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New Year’s Day Heart Attack Rates Soar

I’m willing to bet that tonight we’ll also have the highest rate of apneas during sleep due to alcohol ingestion just before bedtime. Alcohol relaxes your throat muscles, which can aggravate, if not cause obstructive sleep apnea. Sleep apnea is a major source of stress on the heart. We also know that the days after Christmas and New Years Eve have the highest rates of heart attacks.

If you’re inebriated , you won’t have the normal reflexes to wake up and turn over every time you stop breathing. You’ll also have lots of reflux due to vacuum forces suctioning up your stomach juices into your throat. This will cause a lot of sore/dry throats and even much higher rates of pneumonia, asthma, sinusitis and ear infections.

Unfortunately, this is a sad observation and commentary, but likely to be true.

Sore throats, Women’s Periods, and Sleep-Breathing Issues

One of my most popular blog posts is the piece I did about women who have sore throats just before their periods. Take a look at the 45 comments in response to my post. To summarize, the reason why some women have sore throats along with their monthly periods is due to the relative drop in their progesterone levels. One of the positive benefits of progesterone is that it’s an upper airway muscle stimulant. It literally tenses or stiffen your tongue muscle. As progesterone drops, the tongue falls back more easily during deep sleep, causing more frequent obstructions and arousals.

I recently had a woman who told me she gets sore throats when it rains or if she gets wet. How many you have this particular condition?

I Confess – I Ate Late Last Night

I have to admit that for the most part I don’t eat close to bedtime, but it does occasionally happen. Last night, we had a late afternoon event, and ending up eating Korean food at a local restaurant. Not only did I order something spicy, but we ended up eating about 2 hours later than normal. The big mistake I made was in eating a delicious nectarine around 9 PM after we got home, which was a big mistake.

This morning, I woke up with a really sore throat, which traveled up into my ears. Most people would consider this to be the start of your typical cold or allergy attack, but knowing what I know, and based on the timing of events last night, my throat pain was definitely due to reflux. As I write this post later in the morning, my throat pain is completely gone, which proves my point even further.

Imagine if you typically eat close to bedtime, and you have reflux every night. Chronic inflammation and swelling due to normal stomach juices cases narrowing of your nose and throat, which can aggravate more frequent obstructions and arousals. Poor sleep over the long term causes weight gain, and weight gain narrows the throat, aggravating sleep-breathing problems. Whether or not you have obstructive sleep apnea, everyone is susceptible to this process. If this continues for days or weeks, it can set you up for the routine bronchitis or sinus infections that are so commonly seen.

How many of you have a sore throat in the morning? Please enter your answer in the text area below.

The Biggest Throat Problem for Sleep Apnea Sufferers

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.

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?

Is That Scratchy Throat Really A Cold? The Case Against Strep Throat (Part 2)

In my last post I described a typical person that sees me for a few day history of throat pain. She has cold-like symptoms, but her exam is essentially normal. Her voice box does show mild swelling and inflammation, consistent with laryngopharyngeal reflux disease. 

Upon further questioning, she remembers that she did have a late dinner with alcohol the night before she woke up with her throat pain. This confirms her laryngopharyngeal reflux disease diagnosis. But why does eating late cause throat pain the next morning, accompanied by cold symptoms? As I describe with my sleep-breathing paradigm, most modern humans stop breathing to various degrees at night while sleeping. If you're susceptible to this condition (due to having smaller jaw structures), having any additional stomach juices when you go to sleep will allow it to be suctioned up into the throat every time you stop breathing. 

Not only does this cause throat pain and additional swelling and inflammation, it also aggravates more frequent obstructions and arousals, which suctions up more stomach juices.

Well, that explains throat pain, but why would you have fever, chills, and sweats? Isn't this classic for cold symptoms?

Whether inflammation begins with a cold or from reflux, they both cause additional swelling in the throat, aggravating more tongue collapse. When the tongue falls back more and more frequently, this process upsets the balance with your involuntary nervous system. This causes vasomotor symptoms such as fever, night sweats, flashes, and chills. So what may seem like a cold can actually be a nervous system overreaction, with no sign of infection whatsoever.

In this example patients, I just had her stop eating close to bedtime (along with alcohol), as well as to optimize her nasal breathing, by using nasal saline and nasal dilator strips. Usually, most of these problems  go away within a few days.

What can you do if it doesn't go away? Find out my answer in a future blog.

Is That Scratchy Throat Really A Cold? The Case Against Strep Throat (Part 1)

Here's a typical patient that I see 2-3 time every day in my practice: A young woman comes in complaining of waking up Sunday morning with a sore and scratchy throat. She thinks she may have caught her husband's cold, since she is also experiencing some sweats, low-grade fever and unrefreshing sleep. I ask repeatedly if she did something out of the ordinary a few days prior to the onset of her symptoms, and she says no. She denies any traveling, flying, eating or drinking late. She normally sleeps on her stomach, and her father snores like a train. She's worried that she has Strep throat. 

Her general exam, as expected, is normal. No throat inflammation, redness or swollen glands. Looking via a flexible endoscope, the back of her voice box is slightly inflamed and swollen, but there's absolutely no evidence of infection? What would you do?

Is Your Throat Sore Just Before Your Period?

Here’s an interesting observation by more than a handful of my female patients: Their throats are sore for a few days just before their monthly periods. It doesn’t go on to a cold or other more severe symptoms. Just a transient sore throat. Then it goes away.

If you’ve been following my blogs, articles, and especially if you read my book, Sleep, Interrupted, there’s a simple explanation. During your monthly cycles, progesterone levels increase with ovulation, but drops when there’s no egg fertilization. One relatively unknown property of progesterone is that it’s an upper airway muscle dilator. It literally tenses your tongue muscles. When in deep sleep, your muscles (as well as your tongue and other throat muscles) tend to relax to various degrees depending on your sleep stage. If you have less progesterone on board, then it’s more likely to fall back, obstructing your breathing, leading to a temporary vacuum effect in the throat, suctioning up small amounts of normal stomach juices. All this causes a temporary deep sleep deficiency. If you eat a late meal, more of these juices will come up. But once progesterone levels begin to increase again, the tongue tenses, and sleep quality improves as well.

Sometimes, the inflammation in the throat increases to the point of significant deep sleep deprivation, leading to some of the more severe symptoms as pre-menstrual headaches, fatigue, irritability, and weight gain.

For you women out there, do you experience sore throats just before your periods? Please enter your responses in the comments box below.

When Your Cold Is Not A Cold

Every time you get a cold, notice how it usually starts in the throat with a tickle, a scratch, or a slight cough. It then progresses into chest congestion or travels up into the ears and the sinuses. You’ll have a low grade fever, mild chills, and a runny nose. Even if you start out with a runny nose, eventually, you’ll have throat symptoms later on. Sounds like a classic cold, right? When you see your doctor, throat redness and irritation and swollen glands are noted, confirming even further that you’re in the middle of a standard upper respiratory infection, or the common cold. Typically, it’ll last anywhere from 3-5 days. A small minority will progress into one of the classic complications of a common cold, such as a bronchitis or sinusitis.

 

Any time I see patients in the office that come in with any of these classic symptoms or one of the more severe complications such as sinusitis, I always ask about the few days or weeks prior to the onset of the throat symptoms. With few exceptions, most of you will have either increased stress (out of the ordinary), a history of eating later than normal, or drinking alcohol later in the evening. Sudden weather fluctuations such as pressure or humidity changes is another common trigger.

 

If you’re susceptible to sleep-breathing problems at all (most modern humans are to some degree), any degree of inflammation in the throat will cause further swelling, starting up a vicious cycle that brings up more stomach juices into the throat, which causes more obstructed breathing and stomach juice reflux. It’s important to realize that whatever comes up from your stomach includes not only acid, but also bile, digestive enzymes, and bacteria. Even microscopic amounts will cause irritation to your delicate voice box, giving you a scratchy throat, cough or hoarseness. This is why these symptoms are most obvious when you first wake up in the morning.

 

It’s also been shown that these same stomach juices can then travel down into the lungs or up into the ears of the sinuses. Pepsin, a digestive enzyme, and H. pylori, a common stomach bacteria, have been found in lung and sinus washings. This is also why the ears are usually affected before the sinuses—it’s a direct line from your throat to the eustachian tubes, whereas you have to take right angled turn to reach the sinus passageways in the nose.

 

You may now be asking, "but what about the fever and the chills?" Any sudden, or abrupt change in your sleep-breathing status can cause an autonomic nervous system imbalance that can bring about these same fevers, hot flashes, chills and sweating.

 

How does your typical cold start? Please enter your experiences below in the comments box.

When Your Cold is Not a Cold

 

In our current age of economic recession and flu epidemics, experiencing hoarseness or a sore throat can conjure up worst-case scenarios. What I’ve noticed in more recent months is that more and more people with these two symptoms are coming in concerned about throat or lung cancer. If you feel a lump in your throat, the word lump itself can cause feelings of stress or anxiety. If you’re a smoker or a past smoker, the situation is even worse. 

The other day a man came in complaining of an itchy, scratchy throat 4 days prior, with loss of his voice the next day. He didn’t have any other viral symptoms such as fever, chills, or muscle aches. Upon further questioning, he normally eats dinner early, but the night before all this happened, he went out to eat dinner late and also had some drinks. 

 

Here’s the explanation to the sequence: Because of his upper airway anatomy, he was predisposed to acid reflux at night due to occasional obstructions and arousals. I talk about who may be predisposed and why this occurs in my book, Sleep, Interrupted. During an obstruction, vacuum forces can suction up small amounts of stomach juices into the throat, leading to various throat symptoms such as scratchiness, pain, hoarseness, post-nasal drip, lump sensation, and chronic cough. More often than not, doctors will give oral antibiotics in this situation, "just in case."

 

Many typical "colds" start of  with a scratchy or sore throat, with no other viral symptoms. Later, it can "travel" up into the nose and sinuses, leading to nasal congestion and sinusitis. What’s happening here is that there was an initial episode of acid reflux, which first irritates the throat, leading to more swelling and congestion, aggravating the vicious cycle. It’s also been shown that your normal stomach contents (acid, bile, digestive enzymes, bacteria) can travel up into your nose and ears. Chronic inflammation can predispose any part of the body to true viral or bacterial infections. 

 

The typical fevers, chills and sweats that are seen in this situation may suggest a viral infection, but you can also have all these symptoms from an involuntary nervous system reaction, which is called vasomotor symptoms. This happens when your involuntary nervous system becomes imbalanced due to a sudden change in your sleep-breathing status. 

 

Even if you start off with allergies or a runny nose from a cold, eventually, the tongue will collapse more and perpetuate this vicious cycle.

 

So the next time you have a sore throat and are convinced that you have an infection, think again. In many cases, you’ll find that either you must have eaten late or drank alcohol the previous night. If not, then you may have a true cold. But since it’s been shown that having colored nasal mucous of throat phlegm does not necessarily mean you have a bacterial infection, things are not always what it seems.

 

How do your typical "colds" begin? I’d like to know.

 

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