Sunday, January 11, 2009

Monday, September 15, 2008

Commitment And Consistency

One of my greatest frustrations is when I reveal to a patient that a major cause of his or her underlying medical issues (such as high blood pressure, dieabetes or weight isues) are from untreated obstructive sleep apnea. Most people are ecstatic about finally finding an answer to many of their medical problems and are excited to find how how to go about treating it. But there are some individuals that give me a blank stare, with a glazed over look in their eyes. Some are even adamant that they know that they don't have obstructive sleep apnea.

At this point, I go over again all the reasons I think they have sleep apnea, but only some are convinced. The rest go on treating their end-stage symptoms such as migraines and chronic throat pain with either pain medications or acid reflux reducers, which may help temporarily, but the problem usually comes back. Many of these same people will come back months or years later after worsening of their problems, admitting that "you were right."

This phenomenon reminded me of a psychology book I read a while ago called Influence: The Psychology of Persuasion, by Dr. Robert Cialdini. One of the principles that he describes is commitment and consistency. He states that humans prefer to think the same way, act the same way, and take comfort in the consistency of their ways. In their minds, they've already committed themselves towards repeating the same steps every time.

For example, if you've been taking high blood pressure medications for 20 years, and you're suddenly told that it was actually obstructive sleep apnea that caused it in the first place, how would you respond? If you've suffered from migraines all your life, how would you respond to being told that not sleeping efficiently due to partially obstructed airways can aggravate migraines? Being told something that completely refutes the daily actions (taking pills) you've taken for 20 years. It also conflicts with what your doctor said about your health.

If you were told something by your doctor that completely went against what you've revolved your life around for years, how would you respond, and how do you think your doctor should handle this situation? I'd like your feedback.

Saturday, September 13, 2008

Snoring May Cause Strokes

We’ve always known that that heavy snorers are at increased risk for stroke. But a recent study from Australia showed that carotid artery narrowing in the worst snorers was 10 times higher than those who snore the least. In typical scientific journal fashion, a much larger sample size was said to be needed to establish a casual relationship. You can read a layman’s summary here from the New York Times. The authors proposed that perhaps vibrations themselves can damage the thin inner wall lining, leading to plaque buildup and eventual narrowing.
There are many more published articles that associate snoring with stroke. We know that a significant percentage of people who snore will have obstructive sleep apnea, and sleep apnea is strongly linked to stroke. The frustrating thing is that despite regular reports like this that warn of the the dangers of snoring, people continue to equate snoring as something to be laughed at and doctors continue to treat the end effects of obstructive sleep apnea (such as hypertension, diabetes, depression, anxiety, heart disease, heart attack and stroke). At least once per week, I see a younger snoring patient that tells me that his (or her) father snored heavily and suffered a stroke or a heart attack in their 40s or 50s. The frightening thing is that we know now that you don’t even have to snore to have obstructive sleep apnea.

Do you have a parent that snores heavily, and if so, did they suffer from a stroke or a heart attack at a relatively young age?

Wednesday, July 2, 2008

Can Obstructive Sleep Apnea Lead to Alzheimer's?

Sleep apnea and Alzheimer's are not commonly known to be associated, but a recent study in the Journal of Clinical Sleep Medicine reported that the greater the severity of one's sleep apnea, the greater the chance that you'll have what are called lacunar infarcts in your brain on an MRI study. Lacunar strokes (or infarcts) occur when small vessels supplying a specific part of the brain gets blocked and can show up on an a CAT scan or MRI as multiple small lesions. These areas correlate with small areas of dead brain tissue in the distribution of small arteries. In the study, 54% of people with severe OSA, and 12% with mild OSA, were found to have lacunar infarcts. All these people were asymptomatic neurologically at the time of testing. Their conclusion was was people with severe OSA have a higher incidence of silent cerebrovascular lesions than their counterparts with less severe OSA.

An interesting finding, in light of the fact that Alzheimer's is now thought to be a disease of small vessels in the brain. There's still a lot of controversy about the clinical significance of incidental lacunar infarcts on an imaging study, but I think you would agree with me that having dozens or hundreds of these small areas of dead brain tissue is not good for your memory. Add to this all the research studies that show that people with OSA are more likely to clot due to increased inflammation in general. Others studies have shown that people with lacunar infarcts have a higher incidence of heart disease. Over 80% of people with OSA are not diagnosed in this country. OSA is known to be strongly linked to heart disease. The links go on and on.

Do you think this is a valid association that's worth further research, or am I taking the sleep-breathing paradigm a little too far?

Friday, June 20, 2008

What You Must Know About Sinus Headaches

Many of my patients come to see me for their severe sinus headaches with pain, pressure, sinus congestion and pure misery. Most are surprised, if not shocked, when I tell them that their sinus headache is really a variation of a migraine attack in their sinuses. Some don't believe me at all. Many of these same patients can also have mild nausea, light or sound sensitivity. Some have none of these other symptoms. The true test lies in their response to an anti-migraine medication, whether an OTC or prescription medication. Some of my patients respond very well to Excedrin Migraine, a common OTC medication. Others respond to prescription medications for migraine, such as Imitrex.

A recent paper presented at the 111th meeting of the Triological Society's Combined Otolaryngology Spring Meeting, showed that a class of migraine aborting medications (tryptans) brought relief to more than 80% of sinus headache sufferers. They gave these people with normal CAT scans a 40 mg dose of eletriptan and another dose two hours later if not improved. Overall, 31 out of 38 patients achieved 50% or greater relief of symptoms, and another 8 went on to respond to a different type of tryptan medication (82% response total).

The study's findings mirror what I've been seeing in my practice for the past few years. What the presenters don't explain, however, is why these sinus headaches (migrianes) are happening. Again this is another example of covering up a symptom, without getting to the root cause of the problem. What I've found is that almost every one of these patients have problems sustaining deep sleep due to poor breathing at night. By helping them breathe and sleep better, helping them adjust their eating habits and timing, and by calming and relaxing the stress responses that builds up, patients overall feel much better.

Do you suffer from sinus or migraine headaches? If so, how much does it affect your life?

Wednesday, June 11, 2008

SLEEP Meeting 2008 Summary

I spent all day yesterday at the SLEEP 2008 national meeting in Baltimore. I  went to qualify various home testing options (I have three to choose from), but I wanted to mention in this blog a few interesting companies and products that I  saw.

Cure for Insomnia?
For people with severe insomnia, I've mentioned cognitive behavioral therapy or CBT. It's been found work better than sleeping pills, and many people can stop taking these pills as well. The problem has been that it's very labor and time intensive. I was pleasantly
surprised to see an online version of CBT, developed by a Harvard insomnia researcher. Check it out here.

Elephant CPAP Mask
I was walking by a booth and I did a double take, as I thought I saw an elephant's nose. I turned around and saw this device in the picture below. It's made of a soft fabric and it allows you to sleep on your side with no rigid tubing or plastic mask to get in the way. You can find out more information or order it here
Football Helmet for Sleep Apnea?
Many people hate CPAP because they can't sleep on their stomach, face down. The mask and the tubing comes off when this is attempted. A device that I saw looks almost like a football helmet but on closer inspection is a light plastic helmet with  thick rounded bars (like a face mask) in front of the face to accommodate for the CPAP mask and tubing. It's patent is pending and may take another 1-2 years to become available. You can see the design at

After many hours of walking, my tired feet took me to a company called "Happy Feet." Not the penguin movie, but a shoe insert that's filled with glycerin that massages your feet when walking. I bought a pair and so far so good. You can check them out here.

Thursday, May 29, 2008

An Important Reason to Breathe Through Your Nose

In an article about the importance of form and function with regard to the face, one interesting point that was made was the fact the our noses (mostly our sinuses) make nitric oxide (NO), a gas that acts as a powerful vasodilator. When inhaled into the lungs, it promotes oxygen uptake. This is why we're told when running to inhale through your nose and exhale through your mouth. What this implies is that if you're a chronic mouth breather, you may be depriving yourself of oxygen.

Searching further on Pubmed revealed an interesting study: humming increased nasal production of NO 15 fold as compared with quite breathing. They hypothesized that oscillating nasal breathing as a result of humming could explain this process. It's also interesting to note that rapid short nasal breathing taught in yoga classes may have a similar effect.

I strongly recommend that you read the entire article (it's a little long). It's an interesting read about how poor development of our facial bones could be leading to many of our medical ailments today. I can't agree with everything stated in the article, but I do agree with most of the article and the basic fundamental arguments. It parallels and supports all the major concepts that I discuss in my forthcoming book, Sleep, Interrupted. It also references Dr. Weston Price's book, which I use as a one of the foundations for my book.