The problem with a paradigm is that it can’t be proven. There are so many pieces to the puzzle that it would take hundreds of years and billions of dollars to perform necessary definitive studies. We give water for dehydration, but so far there are no randomized, prospective, placebo-controlled trials showing that given water actually improves dehydration. In addition, water is not FDA approved for dehydration, which is a clinical diagnosis. When there’s no evidence, we use common sense and reasoning in making clinical decisions. However, modern medicine fails by separating out all the various body parts and systems into separate specialties. Yes, doctors like to say that we look at the whole person, but how much can your doctor truly learn about you in a 15 to 20 minute consultation? 

My sleep-breathing paradigm actually pieces together hundreds if not thousands of studies that are already out there, connecting the dots. One of my main goals is to strengthen the links between sleep apnea and various other medical and mental health conditions through rigorous studies. For example, there are numerous studies linking reflux to obstructive sleep apnea, reflux to chronic sinusitis, and chronic rhinitis to reflux. If they’re all linked, why can’t sleep apnea be linked to chronic sinusitis? In fact, I presented a poster many years ago showing that people who undergo nasal or sinus surgery with recurrent symptoms or disease had an almost 80% rate of significant obstructive sleep apnea. Now that I’m looking for sleep apnea beforehand in people with chronic sinusitis, the rate of needing to go on to nasal or sinus surgery has dropped significantly. The same analogy applies to ear infections, depression, anxiety, heart disease, irritable bowel syndrome, psoriasis, nocturia, high blood pressure, or diabetes.

The good news is that there are a handful of sleep doctors that do “get it.” I’ve interviewed some of them on my Expert Interview teleseminar series. Most sleep doctors are very good at what they do, but will probably disagree with me on some fundamental principles when it comes to the airway and sleep. For example, I see a few patients every year who are chronically tired and are given a diagnosis of idiopathic hypersomnia by the sleep physician, with a completely normal sleep study (AHI is 0). Typically, they’re prescribed stimulants. When I examine the airway, I see that the space behind the tongue is very narrow, especially when flat on the back. I refer the patient to a dentist who makes a mandibular advancement device, which improves the patient’s symptoms significantly. Sometimes, even helping the patient breathe better through the nose can “cure” the problem.

So the next time you ask me for a referral, my stock answer will most likely be, “I don’t know.” I may know someone I met at a national meeting or recognize prominent names from published studies I’ve read, but that doesn’t mean that they’re going to agree with my practice philosophy. I’ll continue making recommendations based on the information that’s given to me, and if I happen to know someone that I trust, I’ll make that recommendation. Just like getting a referral to a good lawyer, there’s no quick and easy answer. You have to do your research, ask around, and go with your gut instincts.

Come to think of it, as far as I know, there are no known studies showing that going to a doctor by referral from another doctor results in improved clinical outcomes. 

Within the sleep community, we often use the term benign snoring to mean snoring without any sleep apnea. We see it as the least important form of obstructed breathing, without any medical consequences. Every time I see this in our medical journals or in the media, I get mildly annoyed, since there’s so much information to show that snoring is never benign.

Snoring itself is usually caused by vibrations from the soft palate. Think of a reed in a wind instrument, or a flag flapping in strong winds making lots of noise. In the human throat, any degree of abnormal narrowing of the throat promotes vibrations of the free edge of the soft palate. The loudest recorded snore was found in a British woman whose sound levels reached 113 dB, which is louder than a low-flying jet. There are other areas in the throat that vibrate and make sounds, but they’re probably a secondary effect of the soft palate vibrations.

Here are 5 reasons why snoring is never benign:

1. If you snore, you have a 35% chance of having obstructive sleep apnea, which is a potentially serious medical condition where you stop breathing multiple times every hour, leading to oxygen deprivation, heart disease, heart attack, and stroke. The best way to diagnose sleep apnea is to undergo a formal overnight sleep study. If you stop breathing at least 5 times every hour, with each episode lasting 10 seconds or longer, then you’re told you have sleep apnea. But what if you stop breathing 15 times every hour, but you wake up after 1-5 seconds for each episode? Then you’re told you don’t have sleep apnea, with no clear explanation why you’re so tired all the time.

2. It’s been shown experimentally in rabbits that artificially applying vibrations to the carotid artery causes thickening of the carotid artery walls, similar to what we see in humans with plaques.

3. Snoring without sleep apnea has been shown to increase your chances of being involved in a car accident.

4. Not only is snoring potentially dangerous for your own health, it also disrupts your bed-partner’s sleep quality, health, and relationships. There have been reports of bed-partners becoming deaf in one ear.

5. By not taking snoring seriously, it’s likely that you’ll delay diagnosing obstructive sleep apnea. Many people try various over-the-counter anti-snore aids with mixed results. Most end up giving up until the problem gets worse.

If you or your loved one snores, take it seriously and get it checked out by a sleep physician or an ear, nose and throat doctor. Even if you’re found not to have sleep apnea, treat the snoring. Just because the sleep study doesn’t say you have sleep apnea doesn’t mean that you don’t have a sleep-breathing problem.