In this episode, Kathy and I will reveal how allergies can ruin your sleep (and aggravate sleep apnea as well). We’ll discuss proven steps that can help you get rid of your allergies this spring.
1. Stay indoors early morning and late afternoon
2. Shower before bedtime
5. Remove shoes
6. Remove pets from bedroom
7. Remove carpets or rugs from bedroom
8. No eating/snaking or alcohol wishing 3-4 hours of bedtime
9. Deep breathing, relaxation techniques
12. Tongue exercises
1. Claritin, Allegra, Zyrtec
2. Flonase, Nasacort
3. Afrin, Dristan decongestans
4. Sudafed decongestant
5. Other options
1. Topical steroids (Flonase, Nasonex, Rhinocort)
5. Allergy shots
6. Sublingual allergy pills
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Amy felt great a few weeks after undergoing tonsillectomy for mild obstructive sleep apnea. She was sleeping better and was able to focus again in school. This lasted about 2 years, but her symptoms of fatigue, brain fog, and sleepiness slowly started to come back. It wasn’t to the same degree as before her surgery, but she felt a difference from just after surgery.
When I looked at her mouth, her tonsils did seem slightly enlarged. Before surgery, they were touching in the midline (called kissing tonsils). Now they were about 10-20% enlarged, especially in the highest part of the tonsil bed, near the soft palate.
One of the most common questions I get from patients when I propose tonsillectomy is if tonsils can grow back after surgery. My general answer is that yes, in theory, but the overall chances are very small. It really depends on two main variables: how completely the tonsils were originally removed, and whether or not you have persistent inflammation that can cause additional swelling.
In the old days, surgeons used to take out the entire tonsil, including the capsule that surrounds the tonsil on the sidewall of the throat. This was done for recurrent tonsillitis or for sleep apnea. With advances in technology, we can now shave down about 95% of the tonsils (sub-capsular or partial tonsillectomy), leaving a very thin cuff of tonsil tissue next to the capsule. This has been found to be relatively equivalent to total (extra capsular) tonsillectomy for obstructive sleep apnea, as well as being slightly less painful with with faster recovery.
However, if you have persistent sources of inflammation, then any remaining tonsil tissues can slowly get bigger. This can aggravate more obstructed breathing, leading to more stomach juices being suctioned up into the throat, causing more tonsil swelling. Your tonsil tissues are made of lymphoid tissues, which helps educate your immune system and fight infections. In addition to your two tonsils, you also have adenoids (behind the nose) and lingual tonsils in the back of your tongue, just on top of your voicebox. Additionally, you have countless lymph nodes spread throughout your entire body.
Here’s what the research says:
Of 636 children (age < 11) who underwent partial tonsillectomy using Coblation technology, 33 patients (5%) had regrowth. Of these 33 patients, 5 needed repeat surgery due to recurrent symptoms. Of note, these 5 children’s age ranged from 1 to 3 years (1). Other studies found tonsil regrowth after partial tonsillectomy ranging from 6 to 17% (2,3). In most cases, patients did not feel any worsening of symptoms. As far as I can tell, there are no studies on rates of regrowth after total tonsillectomy.
Adenoid tissues are more likely to come back, since it’s impossible to remove 100% of adenoid tissues (there’s no capsule). Investigators from Temple University found that 2 to 5 years after adenoidectomy, 46 out of 175 patients (26%) had symptoms of nasal congestion. Of the children who agreed to nasal endoscopy, not one patient had more than 40% regrowth, and about 70% had only trace or minimal degrees of regrowth (4). Another study from the Mayo clinic looked at 163 revision adenodectomies out of 8245 original cases. Initial younger age at surgery, presence of ear infections, and signs of acid reflux were significant risk factors for patients needing repeat adenoid surgery. Surgical technique, surgical experience, or the presence of allergies were not significant risk factors for needing repeat surgery (5). A third study found that about 13% of children had adenoid regrowth, but most were asymptomatic (6).
Lingual tonsils are not commonly taken out, and sometime can be a major source of obstructed breathing, Not surprisingly, the presence of acid reflux was strongly correlated to lingual tonsil size (7).
If you’re considering tonsil or adenoid surgery for yourself or your child, the good news is that for the vast majority of patients, tonsils and adenoids don’t grow back, but even if it does, it won’t cause any problems. Rarely do you have to go back to repeat the surgery.
What are your experiences with tonsil or adenoid regrowth? Did you have to go back to the operating room again?
1. Doshi, H. K., Rosow, D. E., Ward, R. F., & April, M. M. (2011). Age-related tonsillar regrowth in children undergoing powered intracapsular tonsillectomy. International journal of pediatric otorhinolaryngology, 75(11), 1395-1398.
2. Zhang, Q., Li, D., & Wang, H. (2014). Long term outcome of tonsillar regrowth after partial tonsillectomy in children with obstructive sleep apnea. Auris Nasus Larynx, 41(3), 299-302.
3. Çelenk, F., Bayazıt, Y. A., Yılmaz, M., Kemaloglu, Y. K., Uygur, K., Ceylan, A., & Korkuyu, E. (2008). Tonsillar regrowth following partial tonsillectomy with radiofrequency. International journal of pediatric otorhinolaryngology, 72(1), 19-22.
4. Buchinsky, F. J., Lowry, M. A., & Isaacson, G. (2000). Do adenoids regrow after excision?. Otolaryngology–Head and Neck Surgery, 123(5), 576-581.
5. Dearking, A. C., Lahr, B. D., Kuchena, A., & Orvidas, L. J. (2012). Factors associated with revision adenoidectomy. Otolaryngology–Head and Neck Surgery, 0194599811435971.
6. Kim, S. Y., Lee, W. H., Rhee, C. S., Lee, C. H., & Kim, J. W. (2013). Regrowth of the adenoids after coblation adenoidectomy: cephalometric analysis. The Laryngoscope, 123(10), 2567-2572.
7. DelGaudio, J. M., Iman, N., & Wise, J. C. (2008). Proximal pharyngeal reflux correlates with increasing severity of lingual tonsil hypertrophy. Otolaryngology–Head and Neck Surgery, 138(4), 473-478.
As part of my show notes from my last podcast about the dangers of mouth breathing, I referenced a website that gave a great summary of George Catlin’s book, “Shut Your Mouth to Save Your Life,” published in 1882. Caitlin was an American painter in the latter half of the 19th century whose paintings of Native Americans are found at the Smithsonian museum in Washington, DC. Here’s an even more in-depth article about Catlin’s discoveries and how it relates to sleep apnea breathing.
In this episode, Kathy and I will reveal 7 ways that mouth breathing can cause sleep and health problems.
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Unstuff Your Stuffy Nose ebook
Interview with Dr. Michael Mew on Breathing and the Modern Melting Face
Interview with Patrick McKeown on Buteyko Breathing
Shut Your Mouth to Save Your Life, by George Catlin
Good review of Catlin’s book
Erica was a young woman who I saw yesterday for sleep apnea. She commented to me that despite eating healthy meals, limiting her calorie intake, and exercising regularly, she’s still gaining weight. This seems to be a very common problem for many people today, whether or not you have obstructive sleep apnea. Although it’s been shown that you can still have sleep apnea even if you’re thin, the vast majority of people in the United States with sleep apnea are overweight. A JAMA article in 2012 estimated that about 35% of Americans are obese (BMI > 30), and 69% are considered overweight or obese (BMI > 25).
Here are 5 proven strategies to lose weight, wether or not you have obstructive sleep apnea:
1. Sleep longer
Study after study reveals that the shorter you sleep, the more pounds you’ll pack on. In general, sleeping less than 6 hours per night is associated with being much heavier. This effect was found to be more important in younger people in a study by Patal and Hu from Case Western and Harvard Universities. In fact, a number or studies show a U-shaped pattern, with higher rates of obesity with too little or even too much sleep. Ohkuma and colleagues from Kyushu University found that in type 2 diabetics, excessively short and long sleepers where found to be more obese, as well as having higher levels of hemoglobin A1c (a marker of poor diabetes control).
Americans now sleep on average of 6.8 hours per night, which is about one hour less than what we used to get in the 1940s. Today, about 40% of people get less than 7 hours of sleep. In an unscientific study by Glamour Magazine, 7 overweight readers were asked to sleep for 7.5 hours every night, without making any other changes to their diet or exercise routines. After 10 weeks, 6 women lost on average over 8 pounds, with a range between 6 to 15 pounds. One woman who was only partially able to follow the recommended sleep schedule didn’t lose any weight, but she did lose 2.5 inches off her waist, bust and hips.
2. Don’t eat anything within 3-4 hours of bedtime
I may sound like a broken record, but this is the single most important piece of advice I give to all my patients. Having extra stomach juices due to a late night snack will predispose to regurgitation into your throat, causing more swelling and more obstructed breathing. It’s not only acid that’s coming up, but also includes bile, digestive enzymes and bacteria. It’s also been shown that these juices can reach your sinuses and ears, as well as go down to your lungs, causing major inflammation. If you normally don’t eat late, then this won’t apply to you, but if you’re a late snacker, this is the single most important step to take if you want to breathe better, sleep better, and begin to lose weight.
I know some of you are going to tell me that this is impossible. You’re so hungry a few hours after dinner, or you get home really late after work so it’s not even an option. This is understandable, since we know that poor sleep will cause you to be hungry and you will preferential crave sugary, fatty or starchy foods. Poor sleep in general is known to to lower leptin, a hormone made by your fat cells telling you that you’ve had enough food. Obese people are found to be leptin resistant. Poor sleep also raises ghrelin, a hormone made in your stomach that makes you more hungry.
What patients tell me is that despite being difficult in the beginning, once you get started, it gets easier and easier, since better quality sleep will make you less hungry and less likely to crave unhealthy foods during the day. In general, eating an early, healthy dinner using ingredients with a low glycemic index will prevent you from being hungry 3 hour after dinner. Listen to nutritionist Maria Alexandra Bella‘s advice on how to avoid getting hungry after dinner. Instead of just trying harder, have a plan of action.
3. Don’t drink alcohol close to bedtime
Many people know not to drink alcohol close to bedtime, since it ruins their sleep quality. But some people enjoy their night caps since it helps them to relax and fall asleep faster. The problem is that alcohol is not only a sedative, it also relaxes your throat muscles. Alcohol may help you to fall asleep better, but it will definitely cause more apneas and arousals, leading to significantly worse sleep quality. Red wine, in particular, has additional properties that can aggravate migraines and headaches.
4. Keep your nose clear and open
One major reason why I emphasize good nasal breathing is based on a old study showing that a combination of a nasal decongestant and a pill to help empty the stomach lowered snoring levels significantly. This is also why I’m against eating close to bedtime. Since so many people with strong and sleep apnea have nasal congestion to various degrees, it’s important to make sure that you’re able to breathe fully through your nose. Many people who are chronic mouth breathers deny that they have nasal congestion, since they don’t know what normal nasal breathing is. Whenever I spray a decongestant and lift up the nostrils, oftentimes the patient has a WOW experience. Whether you need to treat any allergies, use saline irrigation, use nasal dilator strips, or even undergo surgery, do whatever it takes to breathe better through your nose. Read my free e-book, “How to Unstuffy Your Stuffy Nose,” for more helpful tips.
5. Exercise outdoors
This recommendation is probably the most anecdotal, but there’s value to exercising outdoors. A few years ago, I saw a middle-aged overweight woman who came to see me for her sinus problems, chronic fatigue, and headaches. I recommended addressing her allergies, but also to avoid eating late and to exercise outdoors in the sunlight. After 6 months, she emailed me saying that her life was changed completely: She began jogging outdoors in the mornings, lost 30 pounds, and recently ran the New York City Marathon. She has much more energy and no more headaches.
My rationale for exercising outdoors is that most modern people don’t get enough sunlight exposure to create healthy levels of Vitamin D. Yes, we do get some Vitamin D though our food sources, but not enough to maintain healthy levels. It’s important to realize that Vitamin D is not just a vitamin to help develop strong bones. Rather, it’s a hormone that has important effects on your entire body, from your brain to your metabolism. There are lots of studies showing a strong association between low D levels and obesity. For a fascinating discussion about the importance of Vitamin D, listen to my interviews with Dr. Stasha Gominak.
Make a goal to start losing weight today
Before you invest in a gym membership or start up a new diet regimen, it’s extremely important to make sure you’re getting an adequate quantity of quality sleep. Otherwise, your results from exercising or dieting won’t work as well or won’t work at all. If you have obstructive sleep apnea or upper airway resistance syndrome, getting 8 hours of sleep won’t make much of a difference, since the quality of your sleep will suffer greatly. Regardless of whether or not you have sleep-breathing problems, the 5 steps I’ve outlined above should be the basic health foundation for everyone.
If you’re having trouble losing weight, make a commitment to try these 5 steps for 4 weeks. Write down your goal as a SMART goal (specific, measurable, actionable, realistic, timely). Also, write down 5 consequences of not taking action and 5 positive outcomes or benefits of achieving your goal. Please come back to this blog and give us feedback on how you did.
In this podcast episode, Kathy and I will talk about the 20 top ways of getting rid of your snoring. We’ll cover 15 non-prescription and over-the counter options, as well as 5 prescription/surgical options.
- How snoring and ADHD are linked
- How snoring can cause stroke
- A better way to lose weight
- Your best sleep position
- How to choose the right pillow
- Why mouth breathing is bad for your health
- 3 proven non-surgical / alternative ways to stop snoring
- The best surgical options for snoring
- Which dental device works best for snoring
- The pros and cons of surgical options
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Dr. Karen Bonuck’s interview on snoring and behavioral problems
New York Times article on spouses sleeping in separate bedrooms
Snoring demonstration video
Reflux causes sensory damage
Snoring causes sensory damage
Snoring and carotid artery plaques
Lingual tonsils and reflux
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Heather is a middle aged woman who came to see me for snoring. She snored so loudly that her husband has to sleep in another room. She also noted that she gained over 100 pounds over the past 20 years working as a night shift nurse. She recently started working during the days, but found it difficult to have the energy to do her job, or spend quality time with her husband. When I looked in her mouth, I noticed that she was missing most of her teeth, and the few she had were rotting away. During our discussion, she lamented that when she was a teenager growing up in Jamaica, she was thin, healthy, vibrant, and with a full set of healthy teeth. Now she’s 110 pounds overweight, has nasal congestion, diabetes, high blood pressure, high cholesterol and will be needing dentures soon.
This is a common problem that I see almost every day in practice. Thin, healthy men and women who grew up eating naturally, come to the US for a better life, only to gain lots of weight, develop a number of chronic medical conditions and seeing doctors almost full-time after retiring. Shift work also takes a major toll on your health in general. More often than not, they lose an excessive amount of teeth due to cavities and tooth decay.
Traditionally, cavities are thought to happen when bacteria that normally live in your mouth feed on excessive amounts of sugar, which lead to plaque buildup over teeth. Over time, acid production underneath plaque starts to dissolve your enamel, creating cavities. Risk factors for cavities include: location of teeth (usually molars), sugary or acidic foods, frequent snacking, bed-time feedings for infants, inadequate brushing, dry mouth and acid reflux.
Heather didn’t have a habit of eating too much candy. She brushed her teeth and flossed regularly. Over the years, as she gained weight and her snoring got worse, she began to breathe more through her mouth, especially at night. Contrary to popular opinion, breathing through your mouth narrows your airway even further. This set off 3 events that aggravated her tooth decay, leading to multiple extractions:
Having a stuffy nose will cause you to mouth breathe. Oftentimes, high blood pressure medications can lower your melatonin levels by lowering sympathetic tone levels (fight or flight response). Since the melatonin production pathway passes through the superior cervical ganglion (which regulates sympathetic functioning), lowering sympathetic tone may lower melatonin.
In addition, having obstructive sleep apnea also is linked with an imbalanced nervous system inside the nose, where there’s too much parasympathetic tone (rest, relaxation and reproduction), leading to swelling of the nasal membranes and turbinates. This leads to a stuffy nose.
Breathing through your mouth also causes drying of your saliva, which has acid neutralizing properties.
Obstructive sleep apnea
In my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired, I described my sleep-breathing paradigm, which begins with the obstruction–reflux–obstruction feedback loop. This causes more swelling in your throat, causing more obstruction. If you have any residual lymphoid tissues like tonsils or adenoids, you’ll get even more narrowing of your upper airway.
What comes up from your stomach is not only acid, but includes bile, digestive enzymes, and bacteria. Even if you take acid reflux medications, your stomach juices can still come up with each apnea episode, bringing up less acidic juices. It’s also been shown that pepsin, a major stomach enzyme, can reach your nose, sinuses, ears and lungs.
The perfect storm
If you place all three of the above conditions together (nasal congestion, acid, and dry mouth), you’ll end up with the perfect storm for cavities.
But wait—there’s more…
Mouth breathing can also prevent proper facial growth and development. The most extreme example of this is what you see in children with adenoid facies: open mouth posture, head forward position, and recessed and narrowed jaws (see example). This relative underdevelopment of the jaws lead to having a smaller mouth, leading to dental crowning, which narrows your airway even further. If you have excessive dental extractions as a young child for braces or when older as an adult, then your mouth gets even smaller.
After improving Heather’s nasal congestion with allergy medications, she was able to breathe better again. She was found to have moderate obstructive sleep apnea is now sleeping much better with CPAP.
If you are someone who was healthy, skinny, and had great teeth before you immigrated to a modern, “Western” country such as the United States, did you experience similar dental problems like what happened to Heather? Do you have or suspect that you may have obstructive sleep apnea? Please enter your comments in the space below.
Maxine was fed up. Month after month, she suffered excruciating sinus pain and pressure. She initially went to her primary care doctor, who prescribed multiple course of antibiotics, but this stopped working after a while. She was then referred to an ENT surgeon, who prescribed a cocktail of stronger antibiotics, allergy medications and decongestants, only with temporary relief.
By the time she came to see me, she was desperate. In addition to her sinus problems, she told me that she also had the following:
- always chronically tired
- daily headaches
- increasing anxiety attacks
- frequent nighttime urination.
She requested stronger medications or antibiotics, but I was reluctant. A CAT scan of her sinuses came back as completely normal.
Rethinking sinus infections
This is a common scenario that I see all too often in my practice. Patients have been on multiple courses of antibiotics for what sounds like a classic textbook diagnosis. Along with a history of stuffy nose and yellow nasal discharge, all her symptoms may be interpreted as chronic sinusitis. Her doctors practiced textbook medicine. So then why was her CAT scan completely normal?
Modern medicine has made amazing advancements in treating infectious diseases. The development of antibiotics revolutionized modern healthcare and likely has saved millions of lives. Most of the recent research has been focused on the body’s response to infectious agents, with drug development aimed towards lessening inflammation. A more recent development is the discovery of biofilms, where bacteria can clump together, forming a barrier that can resist antibiotics. The current recommendation for chronic sinusitis is to consider sinus surgery if aggressive medical treatment (including multiple courses of appropriate antibiotics) don’t help.
However, not all sinusitis is related to bacterial infections. Here are three things to consider before undergoing routine treatment for sinusitis.
1. Sinusitis may be linked to obstructive sleep apnea and reflux
Early in my career as an ENT surgeon, I noticed an interesting phenomenon: Patients with persistent or recurrent symptoms after sinus surgery had a very high rate of obstructive sleep apnea. In fact, about 80% were found to have obstructive sleep apnea based on formal sleep studies. The vast majority of these patients had snoring and sleep problems long before their sinus problems developed.
Around this time, I began to see the link between obstructive sleep apnea and acid reflux, and the vicious cycle of upper airway inflammation that can potentially aggravate sinus symptoms. There are studies showing that treating acid reflux can help obstructive sleep apnea and vice versa.
When I began to look for obstructive sleep apnea and reflux for all my patients with chronic sinusitis and treating them appropriately, they were less likely to need sinus surgery.
2. Reflux and sinusitis
Sinusitis implies inflammation or infection, and not only due to bacteria. Other sources of inflammation can be caused by allergies, viruses, molds, and even stomach juice reflux.
One of the basic tenets of my sleep-breathing paradigm (which I describe in Sleep, Interrupted) is that obstructed breathing can aggravate reflux. Tremendous vacuum forces are created in the chest and throat which suctions up your normal stomach juices into the throat. This can cause chronic low-grade inflammation and swelling, hoarseness, coughing, post-nasal drip, or throat clearing. Even if you take anti-reflux medications, less acidic juices still reflux into the throat, causing more swelling, leading to more obstructed breathing. If you have tonsils, then they can become bigger, leading to more obstructed breathing, leading to more reflux.
Think about sucking water from a cup through a flimsy straw. As you suck through the straw (during an apnea due to palate, tongue or tonsils blocking your airway), tremendous negative pressure is created inside, not only causing the sidewalls of the straw to cave in, but also suctioning up water into your mouth (the throat).
What comes up from your stomach is not only acid, but also includes bile, digestive enzymes (such as pepsin), and bacteria. It’s been shown that pepsin can be found in the middle ear in patients with chronic ear disease. In patients with chronic lung disease, the vast majority were found to have pepsin and lipid-laden macrophages in lung washings.
It’s not surprising that connections have been made between reflux and chronic sinusitis. There’s even a study showing that treating chronic sinusitis with long-term reflux medications can resolve sinusitis in a significant number of patients.
3. A sinus migraine?
It’s now been shown that the vast majority of patients with sinus headaches are actually having a migraine of the sinuses. Many of the symptoms of sinus migraine can overlap with symptoms of sinusitis: facial pain, nasal congestion, post-nasal drip, etc. After reading this article on sinus migraines in 2007, I applied what I learned to the patient described above by trying her on sumatriptan (Imitrex), a commonly prescribed medication for migraine. The patient was extremely doubtful, but reported back later that her headaches and facial pain were completely gone. She was placed on migraine precautions and with good sleep hygiene and stress reduction, her symptoms became more manageable.
In his book, Heal Your Headache, Dr. David Buchholz expands the definition of migraine to areas other than the head. Any time the nerve endings in any part of your body become overly sensitive, you’ll get symptoms that are common to that part of the body. For example, an inner ear migraine can result in dizziness, balance problems, ringing and hearing loss. In your stomach, bloating, pain, constipation or diarrhea.
Lack of sleep or low sleep quality for any reason can lead to a physiologic stress response which can make your nervous system over-react to your environment. Most commonly, you’ll over-react to weather changes (pressure, humidity, or temperature), chemical , scents, smoke, or odors). Notice that these are also classic migraine triggers, in addition to the classic food triggers (red wine, aged cheeses, and MSG).
Given that obstructive sleep apnea and upper airway resistance syndrome patients are more likely to suffer from headaches, migraines, acid reflux and sinusitis, it’s not surprising that you can have all three of the above conditions co-exist together. As you can see, there’s a lot more going on with sinusitis that just a bacterial infection. It’s important to treat or at least consider these 3 important issues (apneas, migraines, reflux) if you have symptoms of sinusitis. Oftentimes, it’s not really sinusitis. Ultimately, you’ll have to deal with your breathing problem during sleep, which can aggregate all of the above.
In this podcast, Kathy and I talk about 7 Ways Doctors Can Ruin Your Sleep:
1. How this one type of surgery can sometimes cause nasal congestion years later
2. Which dental treatments can create smaller airways
3. How modern orthodontics and jaw surgery can aggravate sleep problems
4. Why medical or surgical menopause can ruin your sleep
5. Find out which commonly prescribed medications can prevent you from sleeping
6. What types of surgery can aggravate apneas during your hospital stay overnight
7. The pros and cons of the Back to Sleep campaign to prevent SIDS
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Breathe Right strips
Jaw surgery in Korea
Blood pressure medications lowers melatonin
Medications that make you gain weight
Do birth control medications cause weight gain?
Timing of heart attacks in patients with obstructive sleep apnea
Delayed development in infants who sleep on back
Improved sleep in tummy sleeping infants
If you enjoyed this podcast, please rate and leave a review on iTunes.
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