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.

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

  1. Ms. Morgan,

    Great to hear that you found some answers. The dental option seems like a good idea, to potentially treat your sleep-breathing problem. It should help with the epiglottis as well, but the only way to know is to try it. Epiglottic obstruction can also cause acid to come up into the throat, potentially leading to aspiration pneumonia. It’s also known to lead to sleep position dependent partial obstruction which can lead to noises. In this situation, I generally recommend a drug induced sleep endoscopy. Good luck.