The Little-Known Breathing Problem That Many Doctors Miss

And It's Not Sleep Apnea, UARS, or Asthma

What if I told you that there’s something in your throat that can block your breathing 20 to 30 times every hour while sleeping, but almost never gets correctly diagnosed. This breathing problem doesn’t show up on formal sleep studies. It’s not sleep apnea or upper airway resistance syndrome, and it’s not asthma. 
The epiglottis 
This breathing problem may be due to a floppy epiglottis. Your first question might be, “What’s an epiglottis?” The Greek prefix epi- means on, over, near, around, or before. The glottis describes your vocal folds and the space between the two folds. The epiglottis is a structure that sits just above your vocal folds, just in front of the back of your tongue (see figure 1). It’s made of cartilage (like your ear) and covered with mucous membranes. It’s thought to protect your airway from food going down your windpipe when you swallow. 

                                 Figure 1. Epiglottis

One of the interesting things that I see quite often during drug induced sleep endoscopy is the epiglottis flopping back with each breath in, causing total occlusion. It’s like a one-way valve-like flap. Sometimes, patients can even demonstrate it in the office. When you see it’s quite dramatic (see video below). 
This situation is formally called laryngomalacia, which is much more commonly seen in infants. In most cases, children outgrow this problem, but sometimes need surgery. One recent study found that a floppy epiglottis was the most common reason for persistent OSA after adenotonsillectomy in children. For unexplained reasons, we are now seeing much more of this in adults. One possible explanation is because we’re now doing drug-induced sleep endoscopy. 

Click the photo above to play video. Jaw thrust at the end of video showing improved airway.

However, here’s my take on why we’re seeing more problems with the epiglottis for the following reasons.
3 Reasons for your floppy epiglottis
1.  Shrinking jaws. I’ve commented for over 10 years that human jaws are shrinking, especially in modern, Western countries. This is the main premise of my book, Sleep Interrupted: A physician reveals the #1 reason why so many of us are sick and tired. The smaller the jaws, the more narrow the airway due to soft tissue crowding. The epiglottis is attached in the front to the hyoid bone, a c-shaped bone that sits on top of your voice box, and is attached to the lower jaw. So the more recessed your lower jaw, the more your hyoid bone and epiglottis is positioned backwards. This is also why most modern humans can’t sleep on their backs. 
2. Our bones and cartilage are getting weaker. Osteoporosis, which is much more common now than decades ago, doesn’t just start when you turn 65. It’s a result of problems that starts when you are born. Perhaps even before you are born, due to the your mother’s health status during pregnancy. This is just conjecture, but based on my interpretation of the published research on the detrimental effects of glyphosate on bone formation, it’s also likely to affect proper cartilage development. This is evidenced by a higher rate of lax and hypermobile joints in our children, as well as higher rates of broken bones.  Glyphosate can prevent optimal bone formation by altering chondroitin sulfate synthesis in your cartilage and bones. This may be due to glyphosate’s ability to bind essential minerals such as manganese, which is a metal that’s required for the enzymatic reaction for producing optimal bones and cartilage.
3. Fluoride. Adding fluoride to our drinking water has been hailed as a public health success story. However, there are tomes of studies showing that even small amounts of fluoride may have detrimental effects on brain and bone development. For example, adding fluoride to drinking water to rats given braces showed significantly less widening. Other studies suggest less quality bone development when exposed to fluoride. Any toxin, chemical, or even lack of oxygen during development that diminishes optimal jaw and hyoid bone growth may predispose to a floppy epiglottis.
A combination of less forward jaw growth and weakened cartilage can potentially lead to the epiglottis flopping back with each inhalation during sleep, causing frequent arousals from deep to light sleep. These obstructive episodes are usually too short to be picked up as an apnea or hypopnea on sleep studies. 
How to diagnose and treat a floppy epiglottis
So far, the only way to formally make a correct diagnosis is to undergo sleep endoscopy, where your airway is observed during light sedation in the operating room. It can occur by itself or along with other areas of obstruction such as the soft palate, tonsils or tongue base.  Pushing the lower jaw forward during sleep endoscopy (similar to using a mandibular advancement device) helps most of the time, but not always.
Then what’s the solution?  A mandibular advancement device may help, but the only only way to know if it is going to work is to try it.  The jaw thrust maneuver during sleep endoscopy (shown in video above) can guide you on whether is may be a good idea. The ideal way of treating this is to either grow your jaws using advanced orthodontic or functional appliance options. These options may help in theory, but it can take up to two years, with no guarantees. Jaw surgery is another option but not feasible or practical for most people. The only treatment that works relatively quickly is to trim a portion of the epiglottis, or attach it to the back of the tongue base with a stitch. Like many sleep apnea procedures, it works most of the time, but not always, depending on how severe the epiglottis obstruction or if there are other areas of obstruction.  
The greatest concern for removing the epiglottis is aspiration, where food goes down your windpipe. Although it’s possible in theory, I have yet to see it in my practice. I perform about 2 to 3 such cases every month. More up to date research suggests that swallowing problems are not as much of a concern than previously thought. 
Finding the right surgeon
It’s likely that if you approach an ENT surgeon about this possibility, you may get mixed reactions. Not every ENT surgeon performs sleep endoscopy. There are also widely differing opinions on how to address a floppy epiglottis. Even if you’re sure that you feel like that there’s a flap inside your throat that’s keeping you from getting a good night’s sleep, you’ll likely get a get a puzzled look from your physician or surgeon. This has been reported to me by a number of of my patients, who usually don’t have sleep apnea confirmed on sleep studies, but are extremely tired and suffer from severe anxiety.  CPAP usually won’t work since you can’t breathe in due to the valve-like effect.
More often than not, a floppy epiglottis is seen along with multiple other areas of obstruction. All these areas must be addressed as well using any of the options mentioned above for the floppy epiglottis. If you suspect that you may have a floppy epiglottis, you may have to do some leg work and find an ENT surgeon who is open to this possibility, as well as being comfortable with various treatment options. I have a pediatric neurologist who sends me many of his patients with headaches, but only mild or no sleep apnea confirmed by sleep study testing. Oftentimes, when I treat the floppy epiglottis, the headaches improve significantly or go away completely. 
In an upcoming article, I will describe another valve-like process that can happen in your throat, but during exhalation.

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6 thoughts on “The Little-Known Breathing Problem That Many Doctors Miss

  1. From my sleep endoscopy, my two sites of obstruction were behind the tongue and epiglottis. My SNB is 78deg, however, which is borderline normal (I even had room for fully erupted wisdom teeth). Two oral surgeons told me my tongue was too big and one explained it happened due to my open bite. I’d guess the problem of overgrown soft tissue is also to blame, not just small jaws.

  2. I think discussion of small jaws is oversimplified here. Jaw growth can be grouped into three dimensions: horizontal, vertical, and transverse. We have great options for correcting transverse discprenacy when discovered in childhood, using palatal expansion. Sadly, it’s only used in extreme cases with orthodontic camouflage chosen otherwise. Missing horizontal growth can potentially be addressed by protraction but doesn’t work well via the traditional route, using tooth-borne protraction. Dental side effects and limited efficacy. Bone anchored maxillary protraction holds a lot of promise. To my knowledge, there exists no solution for missing vertical growth, that is a steep angled occlusal plane. That is a common and big problem, since even with normal dimensions between the soft tissue the airway will still be prone to collapse due to the elongated upper airway. I haven’t seen any evidence but it may be that protraction causes a leveling of the occlusal plane as well. The evidence for any orthopedic correction in adults is weak, in my view.

  3. Could you say more about the”valve-like process that can happen in your throat, but during exhalation”? I snore during exhalation, and am beginning to think that the bite guard I wear for bruxism is a contributing factor by pushing my lower jaw back. Thanks.

  4. Greg,

    I’ve written extensively about expiratory palatal obstruction. It can be complete or partial. With partial obstruction, I’ve seen palatal vibration during nasal exhalation which can lead to snoring during exhalation.

  5. I guess the problem of overgrown soft tissue is also a blame, not just a small jaw.The two oral surgeons told me that my tongue was too big and one explained it happened due to my open bite.