Category Archives: Unique Content

Sleep Apnea and the Hazards of Driving

The NTSB recently finished up their review of a fatal train derailment in New York.  What they found is that the driver actually fell asleep behind the wheel while driving the train.  He reached speeds of 82mph in a 30mph section of track.  As a result the trail derailed and four passengers lost their lives.

After the accident the driver was diagnosed with obstructive sleep apnea syndrome (OSA) and treated.

Sleep apnea has many causes but a common end point of causing physical blockages in the throat and upper airway in the deepest phases of sleep.  This causes (sometimes drastic) fluctuations in blood oxygen levels, blood pressure, and heart rate.  These fluctuations eventually cause the brain to “snap you out of it” causing a slight awakening, usually just to a lighter phase of sleep and allow the patient to take a breath and temporarily restore breathing.

When this happens over and over through the night many symptoms develop.  Usually among the first is being extra sleepy, or hypersomnolence, through the day.  While this may be no more serious than an afternoon nap, it also causes hundreds of thousands of automobile accidents a year.

The body also responds very poorly to fluctuations and chronic dips in oxygen levels.  This leads to elevated risks of sudden heart attack, fatal arrhythmia, or even stroke.  Blood pressure will start to creep upwards (hypertension), and the patient may begin to suffer from depression.  Rising levels of adrenaline at night may also cause enuresis, or the need to urinate often through the night.

Treatment options for OSA are varied.  The best studied and “most reliable most of the time” treatment option is positive airway pressure (PAP, CPAP or BiPAP).  Other options such as oral appliance therapy and surgery also have proven benefits are typically considered when PAP therapy fails.  Mild snoring is at times effectively treated with cauterization type procedures that may be done in the office.  Recently however these cauterization or ablation procedures have been taken far out of context and I now hear them advertised on the radio to treat all kinds of true sleep apnea.  Beware!  Usually these procedures are not covered by insurance and basically are useless moneymakers!

If you are concerned about severe snoring or sleep apnea, we can help you arrange testing either from an Atlanta-area sleep lab or even from home most of the time.

Sleep Well!

Sinus Infections: Is Balloon Sinuplasty Right For Me?

Chronic sinusitis affects tens of millions of patients annually (including my own household). Over the years we have continued to refine treatment options, both medical and surgical. The latest incarnation of surgical treatment is the use of small balloon catheters (taken from the cardiac angioplasty world) to more gently stretch the sinus openings, usually done in the office. I did my first balloon procedure in 2006 in the operating room and in 2010 in the office. Now I do them exclusively in the office.

This technique has two distinct advantages: a) improved safety from “surgical misadventure” or anesthesia complications and b) almost zero downtime from work and school.

The big disadvantages are that in many cases the balloons simply “aren’t enough” to adequately solve the problem. A badly deviated septum, ethmoid sinus infection, nasal polyps, and allergies are problems not treated with balloons.

Personally I use balloons for treatment often in the office, citing the advantages above. For certain localized infections, milder infections, and frail patients this is an awesome tool.

However our busy practice sees lots of “second opinion” consults after unsuccessful treatment elsewhere. Many of these patients simply need a more aggressive surgical option. And unfortunately many of these patients were “sold” on balloon treatment for purely economic reasons.

There is an unfortunate trend in my community for certain ENT’s to buy tv/radio advertising to market their balloon treatments. Why? This procedure pays well and only takes a few minutes. Some doctors have built an entire practice around doing this.

The problem is abuse and mismanagement. Just this past week I have seen: a)a patient who got 7 procedures in six months for what turns out to be migraines not even infections, b) another patient with three procedures in 1 year, and c) a patient who got a balloon procedure after a 5 minute initial consultation with never having tried antibiotics or having gotten a CT scan – she actually suffered from allergies without any sign of infection (she stated the procedure only took about 10 minutes altogether which means she probably even had a sham operation).

So yes, I am a fan of balloon dilation for many of my patients. I only hope that the technology does not get crushed by the misuse and overuse that is becoming rampant. I have had some great successes with balloons, even for severe infections, but like any other surgical tool it must be used properly.

Good luck with your sinuses and beware of ANYBODY pitching a medical procedure on the radio :)

The latest in high tech digitial hearing aids

Last month my practice partners and audiology staff went up to Minnesota to tour the Starkey headquarters.  Starkey is the leading manufacturer of fully custom and programmable off-the-shelf digital hearing aids.  Their worldwide headquarters is just outside of Minneapolis.  What an impressive facility!

It is amazing to see exactly how their 24 hour operation can receive orders and construct a 100% customized hearing device in less than 4 days.

Key technology that allows this is the massive computing and hardware power allowing for fully customized 3D digital modeling and rapid stereo lithography (“3D printing”).  Furthermore, round-the-clock engineers and technicians are manually placing the tiny microprocessors and components into your custom aid before going through a final round of quality testing.

Equally impressive are two separate wings of the campus: a truly high-tech troubleshooting and quality control lab that is charged with making aids more durable and determining causes for failure.  An array of photomicrography and cross sectioning instruments allows the lab to pinpoint potential microchip failures, while several micro environments have been created to artificially “age” devices to ensure they remain salt, water, and wax resistant.

Their second remarkable facility is full-on R&D.  Starkey spends almost $100M annually on research and development, the majority of which happens in Minnesota and California.  The labs work on tweaking current projects as well as developing the devices that won’t be ready for another 5 years or so.  This includes everything from industrial design of the shells, to microcircuitry, to microphone/receiver research, to Bluetooth wireless, to iPhone apps.

For Starkey’s robustness in quality, design, and service we see them as a strategic partner for ensuring a truly optimal experience for our patients.

The days of lousy poorly-fitting noisy hearing aids are numbered!

Feature with Dr. Forman: Cardiovascular Risk of Sleep Apnea

This week I had the opportunity to meet with Dr. Mervyn Forman, a distinguished Cardiologist and innovator in metro Atlanta.  Dr. Forman’s medical practice covers the spectrum of cardiovascular disease prevention and long-term management, while his research has focused on reducing heart muscle damage after a heart attack.  He is currently developing a drug coated guidewire for use during stent insertion. 

Dr. Forman sees a number of patients on a daily basis with obstructive sleep apnea that may be complicating their cardiac disease.  I sought Dr. Forman’s perspective on sleep apnea, as he in fact has daily hands-on experience treating the cardiovascular end-effects in his patients.  Our Q&A session is below, revised into a more printer-friendly format.  Dr. Forman can be reached at his medical practice in the Atlanta area on Northside Hospital campus: 960 Johnson Ferry Rd NE, Suite 530, (404)446-1900.  He also consults in East Cobb county.

WHAT ARE THE CARDIOVASCULAR COMPLICATIONS OF OBSTRUCTIVE SLEEP APNEA?

                Obstructive sleep apnea (OSA) is a common chronic disorder with a major effect on morbidity and mortality.  Sleep encompasses about one third of one’s life and induces physiological changes in the human body to rest the cardiovascular, respiratory, and metabolic systems.  OSA is now recognized as an important risk factor for cardiovascular disease.  Hypertension, coronary artery disease, heart failure, heart rhythm (fast and slow) abnormalities, cerebrovascular disease, and diabetes have all been shown to be linked to sleep disorders.  OSA is therefore one of the most prevalent and dangerous cardiac risk factors we know of. 

WHAT ARE THE CHANGES THAT OCCUR WITH OSA THAT AFFECT THE CARDIOVASCULAR SYSTEM?

                Repetitive closure of the upper airway during sleep results in a number of hemodynamic and biochemical derangements which effect the cardiovascular systems.

1.)     Exaggerated swings in the pressure in the chest which impairs filling on the left ventricle (pumping chamber) results in decreased blood pumped to the organs of the body.

2.)    Activation of the portions of the nervous system that affect heart rate and blood pressure (arterial and in the lung circulation).

3.)    Activation of tissue chemical factors which result in the formation of numerous inflammatory mediators and oxygen free radicals which promote damage to blood vessels, activate the blood clotting system and promote cholesterol (plaque) deposits in the blood vessel walls.

CAN UNTREATED OSA AFFECT MY BLOOD PRESSURE (BP) AND WILL TREATMENT IMPROVE THE CONTROL AND REDUCE THE NUMBER OF BP MEDICATIONS?

                There is strong evidence that OSA is an important factor in hypertension (high blood pressure).  This occurs in both sexes, all age groups, all ethnic groups and in obese and non-obese people.  OSA increases both systolic (top) and diastolic (lower number) pressure.  OSA also results in the loss of normal decrease in blood pressure that occurs at night.  It is estimated that 50% of OSA patients have hypertension and OSA often plays a role in patients whose BP is refractory to BP medications.  Treatment with continuous positive airway pressure (CPAP, a therapy for OSA) results in significant decreases in day and nighttime BP, improves control of refractory hypertension and reduces the number of medications required to achieve a normal BP. 

CAN OSA CONTRIBUTE TO CORONARY ARTERY DISEASE (CAD) AND INDUCE A HEART ATTACK?

                There is a strong correlation between OSA and the development of CAD and acute coronary syndromes (heart attack).  65% of patients admitted to the hospital with a heart attack were found to have OSA.  Patients who suffer a heart attack in the early hours of morning (midnight to 6 am) are more likely to have OSA (32%) verses those without OSA (7%).  This is due to OSA producing stress on the heart secondary to the increase heart rate and BP and by increasing the propensity of the blood to form clots.  The co-existence of CAD and OSA worsens the prognosis resulting in 70% increase in death, stroke and heart attack.  Patients with OSA undergoing stent insertions also have a higher risk of death (38%), stent narrowing (70%), and heart attack and stroke (12%).  Nocturnal angina (chest pain) is associated with OSA and CPAP diminishes the frequency of chest pain attacks.  There is also evidence that treatment of OSA may prevent heart attacks and delay progression of plaque buildup in the heart blood vessels.    

CAN OSA PRODUCE AND EXACERBATE HEART FAILURE?

                OSA affects almost half of heart failure patients.  While the relationship is complex, OSA essentially induces the risk factors that lead to the development or exacerbation of heart failure (hypertension, CAD, diabetes, pulmonary hypertension).  Furthermore heart failure can cause and worsen obstructive and central sleep apnea initiating a potentially devastating cycle.  Treatment with CPAP has been shown to significantly improve pump function (ejection fraction), reduce heart size and BP, and improve quality of life. 

CAN OSA LEAD TO HEART RHYTHM ABNORMALITUES AND CAUSE SUDDEN CARDIAC DEATH?

                OSA results in low blood oxygen, abnormalities of autonomic nervous system and changes in the structure of heart muscle which predispose to heart rhythm abnormalities.  OSA is strongly associated with the common heart rhythm abnormality, atrial fibrillation, occurring in 40-70% of patients.  Atrial fibrillation (AF) is an important cause of stroke and heart failure.  OSA is responsible for 25% greater risk of AF recurrence following catheter ablation procedure.  OSA is also linked to other cardiac rhythm abnormalities including a slow heart rate, heart block, fast heart rhythm abnormalities and malignant ventricular arrhythmias.  People with OSA have a dramatically increased risk of sudden cardiac death during sleep.  Treatment with CPAP decreases nocturnal rates of slow heart rate and cessation of electrical pacemaker activity, atrial fibrillation, and dangerous fast heart rhythm abnormalities.

WHY IS WEIGHT LOSS IMPORTANT TO REDUCE THE CARDIOVASCULAR COMPLICATIONS OF OSA?

                Obesity is the single most important risk factor in the development of OSA.   A 10% increase in weight gain is associated with a 6-fold increase in the odds of developing OSA.  Obesity and OSA often coexist with more than 40% of obese patients having significant OSA and 70% of OSA patients being obese.  The link between obesity and cardiovascular disease has been well established.  Obesity induces numerous and similar mechanisms to OSA that can lead to cardiovascular disease including hypertension, heart failure, coronary artery disease, atrial fibrillation, diabetes, and sudden cardiac death.  Therefore the pressure of OSA in obese patients would be expected to place them at higher risk for cardiovascular events than obese patients without OSA.  Aggressive weight reduction programs in addition to treatment of OSA with CPAP is essential to reduce cardiovascular complications of OSA. 

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I want to thank Dr. Forman for his kind and thorough collaboration on this post, and I encourage you to visit Dr. Forman for further assessment of your cardiovascular disease risk.