By Howard Stupak, MD
Most futurists and predictors in healthcare discuss increased technology, more apps, home healthcare, better training, personalized medicine, gene therapy, AI for more efficiency…
In other words, more of the same, just faster, bigger and more easily accessible.
But, what if we stand back a bit and think about whether we are even on the right track in disease treatment, or as in prior eras in medicine (eg bloodletting, frontal lobotomies, etc), perhaps we are headed rapidly, more efficiently and grandly down an incorrect (or only partially correct) track.
I like to look at paradigms…By paradigms, I mean the really big picture…sure technology will progress, and we will certainly have cooler, more high tech tools, scanners, robots and drugs.
But what if our understanding of disease is incomplete and we are generally aiming our treatments at imperfect targets?
Wait a second, you say…how could our best and brightest minds end up on an incorrect pathway in such a large scale?
It is due to excessive “compartmentalization”!
Compartmentalization is essentially breaking scientific concepts into specialized disciplines, where each specialist tends to see only what pertains to their field, without considering other fields. For example, a patient with poor sleep due to airway structural dysfunction who resultantly developed headaches and fatigue might see a headache specialist, a chronic fatigue specialist, a dentist, an ENT and more may be diagnosed with multiple specific ailments within each practitioner’s specialty. Sapolsky discusses an analogous breakdown in the neurologic, behavioral and biologic sciences field.
Rethinking disease paradigms of the airway was born in me not from an interest in paradigms, but from frustration…
As physicians, we give steroids or surgery for inflammatory conditions of the upper airway from sinus disease to laryngitis, and antibiotics for infections of the airway tonsillitis to middle ear infections. Almost never, beyond considering “who we caught it from”, or considering trendy dietary causes (gluten-free, paleo diets, etc) do we even attempt to determine the actual physical origin of these conditions!
Curiosity, (and research) led me to consider a unified hypothesis as a cause of all of these conditions, acute and chronic.
Let’s start with a question…
What really triggers the inflammatory or infectious process of the upper airway from sinus disease to ear infections, to laryngitis…Rogue bacteria and mean-spirited inflammatory cells? Or, perhaps something else entirely, and the bacteria and inflammatory cells that we know are part of it may just be secondary actors or opportunists?
What if the whole infection/inflammation cause of disease is actually backwards, and is the secondary result that we treat and not the cause?
Let me give some examples…
How many of you have been diagnosed at one point or another with:
Sinusitus, tonsil enlargement, nasal allergies, or laryngitis? Ear infection? How about sleep apnea?
Needed sinus surgery, turbinate surgery, adenoids or tonsils removed?
What if you found out that we were only treating the result and not the origin of the problem, unfortunately just improving symptoms temporarily in many cases, and not stopping the problem at its generation!
Have I delivered enough background? Ready for the answers?
It all starts with…Gravity, Vacuums, and Facial Structure. Simple physical things without a lot of high tech!
It is well documented in the anthropology literature that the facial bones (the maxilla and mandible, or upper and lower jaws) are much shrunken in us flat-faced homo sapiens (humans) compared with the huge snouts of our ape-like ancestors. As a matter of fact, these bones seem to be diminishing more even during the course of human history! There are many reasons why this change may be occurring, and determining the exact cause is outside the realm of this discussion, but the actual occurrence is not controversial…Most current thinkers from dentists to anthropologists believe it is related to evolution of our diet, with increase food processing, beginning with primitive cooking in fire to current mass over-processing of grain requiring less jaw structure for less chewing. More recently, however researcher Richard Prum presents the concept that it may be less an adaptive change to processed food than simple preferential selection for human mating for individuals with smaller jaws. This may be a reflection of a taste for mates for reduced testosterone (and thus violence and forced mating), as testosterone is an agent responsible for more prominent facial bony structures like the jaws.
Either way, our current tapered and refined jaw structure compared to our distant ancestors may look good, but has a resultant side-effect that varies by degree of structural petite-ness: Mouth breathing.
Our large-jawed ape-lie ancestors had no trouble keeping their jaws closed with such a large projecting snout permitting their chewing functions to take place far forward from their breathing passage in the back of their throat. Their tongues had plenty of room to operate, and their jaws mechanically were optimized for chewing and staying closed.
But, many modern humans have small jaw structure with a highly domed roof of the mouth (high arched palate), and a tongue that is too big to fit inside at rest. Because of the more protruding, and acute angle of the larger jaws of our ancestors, and apes, the jaws remained closed even with the opening downward pull of gravity, compared to our less acute, more obtuse jaw angles that tend to hang down open more readily.
The smaller jaw mechanically is at a disadvantage to stay open because of its shape, and like an over-stuffed hard-shell suit-case, drops open when we sleep because our resting muscle tone is reduced, and we are not forcing the mouth shut, so gravity takes over and opens the mouth! Jaw shape matters too: A jaw that is at a nearly ninety degree angle from the side view (Gonial Angle) will remain closed, with upper and lower teeth touching even at rest. At greater angles, the jaw remains open without the use of muscular force, and thus during sleep with low tone, there is more jaw opening.
Further, as the snout got smaller, the nasal structures which emanate from the forehead remained the same size. This resulted in an extrusion of the nasal cartilages into what we see is the prominent human nose compared to the flat-nosed ape ancestors. In cases of very small jaw bones though, the nose structures or septum fail to fit completely, creating a buckling or deviation of the septum which blocks the nasal air passage.
Thus, the combination of structural nasal blockage and a tendency for jaw relaxation due to structural and gravitational problems creates a problem or long-term night time mouth-breathing…
So what? The mouth isn’t so bad for breathing, right? It gets the job done. Except that it is NOT good for breathing at all. The final role that gravity plays is that the tongue and palate will “fall backwards” to block the airway, also due to gravitational forces!
Amazingly, astronauts were tested for sleep related obstructions on earth, and then in micro-gravity conditions. Their sleep apnea and snoring were nearly cured demonstrating the important role of gravity! (Am J Respir Crit Care Med. 2001 Aug 1;164(3):478-85.)
So, what are the other factors?
The upper airway is actually a forked structure, with the nose one fork, and the mouth another fork, connecting together in the throat behind the tongue. The lungs inspire, or breathe in via a vacuum effect created by chest expansion. This vacuum, or negative pressure is transmitted into the throat, and then into the mouth or nose, forcing air to rush toward the lungs. However, if the mouth is open, all of the air rushes through only the mouth, and the nose is left with just the vacuum effect.
And what does a vacuum or negative pressure environment do to the nose? It wreaks havoc, similar to placing the end of a vacuum cleaner against your skin. So, the tissue and lining inside the nose are sucked into the air passage, and mucous is sucked out of the lining or skin. This sucking of tissue creates many manifestations, and going back to the compartmentalization we discussed, creates different problems depending on what part is getting the worst sucking, and the degree of the vacuum effect, and depends on who is looking…
For example, the vacuum creates redness and mucous inside the nose, that might get diagnosed as allergies. If the vacuum transmits in a patient to the air-cavities of the cheeks (sinuses), this will cause fluid to build in the sinuses, and the patient will be diagnosed with sinusitis. If repeated vacuum injury causes the wall of the throat to thicken, the patient will be diagnosed as having grown an adenoid or tonsil. Why the inflammation/infection that we see so prominently? Well, the vacuum effect causes sudden or repeated trauma of various force to the tissues it effects, and the body responds to this trauma with inflammation. The micro-organisms, or bacteria that colonize us also respond to the repeated tissue injuries and use the resultant breaches in our tissue lining to invade new territory and cause infection!
How did we get this so wrong? A few reasons…
Most importantly, we may have the order of events completely backwards. About 30 to 40 years ago, very limited monkey studies were performed that urged scientists and dentists at the time to believe that nasal obstruction from growth of the adenoid throat pad in the back of the nose was the CAUSE of poor facial growth, and not vice-versa. This became very well established, and to this day, most specialists recommend removing the tonsils and adenoids to prevent facial growth disturbances, even though both the logic and science behind it are quite limited. And unfortunately, there is not a huge financial incentive in most fields to question the utility of common surgical procedures!
Do we have huge amounts of evidence for this? Not yet. But, we are collecting data and publishing using fluid/structure interaction airflow dynamics, and many others have published supportive data of various forms. Christian Guilleminault has spent a lifetime studying the effects of facial structure on sleep apnea. And, the negative pressure in the throat, and damage to the elastic structure of tissue from the vacuum effect have all been well documented.
So, now that it is all explained, what do we do different??? Our strategy is just one phrase, and involves neither high tech, nor AI:
To avoid the vacuum-effect damage, (and its resultant inflammation and infection) keep the “Nose Open and Mouth Closed!”. That’s it! The specifics are endless, and as long as we stick to our strategy, they can include many modalities.
For example, a garment, strap, or tape can support the chin in its closed position at night if comfortable. A nasal strip available at the pharmacy or a stenting tube can dilate the nostrils. Alternatively, combining nasal surgery to open the airway at the nostrils and septum combined with a mouth-closing oral appliance can do the job too. CPAP is common but unpopular, but forces air under positive pressure to overwhelm the negative pressure effects of the vacuum. This can be an inefficient and uncomfortable but very effective way to sleep. Expanders of the jaws, either via surgery or orthodontics can be effective too!
An individuals own creativity in finding their own DIY solution is the only limitation. So, next time you think about anti-inflammatories, or antibiotics for upper airway disorders, think twice about treating the origin of the problem, and not just the result!