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 video below).
 
 
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 video below).
 
 
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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26 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.

  12. At last I know what it’s called! I’ve been describing it as “reverse apnea” and getting funny looks. I had a home sleep study which found I have an AHI of 30 and severe desaturation (lowest oxygen 40%). I now have an APAP machine, which improved the numbers a lot but I could still feel the “door in my nose slam shut” when breathing out. It happens when I’m awake too, relaxed and reading a book in bed. Then I have to exhale through my mouth. Someone on facebook suggested turning off the EPR function on my machine. It worked nicely last night and I hope it stays that way.

  13. Hi dr Parks, i have mild sleep apnea and anxiety, however there is nothing mild about my sleep. I have downloaded one of your books, it has been an interesting read. Im not over weight, do not drink or smoke, have a sensitive digestive system so need to be careful with my diet…i pray For guidance where my sleep is concerned…im so frustrated because I have spent so much money in trying to find the right treatment.. 10 months ago i had a deviated septum corrected.. I breath much better, however the sleep issue is still there.. My sleep specialist looks at me although im crazy …Hes not sure what is really happening to me … I have lost faith in him and another one that i had seen when i was 37years old, im now 55! I have just started doing some exercises to possibly strenghten the epiglottis? I have read about it and also thought i would go to your site to aee what you had to say, so here i am .. Sick and tired of going to sleep at night 😢

  14. Julie,

    Sorry to hear. Unfortunately, I’m not aware of any exercises that will strengthen your epiglottis. There are exercise for your tongue and palate, however. Epiglottis problems are challenging to treat conservatively, without surgery. Another option that has not yet been proven is jaw enlarging dental appliances, which can pull the lower jaw forward.

  15. I have that same issue, except I don’t have to be asleep. There are times I am sitting up and I start feeling this turbulence in my airway on exhalation then all the sudden on exhalation it feels like something flies up and blocks my airway. It really is kind of freaky. An ENT caught it on video last week

  16. Dr. Park,
    While lying on my back awake I will feel something close at the back of my throat and It blockes off my air. I didn’t know how to describe it to my doctor and they just gave me steroids thinking it must be inflammation. I knew that wasn’t the problem though. It happens every time I lay down within a minute of or two and it will happen repeatedly as long as I live there. He keeps me from falling asleep.
    I went to a sleep doctor and had a home sleep test . It showed that I have mild sleep apnea. But I wasn’t able to lie on my back for the test because of what happens. I went and saw ENT and they did the scope down my nose. I couldn’t find any obstructions or anything.
    I went to the hospital find out what’s going on because I can’t fall asleep but maybe once every four days on my stomach because my throat will close up even on my side . The only thing they found with the scope was my vocal chords close when I feel my throat closing up. Of course they didn’t look at my throat through my mouth to see if anything was closing there, which is where I always feel it closed.
    So a few nights ago I had my husband video tape inside my mouth when I feel my throat closing off. So on exhale through my nose something will clamp shut when I opened my mouth the back part of my tongue was on the roof of my mouth, with the back of my throat being sealed off. Then I have to either open my mouth really wide to break the seal or stick out my tongue to be able to breathe. I cannot breathe out through my nose or mouth and less I do either of those things. Though I can still inhale through my nose one or two small times.
    Soon as I close my mouth and and inhale again it will do the same thing and The back half of my tongue will be up against the soft palate and I can’t breathe out unless I open my mouth wide or stick my tongue out. I’ve been dealing with this for months and I don’t know how to get help. I’m sleeping two days a week when I finally fall asleep out of pure exhaustion.

    No doctors are helping me. My sleep doctor said I have a type 4 mouth. How do I get help for this? No one has seen what happens on the roof of my mouth, they always look down my nasal passage. I’ve seen an ENT, and otolaryngologist , sleep dr. my blood pressure has dropped quite a bit, I get lightheaded dizzy upon standing, my hands and feet are always cold now, and I’m always freezing now when I was always hot before. I am a 52-year-old woman. I’m so stressed out, I don’t know where to go for help anymore!

  17. Ms. Tuzar,

    Sorry to hear about your situation. What you describe sounds like what I’m describing in the article. I will be writing another post about this subject shortly.

  18. Thank you for your comment Dr. Park,
    I went to see a ENT surgeon today. I told him what was happening and I said I would like to get tongue ablation or whatever surgery would help me be able to lie down without my soft palate area being closed Off.
    He was very condescending, and said that I might get that sensation of my throat being closed off but a CPAP will help.
    I told him it was not a sensation , that it seals off my uvula area. I told him that I have a video that my husband took while I was laying down to show what happens. He didn’t want to see it, and I could tell he didn’t believe me and didn’t care. I don’t know where to go from here . It’s costing a lot of money to go to all these different specialists.
    I even brought two of your articles about this, he didn’t want to see them, and didn’t care. I’ve never been treated so rudely. I told my husband about you and your articles and he said he would even drive me to New York, we live in Georgia, to consult with you and get me some help. I,m so scared because this happens every night continuously, not once an hour but as long as I lie down in any position.
    How can any surgeon dismiss someone who is going through something like that without checking to see what is going on? I even told him I’ve lost 25 pounds in the last six weeks from stress over this. He didn’t care.

  19. Hi Sherry. Your problem sounds more serious than mine but like you I could not find an ENT specialist who was interested.
    For some people the solution is quite simple. When going to bed you block both nostrils with tissue or cotton wool, for example. You will then automatically breathe through your mouth all night which avoids the palatal blockage.
    It might take a bit of getting used to but if people can adjust to wearing dentures every day you can adjust to blocked nostrils every night.
    If you suffer with dry mouth, there are solutions (such as Biotene) that you can rinse with to reduce the dryness.

  20. The exhalation one happens to me. On my back and sometimes even sitting upright. I am exhaling through my nose and it’s like a wall goes up and the air pushes out my closed mouth. Scary but yes, the dr said that is what you think is going on but that is not what is going on when I told her it was my nose openings to my throat obstructing not lower down. I’m miserable. I have had the sleep study and they are going to schedule me for the study about what mask and amount of airflow. I’m afraid it won’t work for this.

  21. Hi Ken, when I try plugging my nose my mouth makes loud snoring noises and it’s very difficult to breathe through my mouth. Just like when I lay on my back and breathe through my nose something in my mouth area closes off and I can’t breathe out.

  22. I got the idea of using nose plugs when I had a cold and both nostrils were blocked. My soft palate does not slam shut when breathing out through my mouth when my nose is blocked.

    If I don’t block my nose and fall asleep in my recliner chair while watching tv I wake up with a start feeling as if I am suffocating. Fortunately I can sleep on my side now which eliminates the expiratory palatal blockage.

    Going to the dentist is on my to do list but I haven’t been since this problem became pronounced. I’m wondering how breathing through my mouth will go when my mouth & throat are full of water, drill, etc.

  23. Dr. Park,
    They found a 2 cm nodule on my left thyroid and it’s enlarged and they found two nodules on my right thyroid I’m supposed to go for a biopsy. They also found some lesions on my cervical spine and I’m supposed to have a cervical spine MRI. I can’t do either of these because I would have to lay on my back, and something at the back of my mouth closes within a minute always. It doesn’t open back up on its own. It will continue to close almost nonstop as soon as I open it by opening my mouth and sticking my tongue out.
    It’s the only way to break the seal besides sitting straight up.I don’t know what to do because of the situation I described in my previous post. It also happens lying on my side awake it just doesn’t close all the way It just restricts my breathing.
    Do you know of any good head and neck surgeons in the Atlanta area that you could contact and describe my case to so I can get some help please. I don’t know what else to do.
    it showed on my home sleep study that I slept on my back one of the nights for an hour, which I didn’t I was awake and my throat kept closing and I had to keep forcing it open and it makes a loud snore sound and my uvula pops out from under my tongue and lands on top of my tongue. I know it sounds strange but that’s what happens I have it on video.I have a mallampati class 4 mouth.
    Something in there has changed in the last two months to cause this to keep happening. I’m scared because I need to get these tests done and I can’t lie on my back without having to sit up or force it open. I also need to have a wisdom tooth pulled and they would have to put me out for that and I can’t do that either my life is so scary now. I can give you my phone number or email if you would like to talk more. Please I hope you can help me.

  24. I experience expiratory palatal blockage but have found some help in using a bank of pillows and placing my head so that my face is tilted downwards.
    Before I fall asleep I consciously inhale longer & stronger than usual, then exhale slowly & less forcefully. This eliminates my palatal blockage and I am hoping it will continue while asleep.