The gold standard for recognizing palatal prolapse is to observe it during an endoscopic study[1][2][5]. Due to the invasiveness of the procedure, palatal prolapse may inferred[1] by analyzing the nasal expiratory flow obtained from nasal cannula or a CPAP machine. A repeating abrupt ceasing of expiration nasal air flow near maximal flow may indicate palatal prolapse while a single event may represent a swallow. Due to further reduction in muscle tone in REM sleep[12], palatal prolapse may be especially disruptive to this sleep stage.
Unlike sleep apnea or hypopnea, palatal prolapse usually does not result in desaturation. However, the palate movement by itself may be quite dramatic, resulting in arousals[1][3]. These disrupt the sleep structure and may cause insomnia.
There is no standard treatment for palatal prolapse. CPAP is not very effective due to the one-way valve operation of the soft palate but may still be required concurrently to treat other collapse sites. Paradoxically, CPAP may even aggravate the collapse due to the improved air flow during inspiration. Gabapentin significantly increased the mean AHI[16] possibly through myorelaxation and may have similar effect on palatal prolapse. Pressure reduction on exhalation: EPR, C-Flex or Bi-Level PAP reinforces the expiratory flow, pushing the palate like a sail in the wind and is likely to worsen the prolapse. Mandibular Advancement Splints (MAS) oral appliances were not effective[8][9].
PEEP (Positive end expiratory pressure) is the pressure applied by a mechanical ventilator at the end of each breath so the alveoli will not collapse. PEEP is called EPAP with BiLevel machines or simply the set pressure in CPAP machine. PEEP was shown to be effective in treating palatal prolapse[5] : given pressure, the retropalatal area expands and is less blocked during expiration.
Other possible treatments, not all are compatible with CPAP therapy:
CPAP users discuss palatal prolapse at:
[1] Ali Azarbarzin, Scott A. Sands, Melania Marques, Pedro R. Genta, Luigi Taranto-Montemurro, Ludovico Messineo, David P. White, Andrew Wellman. Palatal prolapse as a signature of expiratory flow limitation and inspiratory palatal collapse in patients with obstructive sleep apnoea. European Respiratory Journal 2018 51: 1701419; DOI: 10.1183/13993003.01419-2017
[2] Dr. Steven Park. Expiratory Palatal Obstruction. Doctor Steven Park Blog, https://doctorstevenpark.com/epo
[3] Dr. Steven Park. Two Things That Go Flop In the Night, Making You Wake Up. Doctor Steven Park Blog, https://doctorstevenpark.com/2things
[4] Shiroh Isono. Two valves in the pharynx. European Respiratory Journal 2017 50: 1701496; DOI: 10.1183/13993003.01496-2017
[5] M. Okuyama, S. Kato, S. Sato, J. Okazaki, Y. Kitamura, T. Ishikawa, Y. Sato, S. Isono, Dynamic behaviour of the soft palate during nasal positive pressure ventilation under anaesthesia and paralysis: comparison between patients with and without obstructive sleep-disordered breathing, British Journal of Anaesthesia, Volume 120, Issue 1, 2018, Pages 181-187, ISSN 0007-0912
[6] C. W. Buffington, C. M. Q. Wells and R. J. Soose. Expiratory Upper Airway Obstruction Caused by the Soft Palate during Bag-Mask Ventilation. Open Journal of Anesthesiology, Vol. 2 No. 2, 2012, pp. 38-43. doi: 10.4236/ojanes.2012.22010
[7] David R. Hillman, Jennifer Walsh, Kathleen Maddison, Peter R. Platt, William J. Noffsinger, Peter R. Eastwood. Airway Collapse or Closure via the Soft Palate as Mechanism of Obstruction in Sedated Patients?. Anesthesiology 2010;112(2):497. doi: https://doi.org/10.1097/ALN.0b013e3181c99a0e
[8] Kenny P. Pang, Brian W. Rotenberg, B. Tucker Woodson. Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea, pp 34.
[9] Daniel Vena, Ali Azarbarzin, Melania Marques, Sara Op de Beeck, Olivier M Vanderveken, Bradley A Edwards, Nicole Calianese, Lauren B Hess, Reza Radmand, Garun S Hamilton, Simon A Joosten, Luigi Taranto-Montemurro, Sang-Wook Kim, Johan Verbraecken, Marc Braem, David P White, Scott A Sands, Andrew Wellman, Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow, Sleep , zsaa004, https://doi.org/10.1093/sleep/zsaa004
[10] Okuno, K, Ono Minagi, H, Ikai, K, et al. The efficacy of nasal airway stent (Nastent) on obstructive sleep apnoea and prediction of treatment outcomes. J Oral Rehabil. 2019; 46: 51– 57. https://doi.org/10.1111/joor.12725
[11] Hirata and Satoh. Pilot Study of a Nasal Airway Stent for the Treatment on Obstructive Sleep. ApneaJ Sleep Disord Ther 2015, 4:4, DOI: 10.4172/2167-0277.1000207
[12] Alon Y. Avidan, Teri J. Barkoukis. Review of Sleep Medicine, 3rd Edition, pp. 80. Elsevier, 11 Oct 2011
[13] F. A. WALTON; PALATAL EXPIRATORY OBSTRUCTION. Anesthesiology 1953;14(3):315
[14] Vena D, Azarbarzin A, Marques M, et al. Predicting sleep apnea responses to oral appliance therapy using polysomnographic airflow. Sleep. 2020;43(7):zsaa004. doi:10.1093/sleep/zsaa004
[15] A. Azarbarzin, S.A. Sands, M. Marques, P. Genta, L.T. Taranto-Montemurro, L. Messineo, D.P. White, and A. Wellman. Palatal Prolapse on Expiration Predicts Inspiratory Palatal Collapse in Patients with Obstructive Sleep Apnea.A30. UPPER AIRWAY DYNAMICS: INSIGHTS FROM HUMAN AND ANIMAL STUDIES. May 1, 2018, A1244-A1244
[16] Taranto-Montemurro L, Messineo L, Wellman A. Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med. 2019;8(11):1846. Published 2019 Nov 2. doi:10.3390/jcm8111846
[17] Povolotskiy R, Abraham ME, Leverant AB, Bresler A, Paskhover B. Complications of Palatal Pillar Implants: An analysis of the MAUDE database and literature review. Am J Otolaryngol. 2020;41(1):102303. doi:10.1016/j.amjoto.2019.102303
[18]Dellweg A, Kampmann M, Tschopp K. Evaluation of a nasopharyngeal stent in patients with obstructive sleep-related breathing disorders. J Int Med Res. 2022 Jan;50(1):3000605211073302. doi: 10.1177/03000605211073302. PMID: 35062854; PMCID: PMC8796092.
[19] Okuno K, Ono Minagi H, Ikai K, Matsumura Ai E, Takai E, Fukatsu H, Uchida Y, Sakai T. The efficacy of nasal airway stent (Nastent) on obstructive sleep apnoea and prediction of treatment outcomes. J Oral Rehabil. 2019 Jan;46(1):51-57. doi: 10.1111/joor.12725. Epub 2018 Oct 21. PMID: 30281824.
[20] J. Sumner1, P. Hyuett2, H. Yang, T. Wang, N. Calianese, A. Azarbarzin, L. Gell1, G. Labarca, L. Messineo, D. White, S. Sands, D. Vena, A. Wellman. Prevalence, Pathophysiology, and Predictors of Expiratory Palatal Prolapse in Sleep Apnea. C110 ADVANCED SIGNAL ANALYSIS: NEW DIAGNOSTICS AND PHYSIOLOGIC INSIGHTS FOR SDB / Poster Discussion Session / Tuesday, May 23/02:15 PM-04:15. PM / Walter E. Washington Convention Center, Room 144 A-C (Street Level).
[21] Bargagna B, O'Connor-Reina C, Rodriguez-Alcala L, Navarro A, Bosco G, Pérez-Martín N, Baptista PM, Carrasco-Llatas M, Plaza G. Tonsillectomy May Not Be the Answer in All OSA Cases. J Clin Med. 2024 Oct 28;13(21):6456. doi: 10.3390/jcm13216456. PMID: 39518595; PMCID: PMC11546683.
[22] Kumar D, Woodson BT, Garcia GJM. Phenotypes of Velopharyngeal Tube Law in Obstructive Sleep Apnea. Otolaryngol Head Neck Surg. 2024 Oct 3. doi: 10.1002/ohn.997. Epub ahead of print. PMID: 39360341.
[23] Yaguchi H, Miyagawa S, Mukai T, Sakuta K. Palatal prolapse during nasal expiration in patients with myasthenia gravis. Muscle Nerve. 2024 Feb;69(2):222-226. doi: 10.1002/mus.28009. Epub 2023 Nov 28. PMID: 38018268.