Sore throat for 9 months... Help!

HI all. I'm here on behalf of my wife, who has OSA and started CPAP last April. The machine is a Philips Respironics One with a nose mask. It has a humidifier, which has generally been set to level 2. The pressure level is set to 7. The CPAP has dramatically improved her energy level; I suppose going from 25 events an hour to actual sleep will do that.

However, another issue has come up: She's a singer and voice actor, and around last July or August developed a sore throat from what an ENT described as silent reflux (LPR). She had a small case of reflux a few years ago, but 2 weeks of Protonix cleared it right up. This time, though, nothing helped the sore throat. She tried Omeprazole and Protonix in various strengths over a few months, and all she seemingly found out was that Omeprazole "changed" the pain, made it different, possibly a little worse. To be totally sure, she also went on a low-acid diet. Long story short, we aren't even sure it was ever reflux at this point. The sore throat remained, and now we're wondering if the CPAP has anything to do with it.

She doesn't get the throat-lump feeling, nor any heartburn. She says it's a more muscular pain on the inside of her throat, almost like it's bruised or pulled. She's had her larynx checked out by an ENT and a speech pathologist and there is no damage or inflammation there, but some of the muscles around her larynx show signs of tightness and inflammation. She's doing speech therapy and says her voice feels stronger, but the soreness hasn't improved. She's also getting massage therapy regularly, which has helped a few things but (of course) not her throat pain.

As I said, she uses a humidifier in her CPAP. It seems to do its job because her throat doesn't really feel dry. The cycle is weird, though. Her throat doesn't hurt much at all in the morning. As the day goes on through afternoon and evening, the pain starts to seep in. It's worse if she talks a lot, but only if she speaks using certain muscle groups. Strangely enough, it hurts even if she pretends to talk, just mouthing words and not even whispering. Singing hurts her least of all, but the pain is still a little prohibitive.

She doesn't really breathe much through her mouth at night that we know of, but she's going to probably try the chin strap anyway. We also tried setting the PR One to "Classic" humidification mode, where it applies more heat, and I'll find out how that went when I speak with her.

Anyone experienced anything similar while using CPAP? We're looking for any ideas you've got.

Thanks!

I had a sore throat for the first couple months on my CPAP but bumping up the humidifier to near max has helped it clear up for me (I live MN so the air is really dry in the winter and I started in Dec). The other thing to be aware of is that many people with OSA have been mouth breathers, both when awake and asleep. The sinuses just don't get used much when you breath like that. Because of this my throat was sore because it wasn't use to that much use, the pressure also opens up sinuses that my not have been opening in the past. As a result sinus infections are also quite common early on. I initially used a neti pot but updated to a sinus rinse squeeze bottle. Using the sinus rinse bottle several times a day helped the sinus infection clear up quickly for me but many people have to get on antibiotics for that.

For now I would suggest bumping up the humidity and checking to see if she has a mild sinus infection. I know some people get killer pain with infections, I just don't so it is work have it checked out.

Which particular PRS1 model does she have? It should say something near the display like "REMstar blahblahblah..."

If it's one of the good models, it records the leak rate, and you can look at the data with some free software and tell if she's leaking air through her mouth, which will tend to cause throat problems.

Sider wrote:HI all. I'm here on behalf of my wife, who has OSA and started CPAP last April. The machine is a Philips Respironics One with a nose mask. It has a humidifier, which has generally been set to level 2. The pressure level is set to 7. The CPAP has dramatically improved her energy level; I suppose going from 25 events an hour to actual sleep will do that.

However, another issue has come up: She's a singer and voice actor, and around last July or August developed a sore throat from what an ENT described as silent reflux (LPR). She had a small case of reflux a few years ago, but 2 weeks of Protonix cleared it right up. This time, though, nothing helped the sore throat. She tried Omeprazole and Protonix in various strengths over a few months, and all she seemingly found out was that Omeprazole "changed" the pain, made it different, possibly a little worse. To be totally sure, she also went on a low-acid diet. Long story short, we aren't even sure it was ever reflux at this point. The sore throat remained, and now we're wondering if the CPAP has anything to do with it.

She doesn't get the throat-lump feeling, nor any heartburn. She says it's a more muscular pain on the inside of her throat, almost like it's bruised or pulled. She's had her larynx checked out by an ENT and a speech pathologist and there is no damage or inflammation there, but some of the muscles around her larynx show signs of tightness and inflammation. She's doing speech therapy and says her voice feels stronger, but the soreness hasn't improved. She's also getting massage therapy regularly, which has helped a few things but (of course) not her throat pain.

As I said, she uses a humidifier in her CPAP. It seems to do its job because her throat doesn't really feel dry. The cycle is weird, though. Her throat doesn't hurt much at all in the morning. As the day goes on through afternoon and evening, the pain starts to seep in. It's worse if she talks a lot, but only if she speaks using certain muscle groups. Strangely enough, it hurts even if she pretends to talk, just mouthing words and not even whispering. Singing hurts her least of all, but the pain is still a little prohibitive.

She doesn't really breathe much through her mouth at night that we know of, but she's going to probably try the chin strap anyway. We also tried setting the PR One to "Classic" humidification mode, where it applies more heat, and I'll find out how that went when I speak with her.

Anyone experienced anything similar while using CPAP? We're looking for any ideas you've got.

Thanks!

Full face mask and more humidity. Or less humidity.

I sing semi-professionally and earn part of my living through speaking and voice-over work. When I started CPAP, I noticed that my jaw and throat felt sore also. My hunch, based on what worked to fix it for me, is that your wife may be holding some unnoticed tension in her throat musculature due to the mask or air pressure.

Some sessions with a voice coach who specializes in musculoskeletal technique could be valuable for her. That's what helped me - my coach watched for it and corrected me instantly whenever she'd see that I was tensing my throat or jaw. When your wife sings, her learned vocal technique is probably trumping most of whatever tension has otherwise developed.

It's also possible that she might be clenching her teeth. Usually that manifests as headaches or ear pain, but I have read and been told that it can also cause tension in throat muscles. I wear a bite guard at night because I'm a habitual clencher. Your wife might also want to consider discussing her symptoms with her dentist. I agree with others that upping the humidity would be good to try (or maybe lowering it, different people have different needs).

Overall, CPAP has helped my voice, once I got past those initial uh-ohs.

Thanks for all the feedback. We put the memory card back in the machine to check the leakage rate, and we're going to start by getting the chin strap. She's going to be looking for a new ENT, as two in a row have blamed reflux and then watched it miraculously disappear.... without the pain going away.

Her speech therapist says that there's still a lot of tension in her throat. Anyone tried a muscle relaxer? I can definitely tell you she's under a lot of stress, and this has just made things worse.

Another possibility may be "globus sensation" -- related to anxiety.

Has she tried a good course of antibiotics? Sometimes the doctors get so concerned with apnea and their fad diseases like GERD that they forget the obvious. They've also gotten so brainwashed not to do antibiotics that they sometimes don't try them when they should. One course of antibiotics over a two week period or so won't do any harm. Just don't let them give her Levaquin or Cipro without trying the safer antibiotics first.

I've had some persistent sore throat/sinus problems that go away with antibiotics. The doctors have sometimes been reluctant to give me anything, but I've had about 3 or 4 cases of this over the past 20 years where it cleared me up and didn't come back for years.

Press the doctor to consider the other possibilities and try all the reasonably safe and experiment with the reasonably safe and inexpensive treatments like antihistamines, antibiotics, etc.

A few days ago she put the memory card back in to check for mouth breathing. I now know that her machine (now in signature!) tracks data going back a few weeks. Not complete data, but enough to come up with some ideas.

Graphs from SleepyHead:
http://i.imgur.com/DYEds.png (Full data)
http://i.imgur.com/T9fQ3.png (Full data)
http://i.imgur.com/GOiiW.png
http://i.imgur.com/ceI0E.png
http://i.imgur.com/hMrOZ.png
http://i.imgur.com/owlP4.png

So, what does this look like to you? That bumpy leak graph is making me think mouth breathing, but it doesn't look massive, just... very inconsistent. Of course, I could just be reading it wrong. That's where I need everyone's help. Thanks!

I would stay away from muscle relaxants, they tend to negatively impact AHI. I took a Flexiril one night for some back pain and my AHI shot up from my normal 0.5 to around 7... they tend to relax the throat muscles and cause more apneas/hypopneas.

If you need to take them during the day, if it's an 8 or 12 hr dosage I'd try to make sure that it wears off before bedtime.

Sider wrote:Thanks for all the feedback. We put the memory card back in the machine to check the leakage rate, and we're going to start by getting the chin strap. She's going to be looking for a new ENT, as two in a row have blamed reflux and then watched it miraculously disappear.... without the pain going away.

Her speech therapist says that there's still a lot of tension in her throat. Anyone tried a muscle relaxer? I can definitely tell you she's under a lot of stress, and this has just made things worse.

Fwiw, I'd vote for a new ENT too. Good move.

Imho, you also have a good idea re. a muscle relaxants. I'm not a doc, but have been prescribed Valium in the past as a muscle relaxer when anti-inflammatory drugs just did not do the job. After two wasted months of time trying various anti-inflammatories and other things, he finally got around to Valium. Worked like a charm. In lieu of vocal muscles, mine were the muscles between vertabrae C5 and C6 and it made the months of tingling in my left thumb and forefinger ancient history.

As your singing wife is also under a lot of stress, this treatment should help out in more ways than just muscular. Again, imho and I'm not a doc. It's good of you to be out here shaking the bushes in her behalf.

Good luck to you both,
Papit

Thanks for confirming that. We're going to speak to this next doctor about it when she goes next week. In the meantime we're going the experimentation route. She's been more scratchy than usual in the past few days since she turned the humidifier up from normal-2 to classic-4 (extra heat), so she's going to completely remove the humidifier tonight (something she's never done) and try doing it that way. She grew up on the west coast and we live in NYC now, so the northeast is REALLY humid by her standards. Let's hope her throat agrees. Will keep updating, and could definitely use some analysis on those graphs.

Can anyone give feedback on the graphs I posted above? If we can have some idea of what problems could be present before the next ENT visit, we'll be ahead of the game in figuring out our options. Thanks!

Sider wrote:Can anyone give feedback on the graphs I posted above? If we can have some idea of what problems could be present before the next ENT visit, we'll be ahead of the game in figuring out our options. Thanks!

First a question: Pre-CPAP did your wife dislike sleeping under a fan? Did sleeping under a fan cause her any problems with her throat? Because if sleeping under a fan could lead to throat problems, then it is possible that the CPAP blowing air directly into her throat could be irritating it the same way a fan can.

Next, you ask for someone to comment on your graphs.

According to this chart from the PR site, your wife's mask appears to have an intentional leak rate of around 21 L/min at 7 cm of pressure. There is some variability from mask to mask and from person to person, but that gives you a basic idea of where the leaks should be.

Your wife's leak line looks really good on Feb. 12 from 2:30 to about 6:15 and less good after that. But even so, the unintentional leaks seem to stay below 10 L/min until it's close to 10:45 am. And so overall, I'd say that the leak line is decent enough for most of the night. When I have a leak line like this, I don't worry too much about it.

The leak lines on the other days look much more ragged, but keep in mind that SleepyHead choses a vertical scale that tends to make the bumps look worse than they are. Note the vertical scale on the leak graphs varies from day to day: The smaller the maximum Total leak, the smaller the vertical range, and the smaller the vertical range, the LARGER each unit in the vertical range is. On most of the days it seems that your wife's total leaks stay below 30 L/min most of the time, and hence her unintentional leaks are below 10 L/min most of the time. That's not enough to affect therapy. And I'd say that any mouth breathing she's doing is pretty minimal. However, she may be having some problems with her lips staying sealed and it could be that if the pressurized air is getting into her mouth cavity that it's forcing her lips to open ever so slightly now and then and that when her lips are slightly open, a bit of air leaks out. That's not really the same as mouth breathing---"lip pursing" may be a better way to describe what I mean.

So does your wife ever wake up with chipmunk cheeks? Or does she ever wake up feeling like she's got gas in her tummy or even further down? It's crude and unladylike, but I'll ask anyway: Does your wife ever seem to fart or burp a lot in the morning after she wakes up? Does she ever wake up with a significant amount of drool on her pillow?

I ask because some of these leak lines look rather like mine do when I've had problems swallowing CPAP air during the night. My tongue's normal resting position against the roof of my mouth. When it is up there, my tongue essentially seals my mouth cavity off from my upper airway and no air gets into my mouth or stomach: It all goes down my upper airway as it is supposed to. But when my tongue relaxes just enough to come off it's normal resting position, the pressurized CPAP air forces its way into my mouth. And one or more of the following happens: I swallow air, and get aerophagia and morning farting. Or I wake up with chipmunk cheeks, and have to turn my machine off, exhale the excess air, and then turn the machine back on. Or my lips will part ever so slightly, I'll leak a bit of air out, and if I'm lucky my tongue then goes back to the roof of the mouth and I don't notice anything until I wake up in the morning with either chapped lips, a dryish (but not bone dry) mouth, or drool on my pillow. And a more ragged than normal Total Leak line with the peaks somewhere between 5 and 10 L/min above my mask's intentional leak rate.

Now I'm not sure if "lip pursing" could be causing your wife's long term throat problems. For me, it causes chapped lips---and bad chapped lips---since the air movement is from the mouth and over the lips. And I'm not sure how much a chinstrap will help. If her jaw is dropping at night, then the chinstrap should help. But if the lips are just opening up without the jaw dropping, I'm not sure it will do much good.

As for other things that I've noticed in the given data:

The apnea appears to be well controlled at this pressure. There are no significant clusters of events. And the AHI is well below 5.

There's a bit of mild snoring, but even on the worst night for snoring (Feb. 5), it's pretty minor in its intensity. More evidence that 7cm is enough pressure.

The two days of wave flow data show a pattern with lots of spikes of larger than normal breaths. In other words, there are lots of places where there are sudden large inhales or sudden large exhales as compared to the baseline. In my own data, I sometimes see this on nights where I've done a lot of tossing and turning---in other words, when my full night wave flow looks spiky, I've often not managed to get into a good, deep sound sleep for much of the night. So that raises the question: How does your wife feel when she wakes up in the morning ASIDE from the sore throat? Does she feel as though she's getting into good, deep sleep night after night? Or does she still feel as though she's been tossing and turning all night?

My throat gets sore when I breathe through my mouth. I would try the chin guard or full face mask first if the humidity thing doesn't work.