Extremely high narrow palate airway problems

Hi Dr. Mason, I would like to get your professional opinion what can be done for a patient who has pretty much exhausted all his options for opening his airway? He is 28 with an extremely high narrow palate thus cannot breathe well. His tongue has the “macro” appearance due to the palate issues. He’s gone through surgeries, ENT referrals, and I started therapy on him to strengthen his lips and to habituate a correct resting tongue posture. I also referred him for a lingual frenectomy that he followed through with. We only worked together around 5 sessions and he was then out of the country with work. He’s back in the USA for a short while and I would love to give him some sort of insight on what he can do… Any thoughts would be great! Thank you, J  

Thanks for your email. You say that this 28 year old has gone through surgeries. I wonder what kind? From your report, he seems an excellent candidate for oral-maxillofacial surgery to surgically expand both dental arches and reconfigurate the hard palate. If this is not an agreeable option, I am surprised that the  ENT did not identify anything that has caused his breathing problems or recommend some option such as removing the inferior turbinates, or part of them.  Usually, there is something that is found in an ENT exam such as a constriction of the posterior choanae, a nasal polyp, or something similar. In some cases, the problem is the anterior nasal valve and in an examination, surgeons spread the nostrils to take a good look at the nasal cavity, missing the fact that the problem can be with the anterior nasal valve (liminal valve). FYI, I would not blame his conditions on a low rest position of the tongue. This could, however, have led to a narrowing of the maxillary arch as the resisting pressures of the tongue with the cheek muscle are no longer present with a low tongue posture. In such cases, the maxillary arch narrows, but not the mandibular arch.But this does not elevate the palatal vault.  The position and shape of the palate, is separate from the configuration of the maxillary arch, and is controlled by the anatomy above the palate, not below. So with a high palatal vault and a narrow arch, I suspect something other than tongue size or posture as causing this situation. I think you are providing appropriate services, but the reasons for his breathing problems remain incompletely diagnosed or treated. If he has not seen an oral-maxillofacial surgeon, this is the place I would recommend he go for a definitive evaluation – especially since ENT sees no problem. However, a problem with such examinations is that surgeons tend to look at the anatomy and then predict what problems are the result of what they see, rather than actually measuring airflow, as is done in most cleft palate clinics. The anatomy is not a good guide to predict the physiology involved. If there is a nearby university program for clefts that involves a team approach, this may be the best place to have this patient fully evaluated, including the aerodynamics. Toning and narrowing the tongue with brushing and icing may be helpful, as well as the other techniques you are using which sound appropriate to me. I’m not sure that m comments are helpful. You are certainly faced with some difficult and unresolved issues, but what you are doing may help. I would consider your therapy to be “diagnostic therapy”, as you have an opportunity to closely observe him during your therapy sessions. Regards, Bob Mason