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How Infections Can Raise Stroke Risk In Children

Here’s an article showing that children who suffer from stoke had some sort of infection in the days leading up the event. Researchers from UCSF found that 29% of children who suffered a stroke had an infection within 2 days of the stroke, whereas only 1% had infections in the control group.

It’s likely that if you already have narrowed breathing passageways, any additional inflammation and swelling will cause even more narrowing, leading to more severe episodes of snoring or apneas. We know that obstructive sleep apnea can significantly increase your risk of stroke. Furthermore, blood in patients with obstructive sleep apnea is found to be much thicker and more prone to clotting. 

I’m willing to bet that these children already had some sort of sleep-breathing problem, and the infection tipped them over the edge. Oftentimes, you’ll see large tonsils or adenoids, dental crowding, a high arched hard palate, nasal congestion, and an inability to sleep on their backs. Parents of these children are more likely to snore in this scenario.

Fortunately, this condition is rare (5/100,000), but the consequences can be devastating. This is why it’s important to pick up and address any underlying sleep-breathing issues before complications arise.

Shocking Revelations About Strep Throat

This is a bit off the topic of sleep apnea, but definitely relevant for everyone. I just finished reading Dr. David Newman’s book, Hippocrates’ Shadow:What Doctors Don’t Know, Don’t Tell You, and How Truth Can Repair the Patient-Doctor Breach. It was an eye-opening book, confirming my suspicions that many of the routine forms of therapy that we as doctors prescribe are more based on tradition or flawed logic than real science.

One shocking example is our obsession with treating Strep throat with oral antibiotics. The main reason why treatment is recommended is to prevent rheumatic fever. In the 1940s on an army base, there was an epidemic of streptococcal infections and rheumatic fever, which can lead to heart disease. By treating with antibiotics, they were able to lower the incidence of rheumatic fever from 2% to 1%. Calculations showed that they had to treat 50-60 soldiers to prevent one case of rheumatic fever.

Now that rheumatic fever is almost nonexistent, it’s estimated that you need to treat 1 million people with strep throat to prevent one case of rheumatic fever. What most doctors don’t realize is that every time you give antibiotics, you have a 10% chance of developing a rash, 10% chance of having diarrhea, and 10% of of suffering from a yeast infection. That’s potentially 300,000 complications. Furthermore, 0.24% of people will suffer a potentially life-threatening allergic reaction, and of these, about 1 out of every 10 will die (240 people). What’s worse, only about 1/3 of people with rheumatic fever will develop long-term heart disease. So you’ll have to treat 3 million people with antibiotics to prevent one case of heart disease. That means 900,000 people will suffer complications and about 720 people may die. Ten million antibiotics are prescribed in this country every year for throat infections.

Does this mean that we should shop prescribing antibiotics? Absolutely not. In selected situations, it would be inappropriate to withhold antibiotics. But in most cases, antibiotics are prescribed for a sore throat, viral infections, or a slight suspicion of a bacterial infection. In many instances, tonsils can become huge and obstruct your breathing, aggravating sleep apnea temporarily. Sometimes it can even lead to an abscess.

I still remember the one time I had Strep throat when I was a senior in high school. I was spiking fevers, sweating profusely, and was weak, dizzy and lightheaded. I was miserable. Despite this I played my bass clarinet solo in our annual symphonic band concert. After the performance, my father took me to the local ER, where they saw huge, inflamed tonsils. I was tested positive for Strep, and was given a penicillin shot. The next day, I felt 95% better. The point of this story is that we should try to avoid using antibiotics inappropriately, especially when there’s no absolute need.

Here’s a related short discussion on this topic.

Do You Really Grow Out Of Your Tonsils? The Possible Link Between Sleep Apnea and Autism

In the 1950s to 1970s, it used to be a rite of passage for young children to get their tonsils taken out. These days, we're a lot more conservative with tonsillectomy, and frequently, parents are told that their child will grow out of their tonsils. While this is true in some cases, there's a consequence to the watching and waiting option. 

 

Your tonsils are lymphoid tissue that's part of Waldeyer's ring, which is a ring of lymphoid tissue made of the palatine tonsils (your typical tonsils), the adenoids (in the back of the nose), and the lingual tonsils (at the base of the tongue in the midline). In some children with overdeveloped lymphoid tissues, you'll see a communication between all four of these glands, forming a complete circle. These tissues are normally involved in educating your immune system, since everything you breathe or swallow has to go through this ring. As a result, it's expected that the tonsils (and adenoids) will be enlarged during the ages of 3-5. 

 

However, with the shrinking size of modern human jaws, now there's less room for the normal-sized tonsils, which takes up relatively more space. This aggravates more frequent obstructions and arousals, leading to more inflammation from refluxed stomach contents and more swelling of the tonsils. The chronic negative pressure created from this process can prevent proper jaw enlargement, similar to what can occur with bottle-feeding. In many children, their snoring and sleep problems will prompt the parents to see an ENT for tonsillectomy. For children with mild to moderately enlarged tonsils that are not causing any symptoms, or those that are symptomatic but are told that they'll outgrow it, there can be permanent long-term consequences.

 

In children with huge tonsils, one of the reasons why they look so big is that the space that the tonsils sit in is too narrow. Taking out the tonsils can make a dramatic difference is most children, but there are some children that won't respond to tonsillectomy or only partially. One recent meta-analysis showed that adenotonsillectomy was helpful in about 2/3 of all children. But the remaining 1/3 still had residual symptoms or signs of obstructive sleep apnea. These are the children that have smaller jaws than the children who responded to the procedure.

 

In a recent Stanford University study, children who were scheduled for tonsillectomy were divided into two groups. One group underwent standard tonsillectomy, and the other under went rapid maxillary palatal expansion. The results were equivalent for both groups. When children in both groups were crossed over and given the other procedure, the overall results were additive. This just goes to show that one reason why you can have large tonsils that that your jaw is too small. Of course, everyone is on a continuum, and as usual in modern medicine, you're treated only if you are at the extreme end of the continuum. 

 

This is pure speculation, but I wonder if the significant increase in the rate of ADHD in the 1980s and 1990s could be related to the dramatic decline in the rate of tonsillectomies. Furthermore, since the peak incidence of autism is around ages 3-4, it's interesting that this is also the time that the tonsils become enlarged in most children. If you have enlarged tonsils to begin with, any simple cold or infection (even vaccines!) can cause swelling which starts a vicious cycle, leading to a sudden increase in breathing problems and poor sleep. Sleep apnea by definition causes systemic inflammation and an increased susceptibility to form microscopic clots in the brain. 

 

This is also the time (around age 4) when the voice box reaches its' final position below then tongue as it descends from its' original position behind the tongue. A space is created behind the tongue and between the soft palate and the epiglottis called the oropharynx, which exist only in humans, and allows for complex speech.

 

One last interesting phenomenon to point out is that in the early 1990s, parents were recommended to place infants on their backs, to prevent SIDs. We know that back sleeping lowers your time spent in deep sleep and leads to more frequent arousals. 

 

All these factors taken together may be what's developed into the "perfect storm," leading to the dramatic rise in ADHD and autism in our current times. Obviously, there are many other dominant theories for ADHD and autism, but from a sleep-breathing standpoint, what I propose is something that definitely needs to be proven in clinical studies. 

 

What do you think about all this? Please enter your responses in the comments box below.

Q: If You Need Your Tonsils, Why Take Them Out?

Q:
If You Need Your Tonsils, Why Take Them Out?

A: Tonsils are part of the immune system, but when they are too large or are prone to frequent infections, then surgical removal is a consideration. One or two infections every year is not too worrisome, but having an infection every month can be debilitating for most people. For many children (and some adults), very large tonsils can lead to breathing problems at night.

For more information on tonsils visit: http://doctorstevenpark.com/what-everyone-should-know-about-tonsillectomy

What Everyone Should Know About Tonsillectomy

Tonsils are one of the most misunderstood structures in the throat, not only by patients, but by many doctors as well. Traditional teaching states that tonsils are glands in the throat that help to fight infection. Because they are blamed for most cases of repeated throat infections, tonsillectomy is one of the most commonly performed operations in the United States. As I’ll reveal in the remainder of this article, many tonsillectomies today are being performed unnecessarily. Simultaneously, there are too many tonsils still left in place when in fact they should be removed. Here’s the reason why.

 

What Are Tonsils?

Before I can clear up the contradictory statement above, I must first explain what tonsils are and what they do to merit removal, if at all.

Tonsils are lymphoid tissue, like glands in your neck, armpits or groins. They are part of the immune system and are involved in learning what’s foreign and helping to make antibodies to help fight off infections. In young children, lymphoid tissues are very sensitive and can become greatly enlarged even after a simple cold or infection. If you have young children, I’m sure you’re familiar with their complaints of sore throats whenever they have colds.

It’s also important to note, however, that tonsils can swell up not only after viral or bacterial infections, but also from allergies and acid reflux. Any degree of irritation or inflammation can cause the tissues to swell up. This is normal, and will happen to various degrees in people after any type of infection, irritation or inflammation. As such, not all complaints of a sore throat are viral or bacterial in origin. There are many factors for an enflamed tonsil—this is the reason why antibiotics are not as effective in curing sore throats.

What Do Tonsils Do?

Tonsils are part of Waldeyer’s ring, which is a complete circle of lymphoid tissue that is made up of both tonsils in the side walls of your throat, the adenoids, which are in the midline back of your nose, and your lingual tonsil, which is located at the base of your tongue in the midline. In some cases, you’ll see small connections between all four glands, forming a complete circle. Anything that you breathe in or swallow has to go through this “ring”, so that the body can learn what’s coming into the body. This process is most active around ages 3 to 6.

It’s common knowledge what happens when your tonsils become infected: your throat hurts, you have a fever, your neck glands hurt (lymphoid glands that drain your tonsils), and you don’t sleep well. Anything from simple cold viruses to bacteria, and even allergies can cause your tonsils to swell. Streptococcal bacteria are very common, but there’s one particular strain called Group A beta-Hemolytic Streptococcus (GABHS) that tested for and treated, since toxins produced by this strain can potentially damage the heart or the kidneys. In theory, non-GABHS bacteria can also give you similar miserable symptoms, but if severe, doctors will typically give you oral antibiotics, which will make you feel better in most cases.

When Tonsils Mean More Than Sore Throats

But there’s one more variable that occurs during a tonsil infection that’s usually not appreciated—the fact that the tonsil can swell significantly. As I’ve mentioned in my book, Sleep, Interrupted, and in other related articles, humans have relatively narrowed upper airway breathing passageways to begin with, and even mild inflammation and swelling in the throat can narrow this airway even further, almost always leading to various degrees of obstruction and arousal from sleep.

What this means is that, your enlarged tonsils not only affect how sore your throat feels, they can also cause you to sleep poorly. Here’s the reason why.

If the inflammation and swelling caused by an infected tonsil causes your airway to narrow or obstruct entirely and this in turn, causes you to stop breathing, you’ll either wake up to light sleep immediately, or stop breathing for 10 seconds or longer and then wake up. In this latter situation, you would have experienced what’s called an “apnea” or “loss of breath." Most people will have lots of short obstructions and arousals—this is why if you have a simple cold, you won’t sleep as well, since you’ll toss and turn more often than normal. Luckily, in most situations, once the infection goes away, you’ll return to normal.

However, there’s one more piece to the puzzle that can prevent you from feeling better: This is the piece that many patients and even many doctors overlook as well. If you stop breathing, even temporarily, you’ll create a vacuum effect in your throat, where your stomach juices literally get suctioned up into your throat. Small amounts of acid, bile, digestive enzymes, and bacteria can cause your tonsils to stay swollen, aggravating this vicious process. Even worse, your stomach juices can then travel up into your nose or down into your lungs, wreaking more havoc. Add to this a stuffy nose, then another vacuum effect is created downstream, and the tongue can fall back even further.

Certain viruses such as the Epstein-Barr virus (that causes mononucleosis) attack lymphoid tissues specifically, and as a result, keeps the tonsils abnormally large.

This is one reason why patients with this condition have prolonged bouts of chronic fatigue.

Misleading Throat Pain

Most people (and doctors) naturally assume that if your throat hurts, it means that you have a throat infection. If the antibiotics that you’re given works, then it means that it was an infection after all, right? Not necessarily. One of the most commonly prescribed oral antibiotics is called azithromycin (brand name is Z-Pak), which is a convenient 5 day course. One of the lesser known beneficial side effects from this medications is that it empties your stomach faster. So by keeping your stomach juices from coming up, your throat will feel better relatively quickly, sometimes working faster than what you’d expect from typical antibiotics. The problem with this medication is that it only works sometimes in some people, and the effect begins to wear off after a few doses.

Notice how for many people, cold and sinus “infections” always start in the throat, with a tickling, sore throat, mucous accumulation, hoarseness, cough and post-nasal drip, all of which are symptoms of throat acid reflux. Then as swelling in the throat worsens, more and more juices are brought up into the throat, causing more swelling. If you have larger than normal tonsils, then the narrowing in your throat will be more severe and you’ll stop breathing more and more often. If this process continues, the end result will be the classic bronchitis or sinusitis.

Normally, tonsils shrink down to very small glands by the time you’re an adult, but for some people, they stay enlarged. One possible explanation is that they are subjected to repeated bouts of inflammation from stomach juices, and the large tonsils can bring up more stomach juices.

A Rite of Passage?

In the 50s to 70s, it was a given that if you had tonsils, they were removed. The number of tonsillectomies has dropped significantly since then, but more recently, it’s climbing back up. The main reason for tonsillectomy back then was for recurrent infections, but now obstructed breathing is the most common indication.

We now know that even mild degrees of sleep-breathing problems in children can cause a wide range of problems, from bed-wetting and ADHD to behavioral issues and asthma.

A recent study published in the journal Pediatrics showed that about 50% of children with ADHD could be cured with adenotonsillectomy (this is when you remove both the adenoids and tonsils). Countless studies report significant improvement in children’s cognitive, behavioral, memory and sustained attention scores, after tonsillectomy. Even my son Jonas had dramatic improvements after his tonsillectomy.

Not all children with ADHD have a sleep-breathing disorder, but since it’s such a common condition that can be treated, it’s worthwhile to at least consider it if your child has ADHD. People are always asking why a stimulant medication such as Ritalin helps children focus and remain calmer. The answer is that they’re sleepy.

Poor quality of sleep can also heighten a child’s senses and cause abnormalities in their involuntary nervous system, making him or her have balance problems or become hypersensitive to certain sensory forms of input, such as touch, sounds or odors.

The Truth About Tonsillectomy

Unfortunately, not all children who undergo tonsillectomy improve. A recent meta-analysis combining multiple tonsillectomy studies showed that overall, about 2/3 had significant benefit. Some children do somewhat well, but not as well as some others. The explanation here is that the tonsils are not the only part of the equation. By definition, if your tonsils are large, then your jaws will be smaller. I’ve mentioned in my book, Sleep, Interrupted that modern humans have smaller jaws than our ancestors even a few hundred years back, mainly due to a change in our diets (from organic foods off the land or oceans to processed foods with refined sugars). Bottle-feeding is another modern Western phenomenon that has been shown to aggravate this process. If you have smaller jaws to begin with, you’ll have more inflammation in your throat via the mechanism that I described earlier, which will predispose your tonsils to become enlarged. Having large tonsils will cause more obstructions, causing a vacuum effect, which can also narrow your jaws, especially since a young child’s jaws are relatively soft and malleable.

A recent study showed that compared with tonsillectomy alone, orthodontic palatal expansion was equally effective. When both procedures were performed, the results were additive. This study goes to show that dental and orthodontic issues may be important considerations long before parents consider braces for their teens.

Outgrowing Your Tonsils

Some of you may be asking, if the tonsils are an important part of the immune system, why take them out? Most of the early education of your immune system occurs before age 6. Either during this time, or even long afterwards, if your tonsils are so large that they literally obstruct your breathing at night, then wouldn’t you think that this is a more important issue that needs to be dealt with? Doctors will also say that children will “grow out of it.” Yes, in most cases, they will, but based on all the recent studies, there’s plenty of evidence that before they “grow out of it,” there can be potential long-term consequences, including your risk for developing obstructive sleep apnea, heart disease, heart attack and stroke later in life.

I once heard a presentation at a national sleep meeting, where they showed children who underwent tonsillectomies all improved dramatically. The disturbing finding from this study was the fact that compared with children who did not have sleep-breathing issues, the children who underwent tonsillectomies never fully caught up to the control children in terms of cognitive and behavioral measures. What this implies is that there’s some degree of permanent brain damage. Fortunately, children’s brains are highly adaptable, and can compensate very well.

By no means am I advocating routine tonsillectomies for all children. But if your child has any of the issues that I talked about in this article, or if you’re on the fence about whether or not your child should undergo some type of treatment, these issues are definitely worth thinking about.

The Real Reason for Chronic Fatigue in Mono?

Q: If You Need Your Tonsils, Why Take Them Out?

A: Tonsils are part of the immune system, but when they are too large or are prone to frequent infections, then surgical removal is a consideration. One or two infections every year is not too worrisome, but having an infection every month can be debilitating for most people. For many children (and some adults), very large tonsils can lead to breathing problems at night. 

 

More Questions About Tonsils

Q: What are tonsils? 

A: Tonsils are paired lymphoid or glandular tissues that sit on the side-walls of your throat just behind your tongue. They are part of a complete circle of lymphoid tissues that is involved in programming your immune system what is foreign and what is self. The adenoids sit in the mid-line at the back of your nose and the lingual tonsils are also in the mid-line at the rear of the tongue, just above the voice box. They are most active from ages 3-5, and this is the time that most problems arise. 

Q: Do you need tonsils? 

A: Yes, especially when you have an infection. Most of the immune system programming occurs in early childhood. As you get older, the tonsil shrink to a much smaller size in adulthood. However, if there is chronic irritation, such as from allergies, colds or acid reflux, they can remain enlarged. Tonsils and adenoids are only a small part of a much larger system of lymph glands and immune mechanisms. 

Q: What happens if my tonsils are too big? 

A: Just because your tonsils are big does not mean they have to be removed. If you have no problems, then with time, they should shrink. But if you have signs or symptoms of a sleep-breathing disorder, such as daytime fatigue, poor concentration, memory problems, attention problems, asthma, cough, nasal congestion, or snoring, then they should be looked at by an ear, nose and throat physician. Sometimes I see young children who snore heavily, with severe asthma, attention and behavioral problems, and who are on Ritalin for ADHD. On exam they are found to have very large “kissing” tonsils. Due to the prevalent myths about tonsils and surgery, the parents refuse any form of surgical therapy. They would rather treat the end result of their child’s sleep-breathing problem (asthma, ADHD) with long-term medications, when surgery could be curative. On the flip side, there are also too many people with tonsils that are taken to the operating room prematurely, with no clinical reasoning whatsoever. 

Q: Can large tonsils cause snoring? 

A: Yes. Anything that narrows the upper airway, from the nose to the voice box, can cause snoring or other breathing problems. In children, large tonsils are a common cause of snoring. Snoring itself in children has been linked to behavioral, memory and concentration problems, asthma, and chronic cough. A significant number of children (and adults) who snore are also found to have obstructive sleep apnea, which can lead to fatigue, depression, high blood pressure, heart disease and many other conditions. It’s also associated with sexual dysfunction and frequent urination at night. 

Q: Doesn’t undergoing a tonsillectomy hurt? 

A: Yes. But with advances in technology, it doesn’t hurt as much. Traditional tonsillectomy using an electrocautery device will leave you with a very sore throat for 4-7 days. You’ll be on soft or liquid diet until the pain subsides, after which you slowly progress to foods of more solid consistency. The best part is that you can eat lots of ice cream. With newer techniques (such as the Coblator) you’ll have only 2-5 days of pain, with some people not taking any pain medications at all. 

Q: What are the potential complications of tonsillectomy? 

A:  As with any operation, there’s always a very small chance of bleeding or infection. If it occurs, then it will be addressed appropriately. Specific to the procedure, there is a small chance that you may have persistent symptoms even after surgery. There are many reasons for this, including not taking enough tonsil tissues out, or it may be due to something entirely different. Two common reasons include post-nasal drip and laryngopharyngeal reflux disease. There’s also a very small risk to general of complications from anesthesia is lower than being hit by a car.

 

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