Tonsils, Mono, and Chronic Fatigue

December 2, 2009

As I was taking out enormous tonsils from a young child yesterday, I was reminded of a young female college student that I treated many years ago who came to see me with severe tonsillitis. She had severe throat pain, difficulty swallowing, diffuse and tender swollen neck glands, and couldn’t sleep at all. Due to the severity of her "infection," I prescribed a course of oral antibiotics, as well as a short course of anti-inflammatory steroids, to get rid of the swelling in her throat. The next day, she reported that she was feeling dramatically better and sleeping better as well. When I saw her three days later, her tonsils were not touching in the midline anymore, and her neck glands were much smaller. Upon further questioning, she did state that she’s always had large tonsils, but they became much bigger with this infection.

You may think that the antibiotics helped to fight the infection, but typically, it takes 2-3 days for antibiotics to reach significant concentrations to begin to work. What actually helped her feel better, faster, was the steroids, which begins to work within a few hours.

In retrospect, she probably had mono. But because it resolved rather quickly, it would be classified as a routine throat infection that resolved with antibiotics. However, since mononucleosis is a viral infection (the Epstein-Barr virus), antibiotics won’t really make a difference. Had she not been given oral steroids, her symptoms probably would have continued for weeks to months, despite being given multiple rounds of antibiotics. Most of these patients eventually start to feel better after some time, but some never feel better. This is the classic mono condition that you hear about. Some are later diagnosed with chronic fatigue syndrome.

The reason for these persistent symptoms is that the Epstein-Barr virus preferentially infects the lymphoid tissues in your body. Since your tonsils are lymphoid tissues, they will swell up. Having larger tonsils all of a sudden will narrow your upper airway, causing frequent obstructions and arousals when in deep sleep due to muscle relaxation.

Frequent obstructions also causes stomach juices to be suctioned into the throat, which causes more swelling and inflammation of the tonsils, leading to a vicious cycle.

You may be thinking that it’s a good idea to take out your large tonsils, since it’ll prevent this situation from happening the next time you get a cold. For the most part, it should help, but don’t think of it as a cure. Studies performed in children who undergo tonsillectomies showed that only about 2/3 improve significantly. Many of these non-responders will go on to have obstructive sleep apnea later in life. Even the "responders" will have a slightly increased risk of obstructive sleep apnea, since their jaw structures are more narrowed, which lead to enlarged tonsils.

Do you have large tonsils and have severe or recurrent throat problems every time you get a cold? If so, please enter your experiences below in the comments box.

Written by Steven Park · Filed Under Blog | 1 Comment

Can H1N1 Cause Sleep Apnea?

November 24, 2009

You may be thinking that I’m stretching things a bit by making the suggestion that H1N1 can cause sleep apnea, but in my mind, there’s no doubt that whether it’s H1N1, the common cold, allergies, or strep throat, any degree of inflammation and swelling in the nose and the throat can aggravate sleep-breathing problems. If you didn’t have sleep apnea to begin with, then you may go into sleep apnea territory temporarily, and come back to normal once the infection is gone. This is why you’ll toss and turn when you have a simple cold. If you already have some degree of sleep apnea, then any infection or inflammation will only make things worse. Some people will recover, whereas others will be stuck in a continuous vicious cycle, leading to various other medical complications.

As I detail in my book, Sleep, Interrupted, most modern humans have narrowed jaws that lead to dental crowding and a predisposition to breathing problems while sleeping at night. My sleep-breathing paradigm proposes that all modern humans are on a continuum, where the upper extreme is formally called obstructive sleep apnea. But even if you don’t have sleep apnea, you can still stop breathing multiple times every hour. This disrupts your sleep and causes more inflammation and swelling due to suctioning up of your stomach juices into your throat. More swelling causes more upper airway narrowing, leading to more obstruction, which leads to more swelling.

The most dramatic example is what happens with mononucleosis. The Epstein-Barr virus which is thought to cause mono preferentially attacks lymphoid tissues. Your tonsils are made of lymphoid tissues, like the glands in your neck, armpits and groins. When your tonsils swell up for whatever reason (infection, irritation, inflammation), it narrows the throat, aggravating more frequent collapse, perpetuating the vicious cycle described above. This is why it takes a long time for mono to go away. In some people, the cycle never stops, leading to chronic fatigue syndrome. The physiologic consequences of this process can lead to hormonal, biochemical, and neurologic changes which may or may not show up on blood tests.

In this situation, it’s not that the tonsils are too big, but the jaws are too small, causing chronic inflammation and swelling, which keeps the tonsils larger than normal. This leads to further narrowing of the upper airways. It’s also been shown that you can have persistently enlarged lingual tonsils, which are lymphoid tissue at the base of the tongue in the midline. The size of lingual tonsils has been correlated to the level of reflux material in the throat. Your adenoids, which are lymphoid tissue in the back of your nose, can also become inflamed from colds or allergies, aggravating nasal congestion, which creates a vacuum effect downstream in the throat.

Ultimately, what’s more important than what’s infecting you is the size of your upper airway and how well your body is able to handle these infections. An underlying sleep-breathing problem can definitely aggravate your symptoms. This is why living by the principles that incorporate my sleep-breathing paradigm will help you to minimize or even prevent serious complications from any infection this winter season. My wife and I live by these principles and so far (knock on wood), so good.

Do simple colds lead to prolonged symptoms or repeated infections for you? If so, please explain in the comments box below.

Written by Steven Park · Filed Under Blog | Leave a Comment

The Real Reason for Chronic Fatigue in Mono?

February 2, 2009

A recent article in the New York Times reports on the widespread incidence of mononucleosis in teens and young adults. The Epstein-Barr virus is thought to be the cause, with most Americans infected by their 30s. It’s thought that up to 50% of people infected develop severe fatigue or other symptoms. The article points out the fact that "mono," or "the kissing disease" has been trivialized due to it’s widespread nature and that trials of new drugs and vaccines are lacking.

My take on this article: Most people who are infected with mono experience little more than your typical cold symptoms, but there are a small, but significant number of people who suffer a variety of potentially life-threatening complications, if not extreme fatigue that can be quite debilitating. Mononucleosis infects your body’s lymphoid system, most of which are found in your lymph nodes and spleen. These lymph glands educate your body about any infections and respond appropriately by making more immune cells. As a result, the glands can swell to various degrees—sometimes, to dangerous levels.

Besides the many lymph glands in your neck, your tonsils (and adenoids) are also made of lymphoid tissue. So if you are a teen or a young adult and still have relatively large tonsils, then being infected with mono will cause your tonsils to swell.

As I’ve stated before, anything that causes either temporary or permanent narrowing in your throat will cause your throat structures to obstruct when you are sleeping, especially when you are on your back (due to gravity), and when in deeper levels of sleep (due to muscle relaxation). Even a simple cold can aggravate temporary sleep-breathig problems, causing you to toss and turn all night long. Once your cold goes away, you’re fine again.

However, if you have larger tonsils than normal, then the enlarged tonsils will cause you to stop breathing more often, and in certain people, the vacuum effect created in the throat causes a suctioning of stomach juices into your throat, which causes more swelling. This irritates your tonsils further and the vicious cycle continues.

One little appreciated piece of information is that if you have large tonsils (or eve if you’ve had your tonsils taken out), you could still have lingual tonsils remaining. Lingual tonsils are lymphoid tissue at the base of the tongue in the midline, just above your voice box. So any degree of swelling will narrow the space behind the tongue significantly. It’s also been shown recently that persistently enlarged lingual tonsils are associated with laryngopharyngeal reflux disease.

I’ve also alluded to my sleep-breathing paradigm (in my book Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired) where many people with sleep-breathing problems have relatively narrow jaws and dental crowding, which leads to chronic low-grade obstructions preventing deep sleep, and constant low-grade inflammation of the throat from microscopic stomach contents.

In my practice, every time I see someone with severe mono, their tonsils are infected and extremely large, sometimes almost touching in the midline. Antibiotics usually don’t work (because it’s a viral infection), and in fact, is not recommended due to a potential reaction to certain antibiotics. The one medication that usually helps patients feel better is a short course of oral steroids, like prednisone. It’s thought to be due to its’ anti-inflammatory effects, significantly reducing swelling.

Anytime there is inflammation in the throat, by definition, there will also be inflammation in the nose. This occurs via a combination of gastric juice regurgitation into the nose, ears and sinuses, as well as through an imbalance of the involuntary nervous system. People with narrows jaws will also have narrow nasal side-walls, since the the width of the nasal cavity follows the width of the upper jaw.

If there is any degree of nasal congestion, then vacuum forces are created downstream, aggravating even more throat or tongue narrowing and collapse.

The well-known residual symptoms of severe chronic fatigue after mono can last from weeks to months. Sometimes, the fatigue doesn’t go away at all. Eventually, some of these people will be diagnosed with chronic fatigue syndrome.

The chronic physiologic stress state that’s created can lead to metabolic and hormonal changes. For example, elevated cortisol levels due to stress can suppress thyroid function and raise glucose levels.

It can even affect reproductive hormones adversely. In women, stress can suppress progesterone, elevating the estrogen to progesterone ratio. Interestingly, progesterone is known to promote upper airway muscle tone, so the lower the level of progesterone, the more your tongue is likely to fall back and obstruct, leading to less efficient sleep.

It’s been suggested that there are many different reasons for chronic fatigue syndrome, but upper airway narrowing due to to anatomic reasons and swelling is one logical explanation that encompasses all other explanations. Ultimately, swelling of the upper airway structures can be from anything that causes inflammation, from the common cold to allergies, to acid reflux. The tonsils are one dramatic example of swelling due to infection or inflammation, but other areas of the throat can become swollen, such as the soft palate and tongue. If you look at mono from a sleep-breathing perspective, the chronic fatigue that results sometimes makes a lot more sense.

Written by Steven Park · Filed Under Blog | 10 Comments