Puffy Cheeks

[walt48]

I am new to the forum and read posts concerning puffy cheeks.

I have been using a CPAP for about 15 years.  I have no medical training whatsoever.  Since I breathe through both my nose and mouth at night, I use a full face mask.  I also get ‘puffy cheeks’ when using the CPAP and full face mask correctly. 

My understanding is that the difference in air pressure between the inside and outside of my cheeks causes them to puff out.  When the full face mask and CPAP machine are on, the pressure in my lungs, throat, mouth, and sinus cavity is higher than the outside air pressure (i.e. the CPAP machine/pump is increasing the air pressure). 

My ribs keep my lungs from puffing out; the cartilage in my throat keeps my neck from expanding; my cheek bones and upper jaw bones keep my sinuses from expanding; the rigidity of the full face mask keeps it from expanding (if it were made of balloon-like latex material it would puff out).  My cheeks, however, expand out without a ridged structure to support it.

I can move my ‘soft palate’ 1/ so that it block air from the lungs and at the same time seal my lips closed; that will prevent air pressure in my mouth.  However, if I open my soft palate my cheeks will puff out regardless of whether my lips are open or not, and vice versa. 
1/ during swallowing, the soft palate is pulled up, causing it to press against the posterior pharyngeal wall. When elevated in this way, it completely blocks and separates the nasal cavity and nasal portion of the pharynx from the mouth and the oral part of the pharynx.

As a consequence of the puffy cheeks and dry mouth, I was treated several times for an infected parotid gland (one type of salivary gland).  The gland got ‘clogged’ when the saliva dried up and blocked it.  I was treated by antibiotics and I was told that if the infection spread to my brain, it could be fatal. 

I found the ‘Respironics Fit Life Total Face Mask’ prevented my puffy cheeks.  I understand this is because the air pressure on the outside of the user’s cheeks is the same as the pressure inside their cheeks.  However, for unrelated reasons, that mask didn’t work well for me. 

I have been using the ‘Respironics Amara View’ full face mask for about five years.  To prevent my cheeks from puffing out, I insert a foam wedge between the lower mask straps and my cheeks to “push” against the outside of my cheeks. I have used this technique successfully for about 10 years or so.  I purchase “Heel Cushions” (Comfort Foot is the brand name) from my local pharmacy (in the section with foot products) that are intended to be slipped into the back of a shoe.  The cushions come with the thick side of the wedge rounded to fit under one’s heel.  I put that thick side towards the center of my face (i.e. towards my front teeth) under my cheek bone, and the thin part near/under my ear.  Obviously the straps need to be adjusted to accommodate the cushions.  The only problem I have had is that maybe once a year, one will slip out overnight.  I have had no reoccurrence of the parotid gland infections.

I also use ‘Orahealth XyliMelts Discs’ to aid with dry mouth.  They may also have had a positive impact of the infections.

[Sleeprider]

Interesting solution to a problem a lot of people share Walt. I have always used a nasal interface, and so the pressure rarely reaches my mouth. The Total Face Mask should mitigate your problem, but it seems like a very invasive mask. For someone that needs this solution, it is a lifesaver. Why didn't it work out? This is the first time I have heard of using foam wedges between the mask straps and cheeks to control the differential pressure. I wonder if a soft cervical collar might help by keeping the jaw closed.

[walt48]

Good point.  I don’t know why your cheeks wouldn’t ‘puff out’ when using a nasal mask if your lips are closed and soft palate (or tongue) is open.  I guess if the pressure is relatively low, there may not be enough air pressure difference make your cheeps puff out. 

I had no claustrophobia issue with the Total Face Mask, but the gasket leaks were insurmountable.  This was one of the masks I tried at the very start of my CPAP use ~15 years ago.  I assumed that the more gasket there is, the more opportunity there is for leaks.  I don’t recall how often the gasket gets replaced.  I buy supplementary cushions for my Respironics Amara View mask I use, so I change the cushions every week to keep the gasket silicon “tacky.”  Maybe I should give the Total Face mask another try.  I am now aware that washing the gasket with dishwashing detergent ‘renews’ some of the silicon’s tackiness.
 
A soft cervical collar works for me to keep my jaw closed, although the first tries were unsuccessful.  All of the soft collars I found (save one) are 3” to 4” wide - not wide enough to span from my chin to my collar bone.  Also, to work even a little, I would have to make them so tight (to keep my chin from sliding down between my throat and the collar) that it put pressure on my Adam’s apple and I would wake up coughing.
 
Then I tried an adjustable, rigid, open frame collar.  It definitely have kept my mouth closed, but was so bulky and uncomfortable, I couldn’t even get to sleep.
 
After some research I found a collar (the only one I found) that is 5” wide.  It works for me.  It is a Medline Serpentine-Style Cervical Collar "ORT 13300 L."  Because it is 5 inches wide, it is pretty effective at keeping my chin closed at night.  I bought it from MedLine over the phone (less than $6 plus delivery), but it should be available at local suppliers. 
 
Although the ORT 13300 L works fine for me, my lips are still able to open, so I still get a little dry mouth.  I did tape my lips for a year or so, with varying success.  I discontinued using the surgical tape primarily because the tape caused sealing problems with the mask’s silicon gasket.

[WalterBob]

YOUR puffy cheeks tip was right on time for me. I just received my cpap machine on 1 July 22. I appreciate your comments and have taken my chin strap and made a temporary fix but will go get those wedges in the AM. Have you attached them to the mask or do you insert them nightly? I do not know if you can send photos on this forum but it would be great if you could. I am 81 and a DIY guy so I have improvised and used VELCRO to attach to my chin strap. Hope it works.. THANK you so much for the tip on the heal cushions.

[walt48]

Sorry for the tardy response.


I use a full face mask.  It has one strap across the top of my head; two across my cheek bones; and two across my cheeks.  I insert a heel cushion between each cheek and its respective strap.  The heel cushions stay in place without any adhesive or Velcro, and are effective at minimizing my puffy cheeks.  I also use one (for naps) or two Xylimelt tablets to relive dry mouth.  Not perfect, but a big improvement for me.

I have no experience with a nasal CPAP mask.  I read a post elsewhere on the forum that explained that the author (using a nasal CPAP mask) had wrapped an elastic bandage (the kind used for joint sprains) around his head and mouth.  Although I have no experience with that solution, it seems reasonable that his elastic bandage could work to hold the heel cushions in place.  I would try that if I used a nasal mask.   

BTW, I was unsuccessful in using a chin strap.  In fact, it caused a dislocation of my jaw of the right side (very painful for a long time).  The chin straps I used didn’t pull directly upwards; they pulled up and back (i.e. my chin was pulled towards my throat (horizontally) as well as upwards (vertically) towards my nose).  I likely overtightened it in an effort to keep my mouth closed and sleeping like that night after night caused the problem.  I now use a cervical collar with a second collar wrapped around the first (see photos).  It is weird looking, but I have used it for several months with success.    


I will attempt to send a photo with this post.  Hopefully, it will illustrate the heel cushions pushing on my cheeks, and the cervical collars I use to keep my mouth shut.  I found that wrapping one collar around the other works better than using just one alone.  A single collar had to be so tight to prevent my chin from slipping inside it and my throat that it pushed on my ‘Adam’s Apple.’  In the photo the white collar is the Medline Serpentine-Style Cervical Collar "ORT 13300 L.”  The black collar wrapped around it is ‘Vive Neck Brace - Foam Cervical Collar.’  Both collars and the Xylimelt were purchased through Amazon.

[SevereApnea]

That is an amazing set up! Admire your determination!

You said:

Quote: A single collar had to be so tight to prevent my chin from slipping inside it and my throat that it pushed on my ‘Adam’s Apple.’ End of quote.

I had a similar feeling with one of my collars pushing against my Adam's apple, the collar is a cheap foam one, quite similar in appearance to your white one around your neck. 

What I did was take some thick cotton, and where my Adam's apple meets the collar in front, I did some quilting type stitches in a diamond pattern, that narrowed the thickness of the collar in that location and allowed the adam's apple some lee-way. Worked OK. The collar I use now is older and softer and so don't need that anymore.

[walt48]

Great idea!  Any port in the storm.

[ErElf]

Walt - 

I hope you see this as you seem to have a better understanding of CPAP and air pressure than many of the experts.

I'm fairly new to the OSA/CPAP world and still a bit in denial, but trying very hard to find the best solution for my sleeping problem.

I know it is best to breathe solely through the nose, and this will work for me most of the time. My current masking approach is to use a nasal-only mask and tape my mouth. (Easiest leak control.) Today I have decided that the mouth tape is really just a helping indicator to allow my body to realize (via puffy cheeks) it has opened the nasal-mouth passage by dropping the tongue and should correct it. Otherwise, I'd be dealing with the puffy cheeks again. 

I believe that a large subset of PAP-people must either naturally close the nasal-mouth passage or they quickly adapted (or perhaps not so quickly but eventually adapted) to do this when they started using the PAP. Otherwise, either the PAP would not work because the pressure would leak out the mouth, or if closing their lips they would have puffy cheeks. I quickly realized that a full face mask, is not a solution, because when mouth breathing, you would get puffy cheeks.

I guess that there is another option in that perhaps people adapt and maintain cheek muscle tone to overcome the pressure differential rather than puffing their cheeks. This seems even more unnatural than using the tongue to the roof of the mouth to close down the passageway.

I actually wondered about an external cheek pressure option similar to your pictured solution. I also wondered about a mask like the FitLife Total Face, but that would just make things worse through more leaking and less ability to lay on my side or stomach.

I find it very odd that this topic is not discussed more. Are cheek puffers such a minority? Is it possible and/or natural to adapt? Must we go the extra mile (like you ingeniously have)?

I'm also wondering if successful PAP people have some common characteristics like clear nasal pathways and a natural tendency to shut the nasal-mouth pathway with their tongue. (And they wonder why PAP is so difficult for the rest of us...)

I am at a stage where I seem to be able to control my OSA with relatively low pressure (10in) if I stay off my back. Now trying to decide if I can make that position constant, crank up the pressure to allow back sleeping, or search/try other solutions (MAD etc.).

I really hope your therapy is going well. I'd love to hear an update on your progress.

Thanks in advance, Eric

[walt48]

I hope you see this as you seem to have a better understanding of CPAP and air pressure than many of the experts.
I have wondered if any CPAP manufacturers employ any designers who actually have OSA and use the equipment they manufacture. J  But I have learned a lot from other users.
I'm fairly new to the OSA/CPAP world and still a bit in denial, but trying very hard to find the best solution for my sleeping problem.

I know it is best to breathe solely through the nose, and this will work for me most of the time. My current masking approach is to use a nasal-only mask and tape my mouth. (Easiest leak control.) Today I have decided that the mouth tape is really just a helping indicator to allow my body to realize (via puffy cheeks) it has opened the nasal-mouth passage by dropping the tongue and should correct it. Otherwise, I'd be dealing with the puffy cheeks again. 
You have more control over your body (specifically your tongue while asleep) than I do.  I have tried to ‘train’ my tongue to little avail.  I also considered crafting a device (‘gluing’ a plate to an upper mouth/teeth guard) that would keep my tongue from dropping down while I sleep.  However, besides OSA I have a deviated septum and chronic sinus problems that require nose breathing be a sometimes-only alternative.  They (and asthma, COPD, old age – mid 70’s) make mouth breathing a sometimes necessity. 

I believe that a large subset of PAP-people must either naturally close the nasal-mouth passage or they quickly adapted (or perhaps not so quickly but eventually adapted) to do this when they started using the PAP. Otherwise, either the PAP would not work because the pressure would leak out the mouth, or if closing their lips they would have puffy cheeks. I quickly realized that a full face mask, is not a solution, because when mouth breathing, you would get puffy cheeks.
You are correct about puffy cheeks being an unintended consequence (or side effect) of using a full face mask.  So is dry mouth (at least for me).   

I guess that there is another option in that perhaps people adapt and maintain cheek muscle tone to overcome the pressure differential rather than puffing their cheeks. This seems even more unnatural than using the tongue to the roof of the mouth to close down the passageway.
At some point I doubt that will work.  My doctor has set my device to 20 to be effective for medical reasons.  As my jaw drops, the surface area inside my mouth increases (assume my lips are taped).  At some point, the pressure acting over the increased surface area will blow my cheeks out (absent external pressure on my cheeks to hold them in).  I really doubt I would ever become strong enough to hold my cheeks in.

I actually wondered about an external cheek pressure option similar to your pictured solution. I also wondered about a mask like the FitLife Total Face, but that would just make things worse through more leaking and less ability to lay on my side or stomach.
I have not tried a mask like FitLife in more than a decade; maybe it seals now better than my memory.  I would have to think about it more, but I  currently lay on my side with a full face mask (Amara View) by doubling the pillow and resting my head on it so that the face mask is hanging over the edge of the pillow.  I might work with the FitLife, but not sure.

I find it very odd that this topic is not discussed more. Are cheek puffers such a minority? Is it possible and/or natural to adapt? Must we go the extra mile (like you ingeniously have)?

I'm also wondering if successful PAP people have some common characteristics like clear nasal pathways and a natural tendency to shut the nasal-mouth pathway with their tongue. (And they wonder why PAP is so difficult for the rest of us...)
I have found that if you talk to one CPAP user, you have met just one user.  Some have (seemingly) no issues (or at least are not whiners like me J); others just give up and aren’t heard from again.  I cannot give CPAP up.  I have had several pre-treatment episodes in which I was partially awake/asleep and realized I could not make my lungs work (like the muscles were paralyzed) - scary.   Obviously, I was able to wake myself up and breath again, but I am a deep sleeper so I may not always be so lucky.
I am at a stage where I seem to be able to control my OSA with relatively low pressure (10in) if I stay off my back. Now trying to decide if I can make that position constant, crank up the pressure to allow back sleeping, or search/try other solutions (MAD etc.).
I would consider several other things that may help.  1) Wash the silicone seal on the ‘cushion’ with soap and water daily.  The tackiness of the silicone depends on it.  2) The best skin-to-silicone seal is achieved in a ‘sweet spot.’  Cranking down on the headgear straps works to a point, but letting out the straps often is very effective at stopping leaks.  I mark the position/length of the old strap settings onto new headgear.  3) Try doubling up the pillow and “cantilevering” the mask over the edge (see above).  
I really hope your therapy is going well. I'd love to hear an update on your progress.
Best to you as well.  In my world, these things keep changing, so I keep trying new things. It is great (for a while) when something works, but new issues always seem to pop up.

Thanks in advance, Eric

[ErElf]

Walt - 

So good to hear from you, which seems odd to say, perhaps misery loves company or something like that. I guess I'm glad to hear you are still trying to make things work and having some success.

I just returned from my first sleep dr. follow-up appointment (with a nurse practitioner). I went in with the lowest of expectations and was still disappointed. They literally only needed to read my usage numbers off the PAP so they could file a "compliance report." I had some short discussions about APAP vs. CPAP, positional therapy, and even ventured to this "mouth pressure" issue. All useless for me. 

I have always been one to take responsibility for my own welfare and treatment, so I'll continue, but I feel bad for others who are not so well equipped to help themselves out.

Thanks for the additional information.

It is clear that different PAP users have such different experiences when starting with PAP therapy. What is odd is that there does not seem to be anyone trying to figure out why.

My search for sleep continues... and today, with such a blah experience at the sleep dr office, I feel even more empowered. 

Best of luck to you, Eric