Temporomandibular joint disease, or TMJD, is a very common disorder that affects millions of people in this country. The most common symptoms are ear pain and headaches. Other less common symptoms that are described are ringing, buzzing, ear fullness, sound sensitivity, popping and clicking. A paper published in April, 2008 issue of Archives of Otolaryngology - Head & Neck Surgery described a relatively high incidence of theses "aural" symptom in patients seen in an academic TMJ clinic. They reiterate and agree with other authors' hypothesis that local inflammation of the jaw joint, due to it's proximity to the ear structures, can aggravate all these problems. In the end, no one really knows why these symptoms occur. As in all scientific papers, they can only show association, but never prove cause and effect.
Let me propose one possible cause for these effects: People with sleep-breathing disorders (obstructive sleep apnea and upper airway resistance syndrome) all have various degrees of nasal inflammation with ear and sinus pressure problems, TMJD, and headaches. If you have nasal inflammation with partial blockage of the tube that connects the back of the nose to the middle ear (Eustachian tube), then you can imagine that you may feel ear fullness, hearing loss, popping or clicking. If your senses are heightened due to a physiologic stress response due to inefficient breathing during sleep, then you can hear noises in your ear or be sensitive to certain sounds or voices. Neurologic stimulation of the various structures can aggravate jaw muscle stimulation and spasm, or even ear or sinus fullness. This is similar to what occurs in a migraine attack. Various papers have suggested that a migraine attack can occur in any part of the body that has nerve endings, so in theory you can have a "migraine" attack anywhere in your body.
This is one of many papers that describe observations between one specific condition and it's symptoms. Their findings and observations are accurate, but when viewed from the more holistic perspective of the sleep-breathing paradigm, you may be able to make sense of all of these various interpretations all that much more. After all, there's really no point in looking at all this research without having an overall perspective to interpret it from.
Monday, April 21, 2008
Friday, April 18, 2008
Insomnia and the Blues
A new study published in the journal Sleep reveals that people with insomnia are more likely to develop depression later in life. The traditional thinking is that insomnia is a symptom of depression, but the authors argue that insomnia may come before depression.
My take on this is: "So what,this is old news". However, if you were to look at insomnia from a sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted the issue becomes a lot more complex and all that more meaningful.
In the book I propose that both insomnia and depression are manifestations of interrupted breathing while sleeping that deprives you of deep, restful, restorative sleep. This process begins in early childhood, and is affected by multiple factors, including anatomic issues, diet, infections or stressful situations.
The beauty of my sleep-breathing paradigm is that it doesn't contradict what's out there in insomnia knowledge and research. Instead, it suggests a revolutionary approach on thinking about medical concepts that we take for granted. For the most part, it even agrees with and supports the evidence in insomnia research. My theory is that it's not important which comes first (insomnia or depression), but that both can coexist together. If this is so, what can cause both to occur?
This is another example of the peculiarities of medical research when you try to isolate and correlate one variable against another. Yes, you'll get some interesting results, but more often than not, you'll end up asking more questions as a result, or end up with multiple conflicting results. Once you look at humans as a complex interaction of innumerable processes, by looking at the "big picture," things just make more sense. This is one of my overriding themes in my book.
My take on this is: "So what,this is old news". However, if you were to look at insomnia from a sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted the issue becomes a lot more complex and all that more meaningful.
In the book I propose that both insomnia and depression are manifestations of interrupted breathing while sleeping that deprives you of deep, restful, restorative sleep. This process begins in early childhood, and is affected by multiple factors, including anatomic issues, diet, infections or stressful situations.
The beauty of my sleep-breathing paradigm is that it doesn't contradict what's out there in insomnia knowledge and research. Instead, it suggests a revolutionary approach on thinking about medical concepts that we take for granted. For the most part, it even agrees with and supports the evidence in insomnia research. My theory is that it's not important which comes first (insomnia or depression), but that both can coexist together. If this is so, what can cause both to occur?
This is another example of the peculiarities of medical research when you try to isolate and correlate one variable against another. Yes, you'll get some interesting results, but more often than not, you'll end up asking more questions as a result, or end up with multiple conflicting results. Once you look at humans as a complex interaction of innumerable processes, by looking at the "big picture," things just make more sense. This is one of my overriding themes in my book.
Get Less Headaches – Raise Your Blood Pressure
A recent study published in the journal Neurology showed that the higher your blood pressure, the less likely you're going to have chronic daily headaches symptoms. This is an interesting finding since the authors conclude that headaches may result from stiffening of the arteries as one develops high blood pressure. In the end, the authors' weren't sure why this happened but were perplexed as to its paradoxical implications.
This finding is not surprising at all if looked at from the sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted. People with upper airway resistance syndrome (UARS) are typically young, thin, don't snore, and are chronically tired, no matter how long they sleep. They also tend to have cold hands or feet, and have normal or low blood pressure with bouts of lightheadedness or dizziness when standing up suddenly. These people also tend to suffer from various headache syndromes, like tension, migraine, or TMJ associated headaches. They'll also have frequent sinus pain and pressure, usually misdiagnosed as a sinus infection. Typically, one or both parents will snore heavily, who frequently have high blood pressure, depression, or heart disease.
Later on in life, about 20-40 years later, UARS patients are more likely to be overweight, with no more cold extremities, dizziness or light-headedness, but now snore and have high blood pressure. At this stage, they are likely to have the classic features of obstructive sleep apnea (OSA).
We know that OSA is a major risk factor for high blood pressure, but patients with high blood pressure are almost never screened for OSA. Instead, they are treated for one of the signs of OSA, which is hypertension. One of the major root causes of high blood pressure is almost never addressed. There are even scientific thinkers that propose that OSA is the main reason for most cases of undiagnosed high blood pressure.
The study authors also commented on other studies that show that increasing blood pressure is linked to lower amounts of chronic pain throughout the body. In sleep research, sleep apnea patients are thought to have diminished autonomic nervous system sensitivity, thus the longer breathing pauses.
Unfortunately, in most cases, we wait for the end result of a disease process (high blood pressure) before starting treatment, rather than preventing it from happening in the first place. In the latter scenario, helping people breathe better at night so that they can sleep better can not only alleviate much of the headaches when they're young, but it can prevent progression into high blood pressure and other cardiovascular complications later in life.
This finding is not surprising at all if looked at from the sleep-breathing paradigm which I describe in my forthcoming book, Sleep, Interrupted. People with upper airway resistance syndrome (UARS) are typically young, thin, don't snore, and are chronically tired, no matter how long they sleep. They also tend to have cold hands or feet, and have normal or low blood pressure with bouts of lightheadedness or dizziness when standing up suddenly. These people also tend to suffer from various headache syndromes, like tension, migraine, or TMJ associated headaches. They'll also have frequent sinus pain and pressure, usually misdiagnosed as a sinus infection. Typically, one or both parents will snore heavily, who frequently have high blood pressure, depression, or heart disease.
Later on in life, about 20-40 years later, UARS patients are more likely to be overweight, with no more cold extremities, dizziness or light-headedness, but now snore and have high blood pressure. At this stage, they are likely to have the classic features of obstructive sleep apnea (OSA).
We know that OSA is a major risk factor for high blood pressure, but patients with high blood pressure are almost never screened for OSA. Instead, they are treated for one of the signs of OSA, which is hypertension. One of the major root causes of high blood pressure is almost never addressed. There are even scientific thinkers that propose that OSA is the main reason for most cases of undiagnosed high blood pressure.
The study authors also commented on other studies that show that increasing blood pressure is linked to lower amounts of chronic pain throughout the body. In sleep research, sleep apnea patients are thought to have diminished autonomic nervous system sensitivity, thus the longer breathing pauses.
Unfortunately, in most cases, we wait for the end result of a disease process (high blood pressure) before starting treatment, rather than preventing it from happening in the first place. In the latter scenario, helping people breathe better at night so that they can sleep better can not only alleviate much of the headaches when they're young, but it can prevent progression into high blood pressure and other cardiovascular complications later in life.
Thursday, April 10, 2008
Moans in the Night
An interesting article in a recent sleep medicine journal describes a rare condition where women moan intensely while sleeping. Contrary to what you may have been thinking, these women were not moaning due to either pain or erotic dreams. These seven women sought treatment at Stanford's sleep clinic due to a condition which has been coined catathrenia. They were all embarrassed by their condition, as well as having family members who were alarmed by the strange noises. Catathrenia has been classified in the parasomnia category, which are disturbances that occur during sleep-wake transitions, in contrast to sleep-breathing problems such as obstructive sleep apnea. This condition is typically seen in younger, premenopausal women, who are relatively thin.
When these women underwent an overnight sleep study, none were found to have obstructive sleep apnea. However, they all had in common the typical feature of multiple breathing pauses with arousals, leading to inefficient sleep. All these women also had in common smaller jaw sizes and a history of dental extractions for crowding or orthodontic problems. Many also complained of chronic fatigue symptoms as well.
This article caught my attention because of the nature of the cure for this condition. All the women were essentially cured with treatment that's normally given for people with obstructive sleep apnea. Yet, they didn't have obstructive sleep apnea. What they really had was upper airway resistance syndrome (UARS). As I've described at length in other articles, UARS is a variation/precursor to obstructive sleep apnea, where people have narrowed upper airway anatomy that causes brief obstructions and breathing pauses that are not severe enough to be called obstructive sleep apnea.
To receive a diagnosis of obstructive sleep apnea, you have to stop breathing completely or partially for 10 seconds or more, at least 5 times every hour while you sleep. But if you stop breathing 15 times every hour, but wake up after 2-3 seconds each, then your apnea score is 0 and you're told you don't have obstructive sleep apnea. These UARS patients are constantly tired and suffer from various other chronic conditions such as recurrent sinus pain or infections, low blood pressure, cold hands or feet, various gastrointestinal symptoms, anxiety/depression, and almost invariably, prefer not to sleep on their backs.
The lead author of this article (Dr. Guilleminault at Standford University) was the first to describe UARS as well. In his original UARS paper, he treated these constantly tired people with CPAP, or continuous positive airway pressure. This is a device that delivers gentle air pressure through the nose, thereby keeping their breathing passageways open. For the most part, they all did well, but in the long term, they could not continue sleeping with masks and hoses attached to their faces. Most UARS patients, due to heightened sensitivities, are unable to tolerate this device.
In this current study describing catathrenia, many of the patients tried CPAP as well, which worked, but they all refused to use it continuously. Most of the patients subsequently underwent various surgical procedures of the throat, and were reported as being "cured."
It's amazing how often I find studies that link common and uncommon medical conditions to sleep-breathing disorders. Knowing that sleep-breathing disorders (obstructive sleep apnea or upper airway resistance syndrome) may be linked to depression, anxiety, cold hands, migraines, irritable bowel syndrome, chronic fatigue syndrome, polycystic ovarian syndrome, obesity, ADHD, TMJ, diabetes, high blood pressure, high cholesterol, heart disease, heart attack and stroke, could a breathing problem during sleep be the common link? I've even seen multiple articles linking obstructive sleep apnea to epilepsy and cluster headaches. In my forthcoming book, Sleep, Interrupted, I propose that the this may be a possibility. It may be a bit of a stretch to say a definite yes, but I'm confident that in 10 to 15 years, the answer to the above question will be more clear. This just goes to show that what we generally take for granted my have an alternate explanation.
When these women underwent an overnight sleep study, none were found to have obstructive sleep apnea. However, they all had in common the typical feature of multiple breathing pauses with arousals, leading to inefficient sleep. All these women also had in common smaller jaw sizes and a history of dental extractions for crowding or orthodontic problems. Many also complained of chronic fatigue symptoms as well.
This article caught my attention because of the nature of the cure for this condition. All the women were essentially cured with treatment that's normally given for people with obstructive sleep apnea. Yet, they didn't have obstructive sleep apnea. What they really had was upper airway resistance syndrome (UARS). As I've described at length in other articles, UARS is a variation/precursor to obstructive sleep apnea, where people have narrowed upper airway anatomy that causes brief obstructions and breathing pauses that are not severe enough to be called obstructive sleep apnea.
To receive a diagnosis of obstructive sleep apnea, you have to stop breathing completely or partially for 10 seconds or more, at least 5 times every hour while you sleep. But if you stop breathing 15 times every hour, but wake up after 2-3 seconds each, then your apnea score is 0 and you're told you don't have obstructive sleep apnea. These UARS patients are constantly tired and suffer from various other chronic conditions such as recurrent sinus pain or infections, low blood pressure, cold hands or feet, various gastrointestinal symptoms, anxiety/depression, and almost invariably, prefer not to sleep on their backs.
The lead author of this article (Dr. Guilleminault at Standford University) was the first to describe UARS as well. In his original UARS paper, he treated these constantly tired people with CPAP, or continuous positive airway pressure. This is a device that delivers gentle air pressure through the nose, thereby keeping their breathing passageways open. For the most part, they all did well, but in the long term, they could not continue sleeping with masks and hoses attached to their faces. Most UARS patients, due to heightened sensitivities, are unable to tolerate this device.
In this current study describing catathrenia, many of the patients tried CPAP as well, which worked, but they all refused to use it continuously. Most of the patients subsequently underwent various surgical procedures of the throat, and were reported as being "cured."
It's amazing how often I find studies that link common and uncommon medical conditions to sleep-breathing disorders. Knowing that sleep-breathing disorders (obstructive sleep apnea or upper airway resistance syndrome) may be linked to depression, anxiety, cold hands, migraines, irritable bowel syndrome, chronic fatigue syndrome, polycystic ovarian syndrome, obesity, ADHD, TMJ, diabetes, high blood pressure, high cholesterol, heart disease, heart attack and stroke, could a breathing problem during sleep be the common link? I've even seen multiple articles linking obstructive sleep apnea to epilepsy and cluster headaches. In my forthcoming book, Sleep, Interrupted, I propose that the this may be a possibility. It may be a bit of a stretch to say a definite yes, but I'm confident that in 10 to 15 years, the answer to the above question will be more clear. This just goes to show that what we generally take for granted my have an alternate explanation.
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