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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2 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!