Is surgery necessary or even better than alternative treatments for sleep apnea? Is it appropriate even if we don’t know the cause?
Comment on “How to Beat Sleep Apnea? Cut It Out (Surgically)” on Morning Edition on 14 March 2011, where I discuss how doctors need to consider environmental causes other than germs, like toxins, as a cause of sore throats. Toxins can damage tissue, attracting predatory microbes. They can also interfere with nerve transmission, preventing proper muscle contraction, gland secretion, and control of fluid flow in the subcutaneous tissues of the nose and throats.
Updated: Aug 16, 2011
This report described cases of sleep apnea in adults. NPR reporter Patti Neighmond interviewed Dr. Erica Thaler, an eye, ear, nose and throat surgeon at the University of Pennsylvania Hospital. She describes a patient, Daniel Sheiner, who had an obstruction at the back of the throat which caused his sleep apnea. He tried different methods to allow him to sleep through the night, but none worked, so she performed a type of robotic surgery that removed excess tissue that had built up in the back of the throat that included swollen tonsils. Another doctor, Rashmi N. Aurora, says surgery should be suggested only for younger patients, and describes several other techniques that can be used.
Daniel Sheiner’s description of his inability to keep up with a conversation or putting things in the wrong places does not tell me that his problem is due solely to sleep apnea but that the brain is preoccupied with something else. We can consider thinking as the act of “running associations” in the brain, checking out cells that represent different things. Thus, thinking can be conscious and/or unconscious. In Daniel Sheiner’s case, a lot of it was unconscious. Yes, lack of sleep tends to set up roadblocks to the ability to focus, but in his case, his lack of focus was far too severe to be attributed only to sleep apnea. In fact, what is causing his apnea may also be causing his unconscious preoccupation. How long will his surgery prevent his apnea if it doesn’t address the cause?
The unconscious brain regulates all unconscious activity in the body, from organ to tissue to cellular function. Daniel Sheiner was unconscious of doing some things, so it sounds like there were problems in the unconscious brain. For instance, if you suddenly find yourself in the kitchen but you do not know why, then the conscious brain is trying to get you to do something, triggering analysis areas to “run associations” until you realize why.
The causes of sleep apnea, as described in this report, (excess body weight or obstruction) are not thought out well enough, nor tested experimentally. They are just guesses. Treating it with surgery is a clear sign that they do not know the cause and cannot think about the mechanics of the pharynx thoroughly enough to guess what the cause might be. Surgery may work in the short run, but if the doctors do not learn to connect other symptoms to sleep apnea, they will miss something that may shorten the lives of patients over a period of time after the surgery. See my comments at “Treating Sleep Disordered Breathing in Kids“. See also my comments posted at the site of NPR’s report on All Things Considered for 10/18/11 “When It Comes To Baby’s Crib, Experts Say Go Bare Bones“.
The brain develops workarounds for every condition and will cover up most conditions over time. The problem with workarounds is that if the condition of organs changes for other reasons, the workarounds may fail, thus continuing something that the doctors and patients thought they had gotten rid of long ago.
I doubt that the doctors have entertained the possibility that the overweight condition and pharyngeal obstruction may both be caused by something else. Furthermore, by focusing on the obstruction, without having a clear theory in mind about how the pharynx might be related to sleep apnea and to excess body weight or how the body works in relation to nervous system control prevents a doctor from ever seeing how other seemingly unrelated symptoms are connected to the sleep apnea.
They also seemed to have forgotten how the lack of proprioception can cause failure in the tone of all muscle, but most prominently in skeletal muscle, the stuff that isn’t working correctly in Daniel Sheiner’s case. We need proprioceptive information constantly or the muscle goes limp. Since proprioception loss can occur at many different levels in the nervous system, it can be difficult to find out what exactly is causing something like sleep apnea.
Proprioception could fail for long periods of time or intermittently. Loss of proprioception could be due to something interfering with the receptors in the muscle (spindle fibers), tendon (Golgi), or with transmission at numerous synapses within the spinal cord, brainstem, cerebellum, basal ganglia, thalamus, primary motor or primary somatosensory cortex, or (in the case of smooth or cardiac muscle fibers, via visceral pathways to visceral centers in the above areas). We also know some brain centers have the ability to block the activity of other centers, which can include proprioceptive input.
Emotions can cause sudden lack of proprioception, and one of the most common is the case of feeling like you are going limp when suddenly feeling fear (some types of PTSD). This is a typical infant response (the “freeze” response) until control of limbs is achieved and the baby can move its own body to safety. There is no doubt that emotions are triggered when we dream and a brief loss of proprioception during dreaming can lead to sleep apnea by blocking pharyngeal muscle tone. See my blog post “Sleep–What it Does” for more on this topic.
There are emotional centers all over the brain, since they figure strongly in almost every physiological response that demands integration across systems and parts of the body. Furthermore, there are several centers which affect motivation, either by blocking an action until another center gets the go-ahead (red nucleus), or which act to increase the likelihood that the person will react to something (putamen). All of these are directly and indirectly affected by emotion as well. All of these centers operate at any time of day and night, thus affecting pharyngeal activity, and possibly leading to sleep apnea.
I mentioned that emotional reasons are usually also involved in sleep apnea. This happened to me. Since getting rid of most of my panic attacks, my sleep apnea has diminished to nothing on most nights. I had a small mouth (micrognathia) but the doctors didn’t do surgery for this condition when I was a child. However, I had constant terror attacks all while I was growing up, never realizing that it was unusual. My entire physiology had developed around these attacks. As a result, it wasn’t until I was an older adult before I learned that I had PTSD, since I had no clue why I should have felt terror. (See my blog posting on the functions of sleep at “Sleep–What it Does”)
Sleep apnea or dyspnea may result from fear of someone you know, characterized by a sudden failure in respiration, or decrease in rate, along with a sudden drop in blood pressure and heart rate. Most people know PTSD as characterized by the exact opposite responses to these, or a sympathetic response, normal for responding to situations and people you do not know. The symptoms I had were part of a pronounced parasympathetic response to someone terrorizing me who I did know and should have been able to trust. Infants show this as part of a fear response, which can change only when they are able to control their own movements (see my post Special Case of Type I PTSD: Rejected Children).
For more of my ideas on the functions of sleep see my blog post “Sleep–What it Does“.
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