's more likely to fall back, obstructing your breathing, leading to a temporary vacuum effect in the throat, suctioning up small amounts of normal stomach juices. All this causes a temporary deep sleep deficiency. If you eat a late meal, more of these juices will come up. But once progesterone levels begin to increase again, the tongue tenses, and sleep quality improves as well.

 

Sometimes, the inflammation in the throat increases to the point of significant deep sleep deprivation, leading to some of the more severe symptoms as pre-menstrual headaches, fatigue, irritability, and weight gain.

 

For you women out there, do you experience sore throats just before your periods? Please enter your responses in the comments box below.

Health Consequences of Routine Medical Procedures

The New York Times recently ran an exposé on the lack of quality control systems that have lead to a surprisingly high number of radiation overdoses, in some cases leading to death. This reminded me of what they used to do in the 1950s to 60s, where they used x-rays to treat everything from pimples to large tonsils to ringworm. Many women's ovaries were irradiated for depression. What they did in the past may seem barbaric by today's standards, but I'm confident that many of the things we do today may seem barbaric to future generations.

 

There are two procedures that are still being routinely performed that have negative consequences years, if not decades later, and these are rhinoplasty, and dental extractions for orthodontic work. I see at least 4-5 patients a week that come to see me for routine problems, only to find that their "routine" procedure 10 to 25 years ago probably aggravated their current condition.

 

During routine rhinoplasty, especially when you're trying to narrow a wide tip, surgeons by definition have to weaken or remove a portion of the support structures (or cartilages) that keep the nostrils open. Current surgical methods take this into consideration to compensate for this fact, but many surgeons are still weakening the lower lateral cartilages without strengthening the remaining structures. This leads to flimsy nostrils that cave in with every inspiration.

 

As a result of this weakening, patients will have stuffy noses, unrelieved by allergy medications or decongestants. Medicines won't work for structural problems. Sometimes, someone with this condition accidentally tries a Breathe Rite nasal dilator strip, and swears by how wonderful it is.

 

Dental extractions are still being performed as part of routine orthodontic treatment. If there's too little space for the teeth, then it's logical that removing a few teeth can create enough space for the remaining teeth, right? What's missed entirely is that the jaw's too small. The teeth, especially the molars, act as support structures for the soft tissues of the throat. Once removed, the space behind the tongue collapses, leading to significantly lessened quality of sleep. Even simple orthodontic adjustments can have a major impact on sleep quality, since the space that that the tongue is contained in can change dramatically.

 

Fortunately, forward-thinking dentists are recognizing the fact that the position of your teeth and size of your jaws have a major impact on your breathing, and your health. Some of these dentists have leapfrogged ahead of the medical profession in terms of understanding the holistic implications of proper facial form and function.

 

Did you have rhinoplasty years ago, only to have continued nasal congestion, or did you undergo dental extractions before undergoing braces? If so, please describe your experience below.

Tongue Scalloping: A Simple Marker for Sleep Apnea?

Besides the typical descriptions of physical features for someone at risk for obstructive sleep apnea (such as male, overweight, obnoxious snoring, and a big neck), one physical finding that's rarely mentioned is tongue scalloping (click here for picture). This is when you have impressions or ridges on the sides of your tongue where it sits against your molars. One past study showed that having tongue scalloping can positively predict the presence of apneas or hypopneas and oxygen desaturation in 89% of cases. Overall, having scalloping is about 70 sensitive in picking up obstructive sleep apnea. 

The traditional explanation is that the tongue is too big, but for sleep apnea patients, the jaw is too small for the normal sized tongue. If you add additional inflammation due to chronic reflux from the stomach with each obstruction, the swelling of the tongue will only aggravate the dental impressions on the tongue. Along with the small jaws and scalloping, you'll also have a high-arched hard palate, and the tongue sits very high in the mouth, preventing you from seeing the back of the throat more fully.

 

This condition is also described in hypothyroid patients, but as I've stated before sleep apnea can cause hypothyroidism.

 

Take a look at your tongue in the mirror right now. Do you have scalloping? Do any of your family members or friends have it? Please enter your responses below in the comments box.

Overcoming Physical Adversity to Achieve Athletic Greatness

There are many stories of athletes that overcome physical adversity to reach elite levels. One such amazing story is about Diane Van Deren, a 49 year old ultra-distance runner that underwent brain surgery to recover from lifelong recurrent seizures. Any time she felt a seizure coming on, she would go out and run intensely, which usually prevented the attacks from progressing. During her third pregnancy, she suffered a severe grand mal seizure, which prompted her to eventually undergo removal of a small portion of her temporal lobe, which eventually controlled her problem. In the dozen or so years since she underwent her surgery, she's become one of the the top endurance runners in the world, winning the 300 mile Yukon Arctic Ultra two years ago, and recently being the first woman to finish the 430 mile version last year.

 

Similar stories come to mind, including Bruce Jenner, the 1976 Olympics decathlon winner, who as a child ran home from school as quickly as possible to take down the bed sheet his mother draped outside his window because he still wet his bed. Wilma Rudolph, another olympic champion, suffered from polio and couldn't walk normally until age 12. 

 

I've stated in past blogs that poor sleep quality, due to narrowed jaws, poor breathing and inefficient sleep at night, is a common condition in many elite athletes. As a way to compensate for feeling tired all day long, they train intensely and regularly for years or decades, eventually reaching their elite levels. Anecdotally, many long distance runners that I know prefer not to sleep on their backs, and is typically tired when they wake up in the morning, no matter how long they sleep. I'm not suggesting that Ms. Van Deren has this particular problem (although she could have it, since we know that untreated obstructive sleep apnea can aggravate seizures, and pregnancy can aggravate sleep apnea). But I do bring up her story as an example of someone who has overcome so many odds to achieve success.

 

We know that all modern humans, due to our smaller jaws and crowded teeth, are susceptible to various degrees of sleep-breathing problems. All of us are on a sleep-breathing continuum, where obstructive sleep apnea is only the extreme end. Since elite athletes are humans as well, they'll be susceptible to these same issues, if not more so than normal. 

 

Come to think of it, untreated sleep apnea is a major cause of bedwetting in young children….

 

What are your thoughts on this? Do you or someone you know very good at a physical activity to potentially compensate for poor quality sleep? Please enter your comments in the text box below.

Did NFL Defensive End Gaines Adams Have Sleep Apnea?

Sadly, the Chicago Bears defensive end Gaines Adams died of a cardiac arrest during sleep early this morning. Preliminary reports state that he had an enlarged heart. He was only 26 years old. There are many reasons for an enlarged heart but one major risk factor Adams had was his build. He was 6' 5" and 260 pounds which gives him a BMI of 30.8, which is in the obese range. Furthermore, just like many NFL players, he had large neck muscles that probably pressed on his upper airway.

 

A study of NFL players in 2003 showed that about 14% overall and 34% of all linemen had obstructive sleep apnea. Reggie White, the Hall of Fame Linebacker, was thought to have died from complications of untreated obstructive sleep apnea.

 

There are certain sports that are probably at higher risk for sleep apnea, including football, body building, and weight lifting. All three involve bulky neck muscles, created intentionally, or indirectly. The human upper airway is unprotected in the throat area, so any enlargement of soft tissues, whether fat or muscle, can press on the airway and make the passageways smaller. One way to compensate for the fatigue that develops is to work out harder, eat better and train smarter. Over time, however, the soft tissues stay collapsed, and no amount of weight loss will completely cure the problem.

 

I've always stated that all football players, serious weight lifters and bodybuilders should be screened for obstructive sleep apnea. Once diagnosed and treated, who knows how much better they will be able to perform? What do you think about this issue? Should certain athletes and professions (long distance truck drivers, pilots, etc.) be routinely screened? Please enter your opinion in the comments box below.

Next Page »