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Why Do Men Snore More Than Women?

For all of us, snoring is a fact of life. Either you snore, your bedpartner snores, or you've been rudely awakened by a loud snore at some time or another. Most of the time, the snorer is a man, but sometimes, it can be the woman. So why is it that men snore more than women?

 

Ultimately, it has to do with your upper airway anatomy. One of the main reasons why humans are susceptible to snoring and obstructive sleep apnea is because of the fact that we can talk. For complex speech and language, the voice box has to drop down from behind the tongue to below the tongue. This opens up a space behind the tongue called the oropharynx, which only humans have. As a result of this "laryngeal descent," the tongue can fall back relatively easily, especially when on our backs, and during deep sleep when our muscles relax. Men's voice boxes also drop lower in the neck, thus the lower pitched voices. 

 

I remember hearing during a plastic surgery lecture during residency the fact that aesthetically, the ideal woman's lower jaw has to be slightly recessed, whereas with men, the jaw should be more prominent, and more defined. What this means is that the smaller the jaw, the less room there is for the normal sized tongue, and the more susceptible for the tongue to fall back and obstruct your breathing while in deep sleep.

 

If you start off with a larger space behind the tongue (in men), then some degree of muscle relaxation during deep sleep will cause a partial obstruction behind the tongue. With the same inspiratory forces created by the lungs, air is forced by the soft palate at a much faster rate, and with additional muscle relaxation, the free edge of the soft palate begins to flutter. 

 

With women, since the space behind the tongue is smaller to begin with, the same degree of tongue muscle relaxation causes you to stop breathing, leading to an arousal from deep sleep. This is why in general, the man snores, and the woman, being a "light" sleeper, is bothered by the man's snoring. 

 

This may be an overgeneralization, but I see it happening over and over. Does your spouse or bedpartner snore? If so, does it keep you from getting a good night's rest? 

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.

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.

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.

Sleep Apnea, Restless Legs and Erectile Dysfunction

There are studies linking sleep apnea with restless leg syndrome (RLS) and sleep apnea with erectile dysfunction, but now there's a study linking restless leg syndrome with erectile dysfunction. Not too surprising, since sleep apnea seems to be the common denominator for almost every imaginable disease, known or unknown. You may think that this statement is over the top, but you'll have to admit that not breathing well during the day, and especially not breathing well at night while sleeping can potentially lead to or aggravate almost every disease known to man. 

 

In this particular study, researchers found that men with RLS  had significantly increased risk for having erectile dysfunction (ED) compared with men who did not have RLS. The lead researcher, Dr. Gao, commented that the findings indirectly support the role of dopamine as a common pathway, in light of another study of his in the past that showed an association between ED and Parkinson's disease. He also points out that these same people with ED were more overweight, more prone to depression and anxiety, and had a greater chance of having hypertension or a history of stroke (sound familiar?)

 

It sounds like dopamine deficiency is a popular explanation for a number of different conditions. For both PLS and Parkinson's, giving dopamine-like agents help with the respective symptoms. The problem is that it never cures the problem completely, with a number of serious side effects. 

 

This approach to medicine is the replenish what's missing method. If you're deficient in dopamine, replace it. If you're deficient in Vitamin C, B12, or thyroid hormone, replace it. The problem is that this approach works in some people, but not in everyone. Then the next step is to increase the dosage, and then even more people respond, but not everyone (with more side effects). Ultimately, you're not addressing what's causing the deficiency. 

 

If you have a sleep-breathing problem, it's been shown that you can easily clot in certain small and large vessels of your brain very easily. If you happen to have a clot in the dopamine area of your brain, or if the brain biochemistry changes as a result of hypoxia, then you'll get various symptoms. But I think even the neurologists will tell you that a lack of dopamine itself won't lead to Parkinsons; it's just one part of a much larger picture. Could it be that obstructive sleep apnea may be that bigger picture, since by definition, all modern humans are susceptible to sleep breathing problems to various degrees?

 

What's your opinion on this? Should we continue to treat every medical condition in isolation hoping to target that one missing protein or gene, or should we step back and try to connect the dots until we see the bigger picture? Please enter your comments in the box below.

Can Sleep Apnea Cause Celiac Disease?

I know that the topic of this post may inflame a lot of readers out there, but please hear me out.

Celiac disease is a well-defined autoimmune condition that was originally described in children with chronic, severe gastrointestinal symptoms (diarrhea, cramping, abdominal pain and bloating). It’s known to exist in around 1/100 people in this country (97% don’t know they have it), and it’s responsible for various non-gastrointestinal symptoms, including a specific skin rash called dermatitis herpetiformis, migraines, ADHD, numbness, depression, chronic fatigue, and seizures. Others have reported a link between celiac disease and migraines, PCOS, and infertility. Only 1 out of 6 people have classic abdominal and gastrointestinal symptoms. For unexplainable reasons, the incidence has increased 4 time in the past 50 years.

The theory behind this widespread condition is that the in susceptible people, antibodies in the small intestines attack gluten, a common protein in wheat-based food. Humans don’t have the enzyme to digest gluten, so it passes harmlessly, but in people with celiac, an immune response is created which causes severe inflammation in the small intestines, leading to the classic symptoms. The only known effective cure is to avoid eating anything that contains wheat, in favor of alternatives such as rice, flax, oats, quinoa, teff, and buckwheat.

People who are eventually diagnosed and who go gluten free have remarkable success stories, with more awareness within the medical community and the lay public. One proposed explanation as to why this condition is so underdiagnosed in the US compared to other developed countries is that there’s no pharmaceutical drug that treats this condition, and that in other countries with centralized medical systems, prevention is stressed, rather than just treating the symptoms.

So far, pretty basic information, right?

Here’s my take on celiac disease: For the past few years, whenever I see patients with known celiac disease who come to see me for various ear, nose and throat symptoms, they all have various degrees of sleep-breathing problems. Almost invariably, they have small jaws, cold hands, can’t sleep on their backs, are tired all the time, and have at least one parent that snores heavily. If you look at the space behind the tongue, the airway is extremely narrow. I’ve always suspected that there’s a link between celiac disease and a sleep-breathing disorder such as upper airway resistance syndrome, but I’ve been waiting to accumulate enough studies and evidence before adding celiac disease to my sleep-breathing paradigm.

Various other gastrointestinal conditions have been linked to sleep-breathing problems such as irritable bowel syndrome, Chron’s and ulcerative colitis, so why not celiac? Remember that with upper airway resistance syndrome (UARS), repeated micro-obstructions and arousals prevents deep sleep, which causes a chronic low-grade physiologic stress response. Stress shuts down blood flow to the intestines, which leads to the food just sitting in your intestines without proper digestion and nutrient absorption. After a while, the food becomes an irritant, which causes an inflammatory reaction, creating antibodies in the process, and food being rapidly expelled in the form of diarrhea. Chronic low-grade stress heightens your nervous system and immune system, where your body tends to over-react to normal stimulants or irritants. Just like in the nose, not only will you have an allergic reaction, you’ll also have a nervous system reaction (since your gut has a lot of nerves).

It’s no surprise that every symptom that you see with celiac disease is also seen with upper airway resistance syndrome, including hypothyroidism, migraines, PCOS, dizziness, low blood pressure, and cold hands. There’s even anecdotal evidence that breastfeeding lessens the chance that you’ll develop celiac, which is consistent with what I’ve been saying about how bottlefeeding can increase your risk of upper airway resistance syndrome and obstructive sleep apnea.

I’m not discounting the significant strides made in celiac disease research. There needs to be more awareness and more screening to treat this all-too-common condition. However, even when people go on completely gluten-free diets, they continue to have many of the various other non-gastrointestinal symptoms, including chronic fatigue, migraines, and poor sleep. The way I see celiac is that it’s kind of like a bad allergy, where your main reaction occurs in the intestines. Removing gluten definitely can help, similar to removing a cat from your house if you’re strongly allergic. But ultimately, you’re not treating what’s making you allergic in the first place. Celiac is possibly one of the early signs of an underlying sleep-breathing disorder, just like hypertension, ADHD, depression and heart disease. In modern medicine, we only tend to treat the end result, rather than the cause.

If you have celiac disease, ask yourself the following:

1. Do you prefer to sleep on your side or stomach?

2. Are you tired, no matter how long you sleep?

3. Do you have cold hands or feet?

4. Do you get frequent sinus headaches or nasal congestion?

5. Do either of your parents snore heavily?

What’s your take on my theory? Please enter your feedback in the comments box below.

The Sleep Apnea Switch

What’s the best treatment for sleep apnea? Believe it or not, it’s not weight loss, CPAP, oral appliances, or even surgery. It’s your mind.

 

What I’m constantly amazed about is how some people are able to instantly turn on a switch in their minds, and decide that one way or another, they must be successful with sleep apnea treatment. Ultimately, a much more powerful motivator for achieving success is not my recommendation, or even then risk of not treating sleep apnea, but the person’s mindset. There has to be an important reason for succeeding beyond the medical consequences. Let me explain.

 

One close friend who’s in his late middle years was struggling with CPAP for his severe sleep apnea. Over time, many of his close friends succumbed to possible complications of sleep apnea: one had a stroke that left him blind, and another was incapacitated for weeks due to a blood clot that went to his lungs. He became determined to properly treat his sleep apnea, and is now doing well. 

 

I often see airline pilots, truck or bus drives for sleep apnea. What I’ve noticed is how well most are able to tolerate and benefit from CPAP compared with the rest of the population. When their jobs are on the line, there’s good motivation to get treated and be able to get back to work ASAP.

 

Another common situation is a newly diagnosed younger sleep apnea patient who happens to have a parent that snored heavily and died of a heart attack or stroke in their 40s. Clearly, he does not want to succumb to his father’s fate.

 

On the flip side, I have elderly patients that have severe sleep apnea (they stop breathing 75 times per hour), but since they feel fine, refuse any treatment. There’s no reason for them to even consider being attached to a machine every night. Eventually, they slowly come back to me many years later, as more and more of their friends die from heart attacks and strokes.

 

For some of these people, success comes easy, no matter which treatment option, and for others, it can be a challenge, trying multiple different options, but they all reach a point where they’re happy one way or another. Once you set a goal, supported by the right reasons behind it, you’ll get there, one way or another.

 

What’s your true motivation for addressing your sleep apnea? Please enter your reasons in the comments box below.

Urine Proteins Can Predict Pediatric Obstructive Sleep Apnea

A recent study showed that a urine test for certain proteins can predict obstructive sleep apnea in pediatric patients. In this study, 60 children with documented obstructive sleep apnea had their urine proteins compared with 30 children with snoring only and another 30 normal controls. Four specific proteins, uromodulin, urocortin-3, orosomucoid-1, and kallikrein, were found to predict the presence of obstructive sleep apnea with 95% accuracy. 

The authors postulate that these proteins are the byproducts of various markers of inflammation and metabolism. This this an interesting study, and I’m sure there are implication in adult populations.

 

 

 

Sleep Apnea and Nighttime Urination

We’ve know for many years that frequent bathroom trips at night are not due to bladder or prostate problems, but mostly due to breathing pauses that make you wake up and and think that you have to go. Numerous studies have shown that most men and women who have to go to the bathroom often at night or have overactive bladders during the day actually have sleep apnea. 

 

A new study confirms these findings again, but points out that the presence of frequent trips to the bathroom is as sensitive in predicting obstructive sleep apnea as snoring! 

 

Sleep apnea also makes the body produce more urine, and because you wake up every few hours, you’ll want to go, but you won’t have a completely full bladder. Sudden shifts in blood flow into the heart after an obstructive event increases production of atrial natriuretic peptide, which makes you produce more urine. One study found that diluted levels of urine during these episodes is also predictive of having obstructive sleep apnea. 

 

I often see complete or near total resolution of these sort of problems after definitive sleep apnea treatment. 

 

Do you suffer from frequent nighttime urination, or have an "irritable" or overactive bladder during the day? Please enter your responses in the box below.

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Copyright © 2008 Doctor Steven Y. Park, MD | New York, NY | Integrative Solutions for Obstructive Sleep Apnea, Upper Airway Resistance Syndrome, and Snoring · Design by Fervent