Two Things That Go Flop In the Night, Making You Wake Up

Occasionally, I will see a patient that experiences obstructed breathing during sleep, but the way that they describe it is bit odd. In fact, when these patients try to describe what’s happening, most doctors may think that they are crazy. This is what happened to one such patient, who after undergoing major tongue and soft palate surgery for sleep apnea, he began to notice a sudden flapping sensation in the throat as he begins to inhale. After complaining repeatedly to his surgeon, he was told to leave the practice.  Another woman complained of difficulty breathing out through her nose during mid-exhalation, starting with a sudden flapping sensation. Both patients did not have any significant apneas on a sleep study.
However, while undergoing sleep endoscopy (looking with a camera at the upper airway while in deep sleep on the operating room), both patients had obvious problems. The first patient was found to have a floppy epiglottis that flopped back suddenly with each inhalation (see example video). The epiglottis is a cartilaginous structure that sits on top of the voice-box and just behind the base of the tongue. Due to either a weakened cartilage or change after surgery, it flops back, causing sudden obstruction at each inhale. This causes repeated obstructions and arousals, without leading to frank apneas or hypopnea. In general, these episodes happen more often while on your back (due to gravity) and when in deeper levels of sleep (such as REM, when your muscles are most relaxed).
The second patient was found to have her soft palate flop back up into the back of her nose during mid-exhalation (see example video). I’ve described this phenomenon in a past blog post. In both cases, the sudden blockage during inhalation or exhalation will lead to an arousal from deep sleep, any time your throat muscles are more relaxed. In some cases, the second phenomenon can be misinterpreted as a central apnea. Think about what happens when you strain mildly during a bowel movement. There’s no air moving through your mouth or nose, and there’s no movement of your chest or abdomen. In this particular situation, if it lasts for more than 10 seconds, it will be mis-scored as a central apnea.
Unfortunately, the standard options for sleep apnea (CPAP or dental appliances) won’t work as well, since these sudden blockages will keep waking you up. I’m not at a point where I can recommend surgery for these problems, but I have seen various degrees of success after trimming the epiglottis or stiffening the soft palate.
If either of these situations describe you, please leave a comment below.

Please note: I reserve the right to delete comments that are offensive or off-topic.

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12 thoughts on “Two Things That Go Flop In the Night, Making You Wake Up

  1. That’s interesting I should read this today Dr Park, as yesterday I was as inpatient in the Lane Fox Respiratory Unit at of Guy’s & St Thomas’ Hospital in London, and Dr Nicholas Hart pointed out I have similar issues to the 2nd patient you mention. I have a very small airway (only a small uvula) but a huge floppy soft palate and I can inhale through my nose (since my turbinates surgery), but my soft palate prevents me exhaling fully through my nose. This is also why I can’t use nasal masks with a chin strap, as I get interrupted sleep when I wake to prise open my mouth to let the excess air out. I am very nasally when I speak too, despite surgery for turbines (twice).

    I am now known as a ‘CPAP Failure’ which is rather ironic, bearing in mind I’ve spent years supporting others to remain 100% CPAP compliant, and I too religiously used mine for many years for my severe OSA. I was still having some O2 dips and retaining CO2, and I have now been changed to a VPAP machine and will be seeing ENT for an opinion too. I might add that I am a side sleeper always and this difficulty in exhaling nasally happens during the day too. Hoping the VPAP is going to help!

  2. I had a terrible time at my last dental appointment because I felt like I was suffocating. When lying on my back I cannot exhale through my nose. This is a recent development – I am 72 and have put on some weight. I think it might be caused by a floppy soft palate. My family has a mild strain of ocular-pharyngeal muscular dystrophy (diagnosed by a hospital research unit). My epiglottis is a bit ineffective too and I often get small food particles in my trachea.

    The nasal blockage on exhaling feels like trying to say the sound made by the letter “k” but getting stuck with no sound coming out. I hope that makes sense.

  3. Hi Dr. Park
    I did have a sleep endoscopy and it said that on my back I had obstruction from base of tongue and epiglottis. I have been struggling with sleep and life quality for about 13 years. I am non functional. I am your typical UARS person. I am 41 female thin and I have been diagnosed with Ehlers danlos hypermobility. What can I do other than piling on the meds. I have tried multiple pap machines and oral appliance… the results seem very inconsistent.
    Thank you
    Lara Taber

  4. I am closer to Ken O’Dwye’a comments and same age. To compound my problem I was in a car wreck in 1984 and the injuries included an aorta graft. At that time the surgeon cut the patient from the middle of back all the way to the middle of the chest. The surgery was a success and I lived, but when they did the surgery they cut one of the nerves to my vocal cord. So I only have one functional vocal cord and that has its own problems.

  5. Thank you. I have had three sleep apnea srudies and end up w obstrucrive and central. But I feel the actual closure of ‘something’ in my nasal airway which blocks my exhale. The result is a very unfulfilling nights sleep and a less functioning brain. It occurs when sleeping on my back. I prefer the back since my shoulders are weak and problematic. Any solutions Dr Park? This can also be a problem with certain breath in yoga.

  6. Mary Ann,

    I’ve had people read this post and go to their ENT but are told there’s nothing wrong with the soft palate. Because it’s not a published finding (yet), no one will acknowledge it. Unfortunately, the only thing that I’ve found potentially helpful is palatial surgery. The only way for me to recommend anything is a good history and exam in the office and possible sleep endoscopy.

  7. Hi Dr. Park
    I am very happy to hear you talk about EPO that hardly could find in Pub Med. It seems the nature of EPO is quite different from the standard OSA. Could you please talk more about it. What’s the ideal operational method of it? What may be the success rate? What’s the recurrence rate? Can we make a classification of OSA into Inspiratory and expiratory sleep apnea? Thank you for your help!

  8. Dr. Park,

    Can EPO create the vacuum effect to suction acid from the stomach the same way OSA or UARS does?

  9. Mary Ann, regarding your comment, I understand sleeping on the side is better but like you have problems because of an arthritic shoulder. You may have already tried this, but I have elevated the head of my bed with 3 bricks and sleep on 3 pillows. This does help me. People often comment on seeing my angled bed but honestly I do not notice it all when lying down. Best wishes & good luck.

  10. Ken,

    I totally agree with you on this. If you can’t sleep in your normal side position due to pain, injury or surgery, elevating the head of the bed (or using a wedge pillow) is the next best option. This can be tried before investing in an adjustable bed. Some people can only sleep in recliners.

  11. Paul,

    EPO is caused by expiratory positive pressure, so stomach juice is not suctioned up into the throat. But it can still cause arousals and CPAP intolerance.