Continuous Positive Airway Pressure Therapy Maladaptation in Patients with Submucosal Palatal Cleft: Report of Two Cases

Keywords

obstructive sleep apnea - CPAP

Introduction: Continuous positive airway pressure (CPAP) therapy is considered the gold-standard treatment of the obstructive sleep apnea (OSA). Despite being the first choice of treatment, adherence to the pressure therapy is yet challenging in many cases. For some patients, anatomical variations and abnormalities pose further difficulty to adaptation.

Aim: To report two cases of difficult adaptation of CPAP in patients with submucosal palatine cleft.

Methods: Clinical and demographic data were collected in the patients’ medical chart; they agreed to have their case reported.

Results: Case 1: A 61 years-old female patient with moderate OSA (apnea-hypopnea index [AHI] of 23/h) in use of CPAP with nasal mask interface presenting with excessive oral air leak and awakenings due to intense dried mouth, even using chinstrap. Case 2: An over-weighted asthmatic 47 years old female also in use of CPAP with nasal mask interface due to moderate OSA (AHI of 25/h), with chief complaint of episodes of sleep awakenings due to oral air leak and sensation of suffocation. Despite optimal management of equipment adaptation measures, both of them maintained presenting symptoms. CPAP's algorithm demonstrated excessive air leak and relative poor control of obstructive events. Trials of increase in therapeutic pressure leaded to rise in estimated air leak and worsening of complaints. Side lying sleeping did not contributed to better control of the AHI. Detailed evaluation of the upper airway of both patients, including nasopharyngeal endoscopy, palate palpation and dynamic oroscopy revealed minor bone failure in posterior palate, which was not related with palatal veil insufficiency but probably could contribute to the nighttime symptoms. Sleep endoscopy was not available to confirm the theory, but examination findings suggested that both patients may have the diagnosis of palatal prolapse.

Conclusions: Specific upper airway anatomical abnormalities may lead to difficulty in adaptation of CPAP therapy. Submucosal palatine cleft is related to excessive “free” soft tissue in retropalatal region and, when using therapeutic positive pressure upon airway, may lead to palatal prolapse to rhinopharynx during expiration and ultimately to flux limitation to the nose. Detailed evaluation of the patients’ upper airway is critical to manage cases of maladaptation of pressure therapy. Alternative treatments to CPAP must be evaluated to control OSA in these patients.

No conflict of interest has been declared by the author(s).

Publication History

Article published online:
15 June 2023