Mystery solved! ever heard of "palatal prolapse" (new article)?

Really interesting thread. My dad has similar obstructive patterns. Any updates on your progress, yrnkrn?

jnk... wrote: ↑

Thu Jul 05, 2018 8:40 am

Recognizing the location and mechanism of airway narrowing and airflow routing may be interesting, but it is, to the best of my knowledge, not significant for titration of airway-pressure-based treatments for OSA.

The study adds to knowledge of mechanism and location, but it is not clinically significant beyond that, as far as I can see. EFL or no EFL, the gold standard remains well-titrated and well-executed PAP therapy.

Obstruction may occur first in a particular way in a particular location, but experience has shown that if you simply try to surgically, or otherwise, address the dynamics of one location, obstruction for the OSA-prone patient then just begins to occur at the next location in the airway most prone to obstruction. This is one of the primary reasons that surgical and jaw-position approaches to OSA are much less successful than PAP.

You don't mean to imply that surgical interventions and PAP therapy are mutually exclusive, right? Shouldn't the different therapies work adjunctively? I don't know if jaw surgery would contraindicate PAP therapy, I haven't heard of such a thing. Also doesn't jaw surgery fix multiple points of obstruction? My memory is rough, but I've read that bimax surgery has a very high success rate at upwards of 90% and a cure rate of about half of that.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

You don't mean to imply that surgical interventions and PAP therapy are mutually exclusive, right?

Nothing in my quoted comments implies that, but it is true that palate surgeries are considered a contraindication for APAPs that use flow shapes to discern airway status.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I don't know if jaw surgery would contraindicate PAP therapy, I haven't heard of such a thing.

I, too, am not aware of MMA, for example, being considered a basis for any PAP contraindications. But why would the average OSA patient go through it just to continue PAP use?

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

Also doesn't jaw surgery fix multiple points of obstruction?

That may depend on one's definition of "multiple."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I've read that bimax surgery has a very high success rate

That may depend on one's definition of "success."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

cure rate of about half of that.

Initial cure rate is one thing. Long term, another. Severe OSA rewires the brain to ignore narrowing. Surgery does not correct that.

That said, if someone is brave enough for jaw surgery and is willing to suffer the pain and risks of such a major procedure, they have my blessing. Palate surgeries, not so much.

More to the point of my post as quoted, my point was that one should not misinterpret a study about recognizing signs of a specific palate issue as being a study that is relevant for PAP choices and pressure choices. That is not what that study is about. Recognizing the specifics of an anatomical problem is not always relevant to meaningful diagnostics and customizing treatment choices in the context of present technologies. "Interesting" does not always equal "meaningful" for decision-making. That was my only point. I just tend to be overly wordy and ambiguous.

Sorry about that.

jnk... wrote: ↑

Sat Jul 07, 2018 8:36 pm

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

You don't mean to imply that surgical interventions and PAP therapy are mutually exclusive, right?

Nothing in my quoted comments implies that, but it is true that palate surgeries are considered a contraindication for APAPs that use flow shapes to discern airway status.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I don't know if jaw surgery would contraindicate PAP therapy, I haven't heard of such a thing.

I, too, am not aware of MMA, for example, being considered a basis for any PAP contraindications. But why would the average OSA patient go through it just to continue PAP use?

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

Also doesn't jaw surgery fix multiple points of obstruction?

That may depend on one's definition of "multiple."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I've read that bimax surgery has a very high success rate

That may depend on one's definition of "success."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

cure rate of about half of that.

Initial cure rate is one thing. Long term, another. Severe OSA rewires the brain to ignore narrowing. Surgery does not correct that.

That said, if someone is brave enough for jaw surgery and is willing to suffer the pain and risks of such a major procedure, they have my blessing. Palate surgeries, not so much.

More to the point of my post as quoted, my point was that one should not misinterpret a study about recognizing signs of a specific palate issue as being a study that is relevant for PAP choices and pressure choices. That is not what that study is about. Recognizing the specifics of an anatomical problem is not always relevant to meaningful diagnostics and customizing treatment choices in the context of present technologies. "Interesting" does not always equal "meaningful" for decision-making. That was my only point. I just tend to be overly wordy and ambiguous.

Sorry about that.

I hear you. I didn't read the studies to see if they're about recommending changes in pressure settings in response to anatomical specificities.

xPAP after MMA - I guess ideally MMA would obviate the use of PAP therapy, especially for patients who are PAP-intolerant. Shot in the dark, but what about cases where people whose required pressure settings cause issues like complex apnea, aerophagia, pressure insensitivity, leakages, discomfort etc. I could see MMA make a large difference in the quality of sleep and hence the quality of life for those patients even if it doesn't cure them. MMA does not have to be all or nothing, its main goal should be to decrease symptoms and minimize systemic damage to the body. If that entails bringing PAP therapy to a level above inadequate then that's very meaningful.

Success and cure rate of MMA - Success is >50% reduction of AHI to <20/H. Do you think that's too modest? But at 90% success rate and >40% cure rate, it seems tempting to roll the dice. What have you found about the long-term outcomes of MMA?

jnk... wrote: ↑

Sat Jul 07, 2018 8:36 pm

More to the point of my post as quoted, my point was that one should not misinterpret a study about recognizing signs of a specific palate issue as being a study that is relevant for PAP choices and pressure choices. That is not what that study is about. Recognizing the specifics of an anatomical problem is not always relevant to meaningful diagnostics and customizing treatment choices in the context of present technologies. "Interesting" does not always equal "meaningful" for decision-making. That was my only point. I just tend to be overly wordy and ambiguous.

Trying to figure out what is causing these waveforms and how/if they could be treated with air pressure. So far no luck.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 11:56 pm

jnk... wrote: ↑

Sat Jul 07, 2018 8:36 pm

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

You don't mean to imply that surgical interventions and PAP therapy are mutually exclusive, right?

Nothing in my quoted comments implies that, but it is true that palate surgeries are considered a contraindication for APAPs that use flow shapes to discern airway status.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I don't know if jaw surgery would contraindicate PAP therapy, I haven't heard of such a thing.

I, too, am not aware of MMA, for example, being considered a basis for any PAP contraindications. But why would the average OSA patient go through it just to continue PAP use?

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

Also doesn't jaw surgery fix multiple points of obstruction?

That may depend on one's definition of "multiple."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I've read that bimax surgery has a very high success rate

That may depend on one's definition of "success."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

cure rate of about half of that.

Initial cure rate is one thing. Long term, another. Severe OSA rewires the brain to ignore narrowing. Surgery does not correct that.

That said, if someone is brave enough for jaw surgery and is willing to suffer the pain and risks of such a major procedure, they have my blessing. Palate surgeries, not so much.

More to the point of my post as quoted, my point was that one should not misinterpret a study about recognizing signs of a specific palate issue as being a study that is relevant for PAP choices and pressure choices. That is not what that study is about. Recognizing the specifics of an anatomical problem is not always relevant to meaningful diagnostics and customizing treatment choices in the context of present technologies. "Interesting" does not always equal "meaningful" for decision-making. That was my only point. I just tend to be overly wordy and ambiguous.

Sorry about that.

I hear you. I didn't read the studies to see if they're about recommending changes in pressure settings in response to anatomical specificities.

xPAP after MMA - I guess ideally MMA would obviate the use of PAP therapy, especially for patients who are PAP-intolerant. Shot in the dark, but what about cases where people whose required pressure settings cause issues like complex apnea, aerophagia, pressure insensitivity, leakages, discomfort etc. I could see MMA make a large difference in the quality of sleep and hence the quality of life for those patients even if it doesn't cure them. MMA does not have to be all or nothing, its main goal should be to decrease symptoms and minimize systemic damage to the body. If that entails bringing PAP therapy to a level above inadequate then that's very meaningful.

Success and cure rate of MMA - Success is >50% reduction of AHI to <20/H. Do you think that's too modest? But at 90% success rate and >40% cure rate, it seems tempting to roll the dice. What have you found about the long-term outcomes of MMA?

This is so easily suggested as a solution, and if it works for the rest of your (hopefully long) life, maybe it’s worth it. Be aware that this is major surgery that not only changes how you breathe, but how you look, how you feel, how you eat, and also your dental health may be negatively affected, and you’ll need to be concerned about infections and using antibiotics for other things in the future, because you’ll most likely have titanium screws implanted. Your jaw muscles will likely not feel/fit like they used to after the surgery, and all of this is if it all goes perfectly. Remember all surgeries have a non-zero chance of fatalities as well, so balance that into calculations.

I can’t say how many people have had this particular surgery (let alone those using this site), but due to a congenital deformity, about 23 years ago I had surgery to extend my lower jaw 7 mm forward and 1.5 mm to the right, which is just the bottom half of this. Note also you should expect numbness (possibly permanently) on parts of your face from cut nerves and the like (I still have numb areas to this day). My surgery went very well, but I still had my jaw wired shut for a bit of time, and with having other health issues related to what I could eat, I lost a lot of weight, even though it wasn’t for all that long: I’d be surprised if this didn’t require a rather lengthy time of your jaw being wired shut.

I realize this is marginally derailing or maybe not since MMA increases maxillary space and the distance between the velum and the velopharynx, but Snoregone, how are you faring with your jaw after all these years? Did you run into any complications so far with TMJ, dental health, infections, etc? How does it feel nowadays moving your jaw for an extended time? As for the mortality rate for MMA, it's so far been zero. So far.

Back to palatal collapse, besides pharyngeal flap surgeries that may contraindicate PAP therapy (IDK, I'm seeing people on forums who've done UPPP and still use PAP), does weigh loss do anything to abate this issue? My dad is obese and gets massive leaks due to mouth breathing. Are these events causing you to mouth breathe, yrnkrn?

love2sleep69 wrote: ↑

Sun Jul 08, 2018 1:20 am

Are these events causing you to mouth breathe, yrnkrn?

Mouth is taped, no leaks or mouth breathing. As an alternative, I plan to try the DreamWear full face.

love2sleep69 wrote: ↑

Sun Jul 08, 2018 1:20 am

I realize this is marginally derailing or maybe not since MMA increases maxillary space and the distance between the velum and the velopharynx, but Snoregone, how are you faring with your jaw after all these years? Did you run into any complications so far with TMJ, dental health, infections, etc? How does it feel nowadays moving your jaw for an extended time?

Back to palatal collapse, besides pharyngeal flap surgeries that may contraindicate PAP therapy (IDK, I'm seeing people on forums who've done UPPP and still use PAP), does weigh loss do anything to abate this issue? My dad is obese and gets massive leaks due to mouth breathing. Are these events causing you to mouth breathe, yrnkrn?

I prefer to quote who I’m talking to so they know they’ve been replied to, and so others can be sure, too whom the parties are when things get complex.

Before I get stuff done in the mouth, I should be taking antibiotics, ahead of time, though I’ve been lax in that.

I’ve never felt like things have mated quite right, and part of that is, I’m sure, the jaw being adjusted to one side, so it’s never going to feel balanced left-to-right.

I can have stuff on parts of my face and be completely unaware of it.

One of my sisters did state after the surgery that my speech was easier to understand, at least S sounds, but... well, family will say things that may or may not be as it appears. Be aware that changing the size/shape of your mouth may require at least partially learning how to speak again. Perhaps it’d be one of those good news/bad news situations: good that sleep problems are reduced and people can’t hear you snoring so much, etc. bad in that people can’t understand you as well as before! On the other hand, perhaps your speech clarity may be improvd, and people will beg for you to shut up

Because my jaw wasn’t properly lined up to start with (malocclusion) afterwards, it’s been easier to chew, since things have lined up better. More than anything, from seeing others in my family have serious dental problems including eventually needing dentures, it was a self-preservation/engineering decision for risks: I calculated my chances were better for long-term keeping my teeth (and all that goes with keeping your teeth, as oral health greatly factors into general health, and studies have shown that) by getting braces and the jaw surgery than by not. At the time I underwent this course of treatment, my medical coverage was via an HMO (HealthSource, IIRC) and they tend to be notoriously cheap on what they cover: imagine my surprise when they deemed it medically-necessary and they’d cover it! My memory is the surgery and several days of hospital stay cost more than my 93 Saturn SC2 when I bought it new (makes me wonder what MMA surgery costs when that’s taken into account for how much more involved it is, and inflation...).

I’d expect both patient and insurance companies would have a rather high barrier to cross before this is given serious consideration due to all that’s involved: for the insurance company, they’d want to be sure no cheaper solution (for them, financially) exists that works for their insurance claimee and, presumably, getting it treated this way is going to cost them less than not doing this attempt at solution. Seems to be sleep studies, new CPAP machines every 5 years and supplies are cheaper in comparison, and also have a far higher treatment success rate for those that are compliant, and for those that fail to meet compliance? They cut their losses quickly enough: it’s just business, though, logically, those not properly treating sleep apnea are going to incur quite a bit more of medical expenses, as long as they keep living.

love2sleep69 wrote: ↑

Sun Jul 08, 2018 1:20 am

pharyngeal flap surgeries that may contraindicate PAP therapy (IDK, I'm seeing people on forums who've done UPPP and still use PAP),

If that statement was based on mine earlier, it doesn't represent exactly what I said.

UPPP is listed at times as a contraindication for APAP, but it is not, to the best of my knowledge, a contraindication for CPAP. Just APAP.

Remember, docs often view APAP as something run wide open, 4 cm as min. Normally snoring or certain flow shapes increase the pressure for effective treatment. UPPP can interfere with that process. Not always. But often enough to get it listed as a contraindication.

In relation to MMA, although it is a major surgery, I consider it the most effective OSA surgery, myself. But only if an experienced doc assesses chances of success and performs it would I recommend its being done. And I am not brave enough to consider it for myself.

jnk... wrote: ↑

Sun Jul 08, 2018 5:02 pm

love2sleep69 wrote: ↑

Sun Jul 08, 2018 1:20 am

pharyngeal flap surgeries that may contraindicate PAP therapy (IDK, I'm seeing people on forums who've done UPPP and still use PAP),

If that statement was based on mine earlier, it doesn't represent exactly what I said.

UPPP is listed at times as a contraindication for APAP, but it is not, to the best of my knowledge, a contraindication for CPAP. Just APAP.

Remember, docs often view APAP as something run wide open, 4 cm as min. Normally snoring or certain flow shapes increase the pressure for effective treatment. UPPP can interfere with that process. Not always. But often enough to get it listed as a contraindication.

Is that a long term contraindication?

Yrnkrn, how are you doing lately? I upped my Dad's min pressure by 2cm on his AirSense 10 but I don't think I'm seeing a difference with these EFL patterns so far.

love2sleep69 wrote: ↑

Tue Jul 10, 2018 2:22 pm

Yrnkrn, how are you doing lately? I upped my Dad's min pressure by 2cm on his AirSense 10 but I don't think I'm seeing a difference with these EFL patterns so far.

Same as before, thanks. Ordered the DreamWear full face and will try it.

love2sleep69 wrote: ↑

Tue Jul 10, 2018 2:22 pm

Is that a long term contraindication?

I am unaware of a firm consensus on that. I believe different docs have differing opinions on that. Much as is the case with APAP in general.

With the aid of a nightly HD (1080P) IR video, I can say this



is an arousal (head position change, nostril scratch) for unknown reason followed by swallows (adam's apple movement), while here



there was no visible sign until an arousal (cheeks de-puff, head position change, nostril scratch) at 02:11:15, so we can assume palatal prolapse caused arousal.

We can see the difference in waveforms. While swallowing, flow completely stops (as it must) and quickly resumes normal expiration and when "palatal prolapse" the flow plateau most of the expiration and fully resumes next inspiration after the palate falls back.

Another example for consideration by the collective. I have run across only a few cases like this, and I'm coming up empty on advise.

Snoregone Conclusion wrote: ↑

Sun Jul 08, 2018 12:46 am

love2sleep69 wrote: ↑

Sat Jul 07, 2018 11:56 pm

jnk... wrote: ↑

Sat Jul 07, 2018 8:36 pm

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

You don't mean to imply that surgical interventions and PAP therapy are mutually exclusive, right?

Nothing in my quoted comments implies that, but it is true that palate surgeries are considered a contraindication for APAPs that use flow shapes to discern airway status.

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I don't know if jaw surgery would contraindicate PAP therapy, I haven't heard of such a thing.

I, too, am not aware of MMA, for example, being considered a basis for any PAP contraindications. But why would the average OSA patient go through it just to continue PAP use?

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

Also doesn't jaw surgery fix multiple points of obstruction?

That may depend on one's definition of "multiple."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

I've read that bimax surgery has a very high success rate

That may depend on one's definition of "success."

love2sleep69 wrote: ↑

Sat Jul 07, 2018 8:04 pm

cure rate of about half of that.

Initial cure rate is one thing. Long term, another. Severe OSA rewires the brain to ignore narrowing. Surgery does not correct that.

That said, if someone is brave enough for jaw surgery and is willing to suffer the pain and risks of such a major procedure, they have my blessing. Palate surgeries, not so much.

More to the point of my post as quoted, my point was that one should not misinterpret a study about recognizing signs of a specific palate issue as being a study that is relevant for PAP choices and pressure choices. That is not what that study is about. Recognizing the specifics of an anatomical problem is not always relevant to meaningful diagnostics and customizing treatment choices in the context of present technologies. "Interesting" does not always equal "meaningful" for decision-making. That was my only point. I just tend to be overly wordy and ambiguous.

Sorry about that.

I hear you. I didn't read the studies to see if they're about recommending changes in pressure settings in response to anatomical specificities.

xPAP after MMA - I guess ideally MMA would obviate the use of PAP therapy, especially for patients who are PAP-intolerant. Shot in the dark, but what about cases where people whose required pressure settings cause issues like complex apnea, aerophagia, pressure insensitivity, leakages, discomfort etc. I could see MMA make a large difference in the quality of sleep and hence the quality of life for those patients even if it doesn't cure them. MMA does not have to be all or nothing, its main goal should be to decrease symptoms and minimize systemic damage to the body. If that entails bringing PAP therapy to a level above inadequate then that's very meaningful.

Success and cure rate of MMA - Success is >50% reduction of AHI to <20/H. Do you think that's too modest? But at 90% success rate and >40% cure rate, it seems tempting to roll the dice. What have you found about the long-term outcomes of MMA?

This is so easily suggested as a solution, and if it works for the rest of your (hopefully long) life, maybe it’s worth it. Be aware that this is major surgery that not only changes how you breathe, but how you look, how you feel, how you eat, and also your dental health may be negatively affected, and you’ll need to be concerned about infections and using antibiotics for other things in the future, because you’ll most likely have titanium screws implanted. Your jaw muscles will likely not feel/fit like they used to after the surgery, and all of this is if it all goes perfectly. Remember all surgeries have a non-zero chance of fatalities as well, so balance that into calculations.

I can’t say how many people have had this particular surgery (let alone those using this site), but due to a congenital deformity, about 23 years ago I had surgery to extend my lower jaw 7 mm forward and 1.5 mm to the right, which is just the bottom half of this. Note also you should expect numbness (possibly permanently) on parts of your face from cut nerves and the like (I still have numb areas to this day). My surgery went very well, but I still had my jaw wired shut for a bit of time, and with having other health issues related to what I could eat, I lost a lot of weight, even though it wasn’t for all that long: I’d be surprised if this didn’t require a rather lengthy time of your jaw being wired shut.

Lifelong ache in your jaw whenever the weather changes. If your sensitive to the ansethic, like me, remember when you wake up your jaw is wired shut. That means for the entire time you better not get sick because you can't puke, your choices are to swallow it back down if you can or choke maybe if they get to you in time they can snip the wires but then more surgery and longer healing. It is a miserable experience and here a I am nearly 30 years later on a bilevel at high pressure. I spent years in braces despite the surgery. I would never recommend it !