August 21, 2010
If you wake up every morning needing to hack up lots of thick mucous, or have throat pain, hoarseness, or a chronic cough, you’re not alone. You may think it’s the beginning of a cold, but a cold doesn’t continue for weeks to months without progressing into the full-blown viral symptoms.
Instead, these symptoms are the beginnings of the most common throat problem sleep apnea sufferers face. And as I explain below, without understanding why this occurs, it can be one of the hardest problems to treat.
Beware of the “Vacuum Effect”
People with obstructive sleep apnea are more prone to breathing problems at night due to partial or total collapse of one or more areas of the entire upper airway, from the nose to the tongue. It’s usually worse when on your back, since the tongue can fall back more in this position. During deep sleep, your muscles naturally relax and you’ll be more susceptible to breathing stoppages.
Pressure sensors placed inside sleep apnea patients reveal that every time an apnea occurs, a tremendous vacuum effect is created inside the chest and throat, which literally suctions up your normal stomach juices into your esophagus and throat. This can happen occasionally, even for normal people, but if you happen to have a late meal or a snack just before bedtime, there will be even more stomach juices lingering in your stomach to come up into the throat. If you happened to drink a nightcap, the situation is even worse since alcohol is a strong muscle relaxant.
What comes up into your throat is not only acid, but also bile, digestive enzymes, and even bacteria. Washings of lung, sinus and ear contents have shown H. pylori, a common stomach bacteria, and pepsin, a major stomach digestive enzyme. So what comes up can cause severe irritation in your throat, provoking the mucous secreting glands of your throat to try to dilute these substances.
Although people generally attribute throat mucous to post-nasal drip, in most cases there’s nothing dripping down the back of the throat. It’s actually coming from your stomach. However, in some cases, since your stomach juices can reach your nose, it can cause nasal congestion and inflammation, which can aggravate tongue and soft palate collapse by creating a vacuum effect downstream. Ultimately, it’s a vicious cycle.
Chronic acid and other irritating substances lingering in your throat can have other detrimental effects. One recent study showed that chronic acid exposure can numb or deaden the protective chemoreceptors in your throat. These are sensors that detect any acid in the throat to prevent aspiration of your stomach contents into your lungs. If these chemoreceptors sense any acid in your throat, a feedback signal is sent to the brain, causing you to wake up so that you can swallow. This is what’s called a reflux arousal.
Treating Reflux For Good
So besides not eating late and avoiding alcohol close to bedtime, what else can you do?
I’m assuming that many of you that are reading this article are already being treated for obstructive sleep apnea, via either CPAP, oral appliances, or even with surgery. The problem is that no matter which option you choose, there will always be some degree of reflux. Taking acid reflux medications can help sometimes, but for the most part, these reflux medications don’t really do anything for reflux. All they do is to lower the acid content content before it comes up into your throat.
Other options include stimulating your stomach via natural remedies or prescription medications to empty your stomach much faster. One fascinating study showed that using a combination of pseudoephedrine (Sudafed) and a pro-motility agent (domperidone) eliminated snoring in most people. Unfortunately, we don’t have the equivalent of domperidone here in the US. Other similar medications are available, but have more serious side effects.
This is why eating early at least 3-4 hours of bedtime is so important whether or not you have obstructive sleep apnea. The same also applies to alcohol. If your nose is stuffy, talk with your doctor to find a way to breathe better through your nose. Make sure you’re sleeping in your preferred or optimal sleep position. Lastly, work with your sleep physician to fully optimize your sleep apnea treatment, no matter which option you choose.
November 9, 2009
Sleep apnea and acid reflux go hand in hand. An obstruction causes a vacuum effect in the throat, which suctions up your normal stomach juices into your throat, causing more inflammation and swelling, causing more obstruction. If you have large tonsils, it becomes even more enlarged, causing severe breathing problems at night. Not only do the mucous membranes of the throat become swollen, the tongue swells up as well, leaving impressions on the sides of your tongue due to pressing on the teeth.
Most people are aware of acid reflux, but what’s virtually ignored is the fact that your stomach juices contain many other irritating substances, including bile, digestive enzymes, and bacteria. In fact, pepsin, one of the main digestive enzymes, and H. pylori, a common stomach bacteria, are both found in ear, sinus and lungs washings. These are major sources of inflammation and swelling in your upper airway.
A recent study published in Otolaryngology – Head & Neck Surgery showed that deposits of pepsin can linger in the throat, and every time acid comes up, it gets activated in the more acidic, low-pH environment. They cultured throat cells with and without pepsin and measured 84 different inflammatory markers, of which 9 were found to be significantly increased, even in a non-acidic environment. This can potentially explain why people with laryngopharyngeal reflux disease have persistent symptoms despite maximal acid reflux medication therapy.
Laryngopharyngeal reflux disease is a common condition where small amounts of stomach juices reach the throat. But it’s important to realize that giving acid suppressing medications like Nexium or Prilosec does nothing to prevent reflux. What these medications do is to lower acid production in the stomach so that whatever comes up doesn’t irritate the throat (or esophagus) as much. It’s not surprising that these medications don’t always help.
I think you’ll agree that constantly having small amounts of digestive enzymes in your throat can definitely cause problems. More commonly, people will complain of post-nasal drip, throat clearing, hoarseness, chronic cough, a lump sensation, tightness, burning, usually with no stomach problems whatsoever.
This is why eating early and not snacking before bedtime is so important for people with sleep apnea (and everyone else, too).
Do you have to clear your throat constantly, or have post-nasal drip, chronic cough, or hoarseness? Please enter your experiences below in the comments box.
January 14, 2009
It’s cold and flu season again, and for many of you, drinking lots of liquids, getting enough sleep and eating chicken soup will be enough to bring you back to health. But for some others, you’ll have persistent or lingering problems that may make you wonder, could it be something else?
Whether it’s a chronic cough, a lump in your throat, headaches, or post-nasal drip, there are a variety of symptoms that can mimic routine colds or flu symptoms. The challenge is in determining what exactly is causing your problem so that you can address it properly.
Cold Versus A Flu: What’s the Difference?
Most routine colds are self-limited, and go away within 4-7 days. Common symptoms of colds are a low-grade fever, a runny or stuffy nose, mild cough, and a mild sore throat.
A flu infection, however, is caused by a different virus, and tends to be more severe, with higher fevers, chills, muscle aches, worse headaches, slightly longer course, and increased generalized fatigue. If you’re otherwise healthy and you follow the typical precautions (rest, fluids, sleep, etc.), both the common cold and the flu will eventually go away. But if you have an underlying medical problem, are more stressed than usual, or run yourself ragged despite your infection, then either the infection may not go away, or slowly turn into something else, or be left with one major symptom that just won’t go away for weeks to months. This is when the real problem begins.
When Colds Never End
There are a number of different conditions that can aggravate your cold and flu symptoms. For example, if you have any degree of underlying allergies, this can make your symptoms even worse, with continued nasal congestion, post-nasal drip or ear and sinus congestions and fullness. If you have a history of allergies, either removing yourself from whatever you’re allergic to or taking an over-the-counter allergy medication may help.
One of the more common situations that cause chronic or persistent symptoms is if you have sinusitis. Persistent nasal congestion can back up your very narrow sinus passageways (or the Eustachian tube for the ears) and after an initial negative pressure sensation, fluid can build up and get infected with normal bacteria that live inside your nose.
However, it’s been shown in recent studies that what most people describe as a "sinus infection" is not truly a bacterial infection, but mostly due to pressure or clear fluid. In this case, opening up the sinuses or ears, starting with conservative methods such as vigorous nasal saline irrigation may help. More aggressive decongestants such as over-the-counter (OTC) decongestant pills or sprays (only for a few days at most) are other options. Antibiotics are rarely needed, since most cases are not really due to bacterial infections. If you can open up your sinuses, your body is able to do the rest. Click here for a FREE brochure on which OTC medications are best for your cold symptoms.
Another interesting fact about sinus pain and headaches is that the pain itself in most cases is not caused by an infection, but by a migraine attack of the nerve endings in your sinuses. In contrast to your classic migraine headache (pounding one sided headaches with sensitivity to bright lights and noised, nausea and vomiting), irritation and inflammation of the nerves in your sinuses can cause pain, pressure, post-nasal drip, and sometimes nausea. In some cases these sinus "headaches" may respond to anti-migraine medications, such as Excedrin Migraine or Imitrex. In this situation, avoidance of certain foods that can trigger migraines is also recommended (such as caffeine, alcohol, MSG, aged cheeses, red wine).
Colds and Acids Don’t Mix
Acid reflux can’t cause colds or flus, but colds and flus can definitely cause acid reflux. For some people, the inflammation from the infection causes narrowing in the nose and throat, leading to stronger than usual vacuum forces in the throat via the following mechanism:
Due to modern human’s unique oral cavity anatomy, our tongues can easily fall back, especially if on our backs (due to gravity) and when in deep sleep (due to muscle relaxation). Many people with this condition naturally like to sleep on their sides or stomachs, but any degree of even mild narrowing due to inflammation can trigger a vicious cycle, where the tongue falls back, leading to partial or total obstruction. (I talk about the reasons why some people are more susceptible to this in my newly released book, Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. For more information or to download sample chapters click here.
Once the tongue falls back and obstructs, as you try to take in a few breaths, tremendous vacuum forces are created in the throat, literally sucking up normal stomach juices into your throat. Your stomach juices include not only acid, but bile, digestive enzymes, and bacteria. Even small amounts of these substances can irritate not only your throat but studies have shown that these can even go into your ears, sinuses and lungs. This causes more inflammation, which narrows the airway even more, causing more tongue collapse. If your nose is stuffier, then vacuum forces are created downstream and the tongue falls back easier. Notice the multiple vicious cycles.
Acid irritation in the throat will produce the classic throat acid reflux symptoms, such as chronic throat clearing, lump sensation, difficulty swallowing, hoarseness, chronic cough, post-nasal drip, and tightness in the throat. This condition frequently coexists with a variety of other upper respiratory conditions.
Not too surprisingly, sinus headaches, post-nasal drip, and throat acid reflux frequently go hand in hand. It’s also been shown that people who are prone to these issues also have what’s called chronic rhinitis or non-allergic rhinitis. This is where your nose’s nervous system is hypersensitive to weather changes such as temperature, humidity, and pressure changes, and other irritants such as chemicals, fumes, scents or odors. This is thought to be due to an imbalance in the involuntary nervous system of your nose.
Sometimes, a patient will come in extremely stressed and concerned about the possibility of cancer, as they’ve smoked in the past, or a parent died of throat or lung cancer. In almost all cases, after a thorough history and examination of the throat structures, patients are reassured that their symptoms are most likely due to the conditions that’s causing inflammation, such as acid reflux, or allergies.
Why Antibiotics Aren’t The Cure
So now that you know what may be causing your chronic problems, what can you do about it? In most cases oral antibiotics are not the answer (although this is too often prescribed by most doctors). In certain cases patients swear that within a day or two of being given a certain class of antibiotics (macrolides, which include azithromycin or clarithromycin), they felt significantly better, which proves that it was a bacterial infection. One possible explanation is that the macrolide antibiotics have a unique property where it stimulates the smooth muscles of the stomach, causing more contractions and thereby pushes the stomach juices and contents down faster into the intestines. So the less acid is lingering in the stomach, the less it can come up into the throat to cause problems. This is probably why many patients feel better after being given a Z-Pak for throat pain. General surgeons use these medications intravenously to stimulate bowel function after major abdominal surgery.
So now that you know the improper way to treat a cold or flu, what should you do to feel better? The first thing to address is to make sure you are able to breathe well through your nose. Try nasal saline sprays or any of the other various ways of getting saline into your nose. Saline acts as a mild natural decongestant, helping to open up nasal passageways and sinuses. The only downside is that it has to be repeated frequently. If you have any allergies, try to find out what you’re allergic to and get it under control. You can start with over-the-counter allergy medications and if that doesn’t work, you may need to see your doctor about your allergies. Worst case scenario, you may need to see an allergist. If your nose is still stuffy, you may want to consider seeing an ear, nose, throat specialist to figure out if you have an internal structural problem that needs to be addressed.
Some people have naturally flimsy nostrils. Sometimes, this occurs years after rhinoplasty, since narrowing the tip of the nose also weakens the sidewall cartilages that support the nostrils. In this case, Breathe-rite nasal dilator strips may help. If this is not strong enough, or if it won’t stay on, there are various internal nasal springs or clips that can be used (Nozovent, Breathewitheez). Having a stuffy nose internally can also aggravate this nostril collapse problem.
One of the most important habits to avoid is eating close to bedtime. If you have stomach juices lingering from a recent meal and you lay down to sleep, if you have even mild partial to total obstructions, you’ll vacuum up these juices into your throat, which can then go into your nose. This causes more inflammation and more obstruction with arousals. You should try to avoid eating about 3-4 hours before you go to bed.
Alcohol is another substance that should be avoided close to bedtime. It may make you drowsy and fall asleep better, but because it relaxes your muscles, you’ll stop breathing and wake up more often. Again, use the same 3-4 hour rule. What this means is that you can still have a glass or wine or beer with an early dinner.
Many of you will naturally want to sleep on your side or stomach, but if you normally like to sleep on your back, try sleeping on your side or stomach, whichever is more comfortable. This will lessen the degree of tongue collapse due to gravity.
I alluded to sinus pain and pressure being like migraine. Even if you’ve never had a migraine, try to avoid certain foods that can trigger migraines (already mentioned above).
Lastly, it’s not too surprising how often people push themselves while sick. It’s just common sense that you should rest, take it easy, and care of yourself. This involves regular exercise, eating healthy, and taking part in activities that is calming and relaxing. If all these conservative options don’t help, then it’s time to see your doctor.
December 10, 2008
A: There are many reasons for losing your voice, but one of the most common reasons for chronic voice problems is due to acid reflux. This is not your typical gastro-esophageal reflux (GRED) in that you don’t have to have any heartburn or indigestion. The only thing you may feel is hoarseness, but more often than not, you’ll also have chronic post-nasal drip, throat clearing, cough, a lump sensation, difficulty swallowing, or pain. This is called laryngo-pharyngeal reflux disease, or LPRD.
Initially, try eating dinner much earlier, and avoid alcohol close to bedtime. There are various over-the-counter medications for acid reflux, but they are not designed for this type of reflux. If your problem persists for more than a few weeks, or keeps coming back, it’s probably prudent to see an ear, nose and throat specialist for a proper evaluation.