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Sleep Apnea Diagnosis in... a Restaurant?!

My sleep certified physician once let me in on his little secret: he can diagnose Sleep Apnea in a person while sitting across a crowded room from that person in a restaurant. Now, he qualified this by saying that he'd only be able to do so with 85% accuracy, but still... it came as quite a shock to me. Especially when he told me how he'd do it. It wasn't by looking at their waistline or gut. It certainly wasn't from hearing them snore. No, he'd do it just by looking at their jaw. If it were narrow enough, he'd be fairly certain they had sleep apnea. No polysomnography or home test involved. The narrower the jaw structure, he reasoned, the more crowded the airway, and the more likely breathing problems while asleep would occur.

Which dispels one of the myths about Sleep Apnea: that it's a disorder for overweight, middle-aged men. I myself am not overweight (I am 6 feet tall and weigh 179 pounds); and I'm not middle-aged (I just turned 35), but I have Sleep Apnea. My friends who have Sleep Apnea don't fit the mold either. They're my age, and pretty fit.

I think Sleep Apnea is under-diagnosed in people who don't fit the mold. Doctors are all too human, and it's a rare general physician who is on the lookout for Sleep Apnea to begin with. Even when they are educated about Sleep Apnea, they're looking for the "usual suspects" -- overweight, middle-aged men. As the medical profession becomes more educated and aware of Sleep Apnea, this will change. When doctors start approaching fit young women with narrow jaws at restaurants, we'll know the day has come.

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Comment by Tim on July 18, 2010 at 6:52pm
I just got back from a week long event near Boston where there was a large number of large men in attendance. The ages ranged mostly from about 30 to 66 (with some on both sides), many were overweight; but not morbidly obese. Many were muscular, and many were both overweight and muscular. I made it a point to ask other attendees if they had sleep apnea; a not surprisingly large number of the men I talked to had severe sleep apnea and were on CPAP. It was actually a good way to get to know people, because through word of mouth, guys were coming up to me to talk about CPAP.

None of the men I talked to had any particular problems with using CPAP, although one guy had to try a couple masks to get one that he liked (he was also the only mouth breather). Very few of the guys used a humidifier; almost all of the guys said that they don't use a humidifier because it is a "pain in the a@@". Several guys had backup batteries for their CPAP and several more were looking at getting a battery.

One thing that I found was unusual is that nobody carried their machine in the manufacturer provided bag; everybody carried them in bags such as normal carry-on bags, computer bags, and large camera bags (I use a camera bag). One guy carries his CPAP equipment in a large aluminum briefcase with custom fitted foam inserts.
Comment by Jo E on May 1, 2010 at 3:26pm
Dr. Park, Thanks so much for that comment! I wish that you could convince all PCPs. I was a very underweight child. My mother frequently got angry at me for not waking up easily in the morning. She told me that I was obstinate (one of the nice words she used) when I didn't just hop out of bed in the morning. She punished me by making me go to be right after supper. Being in bed from 6 p.m. to about 7 a.m. when I was 9 only caused me to wake up with severe headaches. My mother told me the headaches were punishment from God for being such a bad person. Then I became an adult and could go to a doctor on my own. Each PCP I complained to that I was tired all of the time, checked my thyroid. Every test came back normal, so I was always told there was nothing wrong with me, I just needed to get more sleep. (And wake up with splitting headaches? No thanks, Doc!) About five years after my current PCP tested my thyroid, my husband diagnosed my OSA. I had to fight my PCP to get a sleep test. Before the test, the sleep dr told me that I could cure myself by losing weight (I'm not skinny anymore). After he saw the results of my test, he sent me to an ENT. I had a too much tissue in the soft palate (mallampati class 3/4), a severely deviated septum, Haller cells bilaterally, and hypertrophy in the inferior turbinates. He said that no amount of weight loss could help my OSA because my nasal passages and my throat were narrower than most adults are, as well as having too much tissue in the soft palate. I have been through a number of surgeries to correct what problems can be corrected. I can finally breathe fairly well. In spite of having my ethmoid and maxillary sinuses surgically cleared out, a septoplasty, a submucosal inferior turbinoplasty, and a UPPP, my nasal passages and my throat are still narrow. After I was diagnosed when I was in my 50s, my mother said it ran in the family and several of my cousins had been diagnosed and treated by the time they were in their teens and 20s.

Perhaps all PCPs should be required to take a continuing education class on "Sleep Apnea: An Underdiagnosed Disorder in Women, Underweight, and Pre-Middleaged People." The subtitle would be "Dump Your Preconceived Notions."
Comment by Amy on February 4, 2010 at 12:17pm
I do the same thing. It is teh jaw and the neck that is the give away. I think it is underdiagnosed in women as well. I think that the televison info that is shared is that it is the middle age overweight male problem.

In fact as I was watching The Biggest Loser the other night and they showed the contestants on their CPAP machine they were all the men. They did not show the women. On the talk shows the people who use it are the men usually overweight.

Someday I hope that people will realize that this is a disorder that affects many types of people.
Comment by D. W. Conn on August 3, 2009 at 11:10am
This does ring true. The ectomorph, mesomorph, and endomorph have the same rates of sleep apnea. Obesity and/or being underweight can enhance a person’s probability of having Apnea or other sleep disrupting disorders.
Marfan's syndrome a disorder of the circulatory system, it too may have an amplifying affect on sleep disorders such as sleep apnea.
Genetics, Diet, and Environment.
Comment by sleepycarol on January 4, 2009 at 4:49pm
Very interesting!!
Comment by Steven Y. Park, MD on January 4, 2009 at 4:35pm
Mike, your sleep doctor is absolutely right. Sleep apnea is ultimately a bony jaw structural problem. In the obvious patients, small, narrow jaws (side-to-side or front-to-back) by definition means that the airway will be smaller. Think of if this way: If the total volume inside your mouth is on the small side, then your tongue and voice box, which grow to their normal size, takes up too much space. So when you're on your back, your tongue falls back due to gravity, but because of the smaller space to begin with, the tongue falls back even more, and when you add deep sleep, it collapses due to muscle relaxation. This is why most people with small jaws prefer not to sleep on their backs.

If you have normal jaws and gain a lot of weight, then the fat in your throat and soft palate narrows the throat, leading to the more stereotypical OSA type that snores. But if your jaw is more narrow and your tongue keeps falling back, either you'll keep waking up without snoring, or later on, create a vacuum effect upstream, causing the soft palate to collapse and flutter.

This is why we now know that even young, thin women that don't snore can have significant obstructive sleep apnea. More often, however, they will have upper airway resistance syndrome, where they stop breathing and wake up repeatedly but the episodes are not long enough to be called an apnea, since it doesn't last longer than 10 seconds. These are the people who have very low AHIs but are tired all the time, no matter how long they sleep. Later on, as they gain weight, they'll progress into true sleep apnea.

Most dentists agree that there's much more dental crowding these days than in the past. There are a few interesting theories about why this is happening: A dentist named Weston Price, in his book, Nutrition and Physical Degeneration, found that indigenous people living off the land without Western influences had wide jaws and perfectly aligned teeth, with no cavities. Once they started to adopt Western processed foods and refined sugars, their children's jaws became more crowded. Another interesting theory is that with the introduction of bottle-feeding, the abnormal swallowing mechanism can cause dental crowding.

Unfortunately, most doctors still think that you have to be a heavy-set, snoring, middle-aged man with a big neck to have sleep apnea. This is why 90% of people with sleep apnea are not diagnosed.

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