[Diagnosis] Could a Fractured Hyoid Cause Epiglottis Prolapse=OSAS

[jtucker803]

Hey folks, I have seen a Pulmonologist, Neurologist, Dentist, 3 PCP, an ENT and a Allergist trying for years to understand my confusion/memory, major sleeping issues, and propensity to get strep. All of these care givers agree I have severe sleep apnea and my allergist added that I have several severe allergies 6 months out of the year.  I have started immunotherapy this week.  
 
I have had the Uvulopalatopharyngoplasty (UPPP) surgery with correction of a deviated septum, which helped for about a year, I was placed on a CPAP with all the bells and whistles, I tried every mask, and learned I just could not tolerate it anyway we spun it. For me, it was like trying to sleep with a bag full of spiders tied around my head. The result of the CPAP was, I got less sleep, missed more work due to increased infections, and my memory and fatigue issues increased significantly.  Over the years my BMI has fluctuated from 30-32 but having been in law enforcement, I have always stayed in decent shape.  Each of my PCPs have agreed that BMI does not accurately represent my body comp.  They say I have a higher-than-normal body muscle mass.  June 2021, I ran 100 miles in 30 days to get donations for a good cause.  When I run, I have little to no breathing issues, but when I sleep, I snore terribly and I have been told more than once, I run a distinct risk of never waking up without a CPAP.  My snoring started when I was 28 y.o. after I was strangled during a work-related encounter and my hyoid bone was fractured.  Around 30 I was diagnoses with high blood pressure and OSAS at 38.  My high blood pressure and allergies are controlled with medications.  I was hoping through better diet and exercise I could decrease the risks of OSA but after losing 20 lbs., it does not seem to have improve my sleep or comfort at all.  I am 45 now.  It has been a long battle.
 
The latest specialist suggested I get an upper airway stimulation device installed or that I get the Maxillomandibular advancement surgery (MMA).  I am against the UAS because every 10 years the device must be cut out and the battery changed.  I cannot find any oral surgeons who will perform the MMA even though I am told it is successful 90+% of the time and it is a one and done.
 
My unprofessional thoughts are that when my hyoid was fractured and never repaired, this created an impact on my epiglottis.  It was around the same time my hyoid was fractured, that I started having problems aspirating fluids to include my own spit.  After the UPPP this got much worse.  I had to learn to use my tongue much like the action of the epiglottis.  I believe with the damage to the hyoid, the UPPP surgery, and age-related effects on the hyoepiglottic ligament have created a rare form of OSAS that few specialists can detect, let alone treat because generally 2/3 of all OSAS involve the tongue.  I know it sounds crazy right?
 
Some other procedures I am exploring are a hyoid suspension, genioglossus advancement, lingual tonsillectomy, or a midline glossectomy. If you have got this far, perhaps you have some words of encouragement, advice, or maybe some constructive criticism.  I welcome all your input.

[2SleepBetta]

I have no idea how to answer your question, jtucker803, but offer the following hoping something there may help. My guess is the answer to your question will be "yes", based on what is below.

A tough case. My only bases for response are approaches I would try now , one at a time or more in combinations--until I would "surrender" and go back to trial of CPAP yet another way,  along with any helpful measures discovered. One has to deal with the apnea some way, ASAP, while exploring how to proceed.

You mentioned things you have tried and are exploring and show you have used and are consulting with MD help--all good ones we both hope. Good. Information in links below and  quotations from them along with indirect experience are all that informs my ignorance in your case--those parts of the medical papers I understand (?), that is. 

Only after seeing your then-unanswered post did I try to dig deeper--first time, into the hyoid matter--deeper than what I had been reading about mechanical properties of the upper airway. I did remember from the paper, linked below, it mentioned that  lifting the hyoid (by extension backward of the neck and head?)  caused "caudal traction" and mitigated airway collapsibility . The same paper explains why the cervical collar is such an effective help.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3770742/

The hyoid mentions there:

"For instance, in the pharynx, the posterior constrictors insert directly onto the pharyngeal mucosa, but the rest of the upper airway muscles act on the airway indirectly, through their attachments to the tongue or hyoid (111, 145). As these muscles contract, they change length and tension. The nature of the mechanical events linking hyoid movement to airway mechanics is unclear, although a caudal traction force yields an improvement in airway collapsibility (18, 33, 34, 131). Of note, anterior movement of the airway wall can be produced by anterior movement of the hyoid (133)." 

Flexion of neck, bad, extension of it, good, and hyoid mentions:

"Flexion and extension of the neck affect the mechanics of the upper airway (104, 129, 147), because the axis of rotation for extension and flexion is behind the airway. Because the jaw is more anterior than the hyoid, extension results in a lengthening of the muscles that elevate and anteriorly draw the hyoid and a shortening of those that draw it posteriorly. Flexion has the opposite effect, and causes the whole tissue mass behind and below the jaw to be displaced inferiorly and posteriorly, into the airway."

Here are things I'd try, preferably with the contact-minimal nasal pillow mask, like Resmeds P10, which I as a mouth breather "cannot use" but adopted anyway (years ago)  with a good mouth sealer (Silipos Gel-E-Roll), a retainer for it, and a high c-collar:

1. Try the cervical collar. If one won't help you, try a different width. Slow to adopt one, I tried a 3 1/2 inch, but now use the 4 inch height I thought was too high when I first tried it. Collar top is as high as easily tolerated and it allows little range of up-down chin motion with mouth closed: head rotation L-R, no problem. Further, I measured sternum to chin with head held level, as if at the firing line looking at an eye level bullseye at 50 ft.

2. As in this research paper, found hours ago, for anesthesiologists (maintaining respiration for those "out" on the operating table), try Sitting position, Sniff position,  and head or neck extension measures. But avoid tilting chin down as cautioned not to do.

Link to information dealing with patients breathing while"out":

https://aadsm.org/docs/JDSM.03.01.11.pdf...0discussed.

3. Take steps to prevent supine sleep. I had to improvise a drastic measure, but it worked. After a year+ using the block, which required I nearly sit up to switch sides, I tried going without the block and found that the wider cervical collar (I had changed to after fashioning my supine block ) would do the job of suppressing OA, even if I did sleep some on my back, as I now do.

Obviously your hyoid bone break and/or suspension damage may dictate differently at all points above.


Good luck!


JDSM.03.01.11.pdf (aadsm.org)

[SevereApnea]

@jtucker803

Wow, sorry to hear about your event at age 28, that's really terrible.

I recently replied to another thread and felt I needed to copy that here in case this gives you and your PCPs something else to look at.
(Marques et alia specifically mentioned the epiglottis.)

http://www.apneaboard.com/forums/Thread-...#pid417607

"Recently found this article by Marques and others.

Whether you wish/need to sleep on your back or side may depend on your individual anatomy.

Small sample number but interesting observations nevertheless.

Summary in the Discussion:

1. Patients with tongue related obstruction did not exhibit a change in tongue position or airflow upon moving onto their side.
2. Airway patency improved slightly with lateral positioning in patients "without" tongue related obstruction.
3. Epiglottic collapse improves substantially with a change to the lateral body position during sleep.

This highlights how complex this whole business is and how unique solutions are needed for each individual.

Hence the benefit of this Board where we can all learn from each others situations."

Marques


As your own situation indicates we all have our own puzzle to deal with, hoping this gives you another piece to look at and think about.
I know it's not much, but each little bit may help. Wishing you all the best, 

@2SleepBetta

Great articles, huge thanks for the links, really appreciate your sharing those.

So much to read and absorb and somehow apply to our own situation.

[SevereApnea]

Here is another article discussing the challenges with epiglottic issues:

deBeeck