Tongue Placement During Sleep

In a prior post, we discussed how laxity of the jaw, which usually leads to a widening of the angle of the jaw, causes further obstruction in the back of the throat. We walked through the “jaw-dropping” exercise so you could feel the distinction in the flow of air through the nostrils when the teeth are held together versus when the teeth no longer touch; the chin falls into a downward position. 

Now, looking inside the throat, we see a related phenomenon regarding the positioning of the tongue. For starters, let’s have you do something really rude: stick out your tongue as far as you can. Again, if you cycle back and forth, taking a few breaths in each of the two positions (tongue out or tongue in), it is quite obvious how much easier breathing feels both in and out through the nostrils when the tongue is thrusted well forward out of the mouth, like Michael Jordan used to do running down a basketball court

Even when the tongue is inside a closed mouth, there are different positions affecting breathing. Many people may not recognize that the tongue’s natural resting site is not on the floor of the mouth where the tip of the tongue presses against the backs of the lower teeth. Rather, the natural position is a slight elevation of the tongue where it rests at or between the smooth front of the hard palate (the roof of your mouth) and the rugae (corrugated tissue between the smooth part of hard palate and the lining of gum tissue above the upper teeth). Again, if you play with these positions, taking a few breaths with the tongue stabilized against the smooth hard palate, the rugae, or the lower teeth, you will notice easier breathing in and out with first two positions and more difficult breathing in the latter position when the tongue presses against the teeth.

In some of these positions, you will almost always notice easier breathing in and often easier breathing out as well. But, in some instances you may notice minimal distinctions during inhalation, but a clear distinction in breathing out. Playing with the different positions is a useful exercise, because you may want to consider these techniques while using PAP or OAT (the oral appliance device to treat OSA/UARS). On a very practical level, I wanted to address this topic because it may prove useful to those types of patients who cannot easily adapt to pressurized airflow or OAT.

With the PAP patient, it is not uncommon for many patients to develop claustrophobic-like experiences when trying to adjust to the flow of pressurized air. As written about extensively in prior posts, this problem often arises when the individual struggles to breathe out against air flow coming inwards. We have had a great deal of success using advanced PAP technology such as ABPAP or ASV to provide maximum expiratory pressure relief; however, some patients still suffer distress in trying to use the device. In these circumstances, the patient may be trying too hard to adjust to the pressure sensation instead of just letting the process unfold in more relaxed fashion. The problem, though, may not be simply that the patient cannot relax. Rather, the problem may be the patient’s tongue position is hindering the adaptation experience.

At this point, and certainly earlier in the time course of adaptation as well, the patient could be instructed to experiment with different tongue positions with the mask off the face. Then, if the patient discovers a position that improves the sensation of airflow, the PAP mask can be put on and the pressure restarted, at which time the patient renews his or her effort to situate the tongue in the more comfortable breathing position. This step may turn into a two-for-one benefit. Clearly, if the airflow feels smoother, the person could start relaxing and begin to feel that pressurized airflow is not such a difficult experience. The second benefit is that the patient is now focused on a very small part of the PAP experience and might forget about the mask or possibly the pressurized airflow altogether or at least notice a diminished sensation about masks or pressures like any other mental or sensory distraction technique.

The same potential exists with OAT, but in this case there may be two position choices available to the patient.   Most OAT devices block off the tongue tip so it will not slip between the upper and lower arches of the appliance.   In this case, the individual would only have the option of positioning the tongue against the front part of the hard palate.   Among the few inventors who have created a larger space between the two arches of the dental device, the tongue can glide through the space and touch the inner portions of the lips. Because the teeth are covered by the dental device, there is no fear that the teeth could bite the tongue. In both of these positions, an OAT user may notice an easier exchange of airflow and thus may choose to add one of these positioning techniques to their nighttime routine.

In related items, research on tongue exercises that might decrease the severity of OSA/UARS not only strengthen the tongue muscle but also focus on its position while sleeping, and this area of research appears very promising, because clear-cut benefits have been documented with various methods. (1-5)

The tongue is a hugely important factor in the onset and persistence of OSA/UARS, so much so that other research is forging ahead with the use of devices for nerve stimulation of the tongue muscle. (6)

Thus, all told, there may be many new ways to approach OSA/UARS by greater focus on the tongue muscle and its position in the mouth during sleep.

References

  1. Verma RK, Johnson J JR, Goyal M, Banumathy N, Goswami U, Panda NK. Oropharyngeal exercises in the treatment of obstructive sleep apnoea: our experience.Sleep Breath. 2016 Mar 18. [Epub ahead of print]
  2. Corrêa Cde C, Berretin-Felix G. Myofunctional therapy applied to upper airway resistance syndrome: a case report. Codas. 2015 Nov-Dec;27(6):604-9. doi: 10.1590/2317-1782/20152014228.
  3. Rousseau E, Silva C, Gakwaya S, Sériès F. Effects of one-week tongue task training on sleep apnea severity: A pilot study. Can Respir J. 2015 May-Jun;22(3):176-8. Epub 2015 Apr 15.
  4. Guimarães KC, Drager LF, Genta PR, Marcondes BF, Lorenzi-Filho G. Effects of oropharyngeal exercises on patients with moderate obstructive sleep apnea syndrome. Am J Respir Crit Care Med. 2009 May 15;179(10):962-6. doi: 10.1164/rccm.200806-981OC. Epub 2009 Feb 20.
  5. Ieto V, Kayamori F, Montes MI, Hirata RP, Gregório MG, Alencar AM, Drager LF, Genta PR, Lorenzi-Filho G. Effects of Oropharyngeal Exercises on Snoring: A Randomized Trial. Chest. 2015 Sep;148(3):683-91. doi: 10.1378/chest.14-2953.
  6. Friedman M, Jacobowitz O, Hwang MS, Bergler W, Fietze I, Rombaux P, Mwenge GB, Yalamanchali S, Campana J, Maurer JT Targeted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea: Six-month results. Laryngoscope. 2016 Mar 24. doi: 10.1002/lary.25909. [Epub ahead of print]

Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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