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All That Shivers Is Not A Cold

You wake up one morning with a sore, scratchy throat, feeling a little run down. The next night, your throat pain gets even worse, and you experience mild fever, with sweats and chills. Your nose is a little stuffy and runny. Your muscles ache. You're feeling even more tired. After a few days, your symptoms slowly improve, and in retrospect, you conclude that it was a passing cold. 

This is a description of the classic cold, where once you catch a cold virus, it invades your body, releasing toxins and chemicals which causes fever, aches, and general fatigue. But what if I told you that the same symptoms can happen due to an allergy attack, or whenever the weather changes, or even during menopause?

About once or twice every month, I see young men who complain of hot flashes, night sweats, chills, and fever. This occurs for weeks to months. But this history isn't consistent with a typical cold. What's going on?

Whenever your involuntary nervous system is upset or imbalanced, it reacts with what are called vasomotor symptoms. This particular part of your nervous system is what normally controls sweating, temperature, blood flow, digestion, and other automatic body functions. So technically, you can have fever, chills, and even sweats from this reaction.

What then can cause this type of reaction? Let me answer by giving you the story of someone I saw this past week. He was a young man who noticed a mild sore throat 4 days prior to seeing me, and by the next morning, had a horrible sore throat. That night, he felt hot, had some sweats and shaking chills. He felt much more tired than usual, and also had some muscle aches. He saw his medical doctor that same say and was given a strong antibiotic, but didn't feel any better over the next few days. 

When I saw him, I was expecting to see the typical tonsillitis with pusses out tonsils, but was surprised to find only mild inflammation and swelling. An endoscopic exam revealed severe narrowing of the space behind the tongue, made much worse when on his back.

It turns out that on the night previous to the onset of his sore throat, he had been out eating and drinking later than usual. He also normally prefers to sleep on his stomach, but felt that his sore throat might improve is he slept on his back, as he's heard about the health benefits of sleeping on his back. 

What happened to this patient was that by eating and drinking late, more of his stomach juices were forced up into his throat over the first night. Then, as more swelling arose in the throat, more frequent obstructions and arousals occurred, leading to more reflux of gastric contents into the throat, adding to the swelling in the throat, along with much less efficient sleep. 

Lack of deep, efficient sleep causes a physiologic stress response that makes your involuntary system overly sensitive. Hypersensitivity of your involuntary nervous system can lead to vasomotor symptoms, such as fever, hot flashes or sweats. This is why as women go through this process (since progesterone, which stiffens tongue muscle tone, relaxes), symptoms can occur. The same thing can happen when young men are slowly gaining weight.

All I recommended for him to do was to go back to sleeping on his back, and avoid eating or drinking within 3-4 hours of bedtime. 

Do you get sore throats in the morning, or have fever, chills or sweats at night?

Seizures And Sleep Apnea, Revisited

I just came across an article in the NY Times that described a condition called SUDEP (sudden unexplained death in epilepsy), where people with seizures can die in their sleep. It’s throughout to be due to loss of protective reflexes and possibly obstruction. This article brought back memories of the time I was on my neurosurgery rotation and a young woman with seizures just died in her sleep. It was a very emotional and distressing situation for everyone involved, especially when I had to tell the family about what happened. In retrospect, she probably died of SUDEP, and come to think of it, I vividly remember that she had a very narrow face.

What I found interesting was the fact that when it happens, people are usually found lying on their stomachs. References were made to SIDS (sudden infant death syndrome) and its’ many similarities. Unfortunately, it goes on to describe the typical genetic causes for this condition, without exploring the upper airway issue at all.

If you Google sleep apnea and seizures, you’ll see tons of papers and references showing a highly significant association between these two conditions. Just to review, here’s my take on this link:

Seizures are thought to develop when abnormal connections form between nerve endings in your brain, leading to a short of “short circuit.” Many of the medications that are used to control seizures essentially calm or lessen the excitability of the brain’s nerve cells. Even the newer vagal nerve stimulation technique works by enhancing the parasympathetic nervous system (which controls the vagus nerve). Anything that helps to calm or relax your nervous system can also help to prevent seizures.

Not too surprisingly, numerous recent studies have shown that untreated obstructive sleep apnea can cause brain damage in a variety of different ways, including multiple mini-strokes, major strokes, decreased brain tissue density, decreased brain volume, diminished brain functioning, and diminished reflexes. All these effects were found to occur in critical areas of of the brain, such as areas that control memory and cognition, executive functioning, breathing, autonomic nervous system control and motor movements.

I’ve also noticed that every patient that I see that has a seizure diagnosis has very narrowed upper airway anatomy, and usually can’t sleep on their backs. More often than not, parents of people who have seizures often snore heavily and likely have untreated obstructive sleep apnea. We also know that untreated obstructive sleep apnea can significantly lower your seizure thresholds, making you more susceptible to experiencing attacks.

What all this implies is that if you have an underlying sleep-breathing problem, whether or not you have obstructive sleep apnea, you’re going to be more prone to various degrees of brain disfunction and miswiring.

What do you think about my theory? Should all epilepsy patients get screened for obstructive sleep apnea? I’d like to hear your opinion.

Car Accidents and Sleep Apnea: A New Perspective

It's commonly known that if you have obstructive sleep apnea, your risk of getting into a car accident is anywhere from 3 to 10 times normal. But if you don't have sleep apnea, can injuries from a car accident lead to obstructive sleep apnea? In certain situations, yes.

 

Just yesterday, I saw two patients in a row who came in for various ear, nose and throat complaints, including headache, ear fullness, nasal congestion, sinus pain and pressure. It turns out the both got into major car accidents many months to years ago, and ever since then has not been able to sleep as deeply or efficiently as they normally did. It turns out that both of these women naturally preferred to sleep on their sides or stomach. Both attributed their poor sleep to various neck and back pain. As a result, they ended up sleeping on their backs. 

 

I talk about how most modern human's jaws are smaller than what they used to be hundreds of years ago, and as a result of dental crowding, the tongue takes up relatively too much space. This makes the tongue more susceptible to falling back and blocking your breathing at night, especially when you're in deep sleep, due to muscle relaxation. Most people with these issues naturally prefer to sleep on their sides or stomachs, but when they are forced to sleep on their backs for whatever reason, their sleep efficiency drops significantly. We know that in many people with severe obstructive sleep apnea, sleeping on their sides can eliminate apneas almost entirely. 

 

More frequent obstructions and arousals not only cause poor quality sleep, but it also creates a vacuum effect in the throat that suctions up your normal stomach juices into your throat, which can then go into your ears and nose.

 

This situation applies not only with car accidents, but any type of injury that prevents you from sleeping in your preferred sleep position. I also see it happening during pregnancy, surgical procedures, or sleeping next to a new bed-partner. More recently, women are starting to sleep more on their backs after reading in magazines that they should avoid stomach or side sleeping since it can cause facial wrinkles. Really bad advice. Since back sleeping lessens your sleep quality, you'll develop even more facial wrinkles.

 

Did you used to sleep on your stomach or your side, but had to switch to your back due to an injury? 

Can Breast Implants Cause Sleep Apnea?

I saw a woman today who came in for a routine ear problem, but just happened to mention that her sleep has been poor for the past 2 years. It turns out that she underwent breast augmentation 2 years ago and ever since has been forced to sleep on her side or back. Normally she prefers to sleep on her stomach, but since the surgery, it's been uncomfortable to sleep in this position.

I see this situation more commonly after women read articles in magazines where dermatologists are telling women to avoid sleeping on their stomachs or sides to avoid facial wrinkles. Of course the timing is perfect, where the onset of various symptoms (headaches, fatigue, sinus problems, etc.) began around the time that they started sleeping on their backs.

As I've stated before, many modern humans have smaller jaws, and this leads to the tongue to take up relatively more space in the mouth. When on our backs, the tongue can fall back partially due to gravity. Once you reach the deeper stages of sleep, your muscles relax, and you'll stop breathing and then wake up. Most people toss and turn and figure out that they prefer to sleep on their sides or stomach. Anything that prevents the preferred sleep position (pregnancy, neck injury, surgery, etc.) can prevent deep efficient sleep.

So technically, breast implants don't cause obstructive sleep apnea directly , but it can definitely cause you to stop breathing more often. 

How many of you have had a similar situation? What made your sleep position change for the worse? Please enter your answer in the comments box below.

My Magic Sleep Sofa-Pillow

Due to various reasons (my father visiting, and my 1 year old son sleeping in a Pack-And-Play crib in the living room), I ended up sleeping on our old leather sofa the other night. Although I only slept for 5 hours, I woke up much more refreshed than my usual night's sleep. I do remember that I had a similar experience a few months ago when I had a bad cold with severe cough, and I  felt better sleeping on the same sofa. Now I realize that it wasn't a coincidence. The curvature of the armrest is a low gentle slope, with my feet resting on the other side's armrest (preventing me from sliding down). 

What I realized was that due to the armrest lifting up my upper back/shoulders and tilting back my head slightly, my airway must have opened up. This is a normal situation for almost everyone. Whenever you tilt your head forward slightly, the space behind your tongue narrows, whereas tilting the head back opens the airway. This is also why in many cases, "Contour" pillows have this same effect: By lifting up your neck and cocking your head back slightly, you're opening up your airway. Most contour pillows, however, don't function the way they're meant to work, since as you slide down, the the lower part of the pillow that's raised ends up tilting your head slightly forward. 

As a result of this experience, since I like to sleep on my back, I added a bit of support using a rolled up towel, just below my Contour Pillow, slightly lifting up my shoulders. Not too surprisingly, I did seem to sleep better. Next, I'm going to add one more thing: Breathe Right strips. By artificially opening up my nasal passageways by using these nasal dilator strips, perhaps I can finally sleep more deeply and wake up much more refreshed in the morning.

Does sleeping in strange environment or bed make you sleep better or much worse than your normal nights' sleep? Please enter your answers in the comments box below.

Snoring Cure? The Old Tennis Ball Technique Revisited

When Exercise Becomes Hazardous To Your Health

As the obesity numbers keep climbing, everyone wants to eat less and to exercise more. This is great if you’re able to exercise moderation and common sense. But if you’re already sick and your frame of reference is unhealthy to begin with, it’s difficult to know when enough is enough. 

Just as those with anorexia diet excessively to cover up their faulty body image, some people with sleep breathing problems like upper airway resistance syndrome (UARS), or obstructive sleep apnea (OSA), abuse exercise as a means to cope with the lethargy created by their chronic sleep deprivation.

Addicted to Exercise

A lot of patients I see with UARS and OSA become exercise junkies in the same way that people who don’t sleep enough become coffee addicts. Rather than consume substances to give them a "high", these exercise addicts crave the endorphin fix they get while working out to overcome the constant fatigue they feel from not getting the quality sleep they need. Many of them admit that If they miss even one day of working out, they’ll get agitated, moody, and sometimes downright catatonic. 

For these people, exercise or any physical activity is a coping mechanism for the constant energy drain they feel. The problem is, like any drug, too much exercise, if it’s used to deter them from taking care of their underlying sleep breathing problem, will manifest later into health complications that no amount of exercise may be able to cure. 

What’s Your Sleep Position?

Obviously, not everyone who exercise excessively do so to compensate for an underlying sleep breathing problem. One quick and simple way I use to discern who is and who is not susceptible to having a sleep breathing problem is to ask whether or not they can or like to sleep on their backs. You see, those with sleep breathing problems can only sleep on their sides or more commonly their stomachs. The reason being, that they’ll have difficulty breathing when they’re sleeping otherwise. 

To summarize, my sleep-breathing paradigm proposes that all modern humans have difficulty breathing at night to various degrees due to our unique upper airway anatomy. The voice box is located underneath the tongue, as opposed to animals, where the voice box is located behind the tongue. This location of the voice box under the tongue is necessary for complex speech and language. But this is also what makes our airway vulnerable and unprotected, making us more prone to having the various breathing and swallowing problems that we, as modern humans have. 

What’s worse, it’s thought that due to a radical change in our diets (highly processed foods and refined sugars) over the past century, our jaws are getting narrower and we have more dental crowding. Furthermore, dentists have stated that introduction of bottle-feeding to infants can aggravate dental crowding and malocclusion, which makes everything much worse. All these factors aren’t the only reason for everyone’s sleep problems, but they are problematic if your anatomy is already predisposed. 

So what does breathing have to do with sleep quality? There are two components to this issue: When lying flat on your back, your tongue falls back partially, due to gravity. This narrows the breathing passageway behind your tongue to various degrees. As you fall asleep, the deeper level of sleep you enter, the more your muscles relax, and at a certain point, your tongue can fall back and obstruct your breathing. The more narrow your airway (due to smaller jaws or inflammation due to a cold or allergies), the more likely you’ll stop breathing and wake up to turn over. When you were young, you tossed and turned and eventually figured out that you can sleep much better when sleeping on your side or stomach. The problem is that even on your side or stomach, it’s never perfect, and you’re not able to get deep, efficient sleep, no matter how long you sleep.

Sleep Among Athletes

It’s also not too surprising that many personal trainers and fitness professionals have very similar features: Almost invariably they prefer to sleep only on their sides or stomachs. The same can be said about bodybuilders—a personal trainer/natural body builder friend of mine told me that almost every one in her gym snores. Snoring, incidentally, is a very common trait amongst those who have OSA or UARS. 

Professional football players also have a much higher incidence of obstructive sleep apnea. About 1/3 of all linemen were found to have mild or moderate sleep apnea. Many people assume that this is due to the abnormally thick necks that many football players have. However, it’s not only the fat in the neck—it’s also the muscle mass that impinges on the soft tissues of the upper airway. So in theory, the more muscle bulk you have in your neck, the more breathing problems you’ll have while sleeping, and therefore more fatigue to cope with. This in turn, makes you work all that much harder than let’s say, someone else who may not be sleep deprived, to get the same level of intensity.  It’s hard to say which came first, the sleep breathing problem, or the intense work outs, but once it’s started, it ends up being a self-perpetuating vicious cycle. 

Sleeplessness Can Aggravate Injuries

As a long time track and field enthusiast, I know how important it is to eat right and exercise–especially as you get older. Running helped invigorate me after being cloistered for days studying for finals during medical school, and it still helps me maintain my health while balancing the demands of my work and family. Yet, there are times when I’ve let the running take control. This often happens when I’m outpaced by someone in my age group, or when I’m coping with a stressful event. During these times, I’d often train to the point of illness or injury—at which point, I’m temporarily unable to do the one thing that keeps me healthy and sane.

In this way, if you’re an exercise junky, you’re also more prone to having injuries. It’s like that saying: "The higher you climb, the harder you fall." Unfortunately, once injured, it becomes all that much harder to gain the momentum back. What often occurs is common trap for any athlete but much worse if you have UARS or OSA. The sudden lack of activity can cause you to eat more due to increased levels of stress from increased sleep deprivation. As you gain weight, your upper airway narrows even further, leading to worse deep sleep quality. Another scenario that can happen is if you injure your neck or shoulder. This will prevent you from being able to sleep on your side or stomach, which again, aggravates the vicious cycle.

What I just described may seem a little far fetched, but if you are prone to constant fatigue, snore, or have any other chronic health problems like chronic sinusitis, nasal congestion, throat problems, then the sleep breathing paradigm can potentially explain and help you avoid the various health complications you may experience down the road. One way to see where you’re headed is to look at your parents. More often than not, one or both your parents may snore heavily, and in many cases will have one or more of the complications of untreated obstructive sleep apnea: depression, anxiety, diabetes, hypertension, heart disease, heart attack or stroke. 

The best way for you to stay healthy and fit is to eat well, exercise, and most importantly, to sleep better.
 
 

Multiple Sclerosis And Obstructive Sleep Apnea: Is There A Link?

I participate on a medical forum called Medhelp.org, where I’m the sleep-breathing expert. I answer people’s questions on various topics related to sleep and breathing. Somehow, I stumbled onto the multiple sclerosis (MS) community and was surprised to see that many people have severe fatigue issues, cold hands and various sleep issues. Their symptoms sounded surprisingly like upper airway resistance syndrome, which I’ve described before. So I decided to take a poll: I asked three questions: 1. How many MS patients have cold hands or feet? 2. How many MS patients have one or both parents that snore heavily, and if so, what kind of medical problems do they have? And 3. What’s your favorite sleep position (back, side, or stomach)?

The answers to this informal and unscientific poll was surprisingly lopsided. Out of 36 responses, 31 people said that they had either cold hands or feet. Many had to wear socks before going to bed, but some had to kick them off later. Fifteen out of sixteen stated that a parent (usually their father) snored heavily, and many also had major heart disease. Lastly, 26/30 responded that they prefer to sleep on their sides or stomachs. Many complained of intense fatigue.

This is the exact pattern that I see in patients with upper airway resistance syndrome, where they also have cold hands or feet, has a parent that snores, and wears mittens and socks to bed. Typically one or both parents snore, and have various degrees of heart disease. As many people with UARS slowly gain weight over the years, their cold hands may get better, but they’ll slowly develop into obstructive sleep apnea.

It’s a given that both UARS and MS will have a physiologic stress response, for different reasons. This can lead to various autonomic nervous system dysfunctions, such as cold hands or feet. It’s also known that chronic low-grade physiologic stress can stimulate the immune as well as the nervous system, heightening both these systems, leading to various pain issues or autoimmune conditions. I can’t say if there’s a definite cause and effect relationship between UARS and MS, but one thing for sure is that both have problems staying in deep sleep. The only definitive way to find out is is examine these MS patients with a flexible fiberoptic camera to examine the airway.

Am I going too far with my sleep-breathing hypothesis, or could I be onto something big?

 

 

 

Ear Mystery, Solved

In many cases, taking a good history and asking some pointed questions can solve a medical problem without resorting to medications. For example, I saw a man in his late 30′s who came to see me with 3 days of left ear sound distortion and reverberation with mild fullness. He had no other problems, including hearing loss. His exam was completely normal. Most doctors at this point will give a diagnosis of Eustachian tube dysfunction, where due to mild nasal inflammation, the tube that connects to the ear is partially blocked, leading to pressure changes that can cause ear problems. Many patients will walk out the door with prescription allergy mediations or over-the-counter decongestants.

After going through my standard list of questions addressing what changes or lifestyle issues that he’s been going through, it turns out that his wife delivered their first child 2 weeks ago. Obviously, this can be detrimental to sleep. Upon further probing, he admitted to working later the last few days, coming home late, and eating just before going to bed. He also had some alcohol late at night as well. To top it off, he normally likes to sleep on his left side.

 

The history alone solved the puzzle: He normally likes to sleep on his side to partially compensate for his tongue falling back during deep sleep (due to muscle relaxation). When he ate late the last few days, every time he stops breathing even temporarily he sucks up small amounts of stomach juices into his throat, and since he’s lying on his left side, it can easily travel to his left Eustachian tube, causing mild swelling and partial blockage. He also noted afterwards that he has post-nasal drip and mild throat clearing, which is consistent with reflux in the throat.

 

He was advised to eat dinner much earlier and avoid alcohol close to bedtime. This should be a life-long habit. Another great example of using my sleep-breathing paradigm to solve a medical problem without the need to give to medications.

 

 

Q: What’s the best sleep position?

A: Although there are many studies in the psychology fields about personality types and sleep position, you may be surprised by how important sleep position may be for some of you. If you normally like to sleep on your back and are able to sleep well, waking up refreshed in the morning, then continue to do so. If you prefer to sleep on your side or stomach, then keep doing what you’re doing. But if you used to love sleeping on your stomach and now have to sleep on your back due to a neck, shoulder or back injury, then try to do everything possible to go back to your side or stomach again. If your grandmother told you that it’s healthy to sleep on your back, but you love to sleep on your stomach, ignore your grandmother. If your dermatologist tells you to sleep on your back to prevent facial wrinkles, then ignore your dermatologist as well. Sleeping better will be much more to prevent wrinkles and aging than keeping your face off your pillow.

The reason that sleep position is so important is that for many people, due to certain oral cavity features, the tongue falls back somewhat due to gravity. But if your jaw is on the small side, then the tongue falls back even more, and then when you go into deep sleep on your back, due to muscle relaxation, you obstruct and wake up. You can wake up subconsciously to light sleep or completely awake. People with these issues generally compensate well by not sleeping on their backs, but can never get deep refreshing sleep.

 

 

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