Genioglossus Advancement

History

• 1.

  OSA history

  • a.

    OSA diagnosis and severity

  • b.

    Sleep-related symptoms

  • c.

    Medical comorbidities (e.g., hypertension, heart disease)

  • d.

    Prior OSA medical therapy (e.g., continuous positive airway pressure [CPAP], bilevel positive airway pressure [BIPAP], oral appliance)

  • e.

    Prior OSA surgical therapy (e.g., UPPP)

  • f.

    Comorbid sleep medicine disorders (e.g., insomnia)

• 2.

  Past medical history

• 3.

  Past surgical history

• 4.

  Family history

• 5.

  Social history, particularly alcohol and tobacco use

• 6.

  Medications, especially anticoagulants or herbal products

Physical Examination

• 1.

  General —A general examination of the patient is important to assess his or her overall health and development. It is also important to consider his or her body habitus or body mass index (BMI), as patients with high weights or BMI are less likely to benefit from a GA alone.

• 2.

  Head and Neck —It is important to carefully examine the patient’s head and neck to look for any signs of skeletal hypoplasia that could be contributing to the patient’s obstructive symptoms. Those individuals that could benefit most from GA often present with mandibular hypoplasia and/or microgenia. Mentalis strain and the competence of the lips are also important; often, skeletal Class II patients have lip incompetence and exhibit mentalis strain when trying to close their lips. Neck circumference and hyoid position are two other factors to consider, as larger, thicker necks are associated with higher risk of OSA, and a low-set hyoid may indicate the same.

• 3.

  Nasal airway —It is important to thoroughly examine the nasal cavity for any evidence of obstruction that could be resolved via nasal surgery alone or with a combination of nasal surgery and surgery, affecting another level of obstruction.

• 4.

  Oral cavity and oropharynx —This is a very important examination because it gives valuable information regarding the size of the tongue and its contributions to the patient’s obstructive symptoms, the volume of soft tissue comprising the soft palate that may be amenable to UPPP, and the size of the tonsils, which may contribute to the symptoms. It is important to note that the presence or absence of periodontal disease could increase the risk of fracture if a GA is performed. The amount and health of the keratinized tissue located buccal to the mandibular incisors are important during the postoperative course, as the incision, closure, and any subsequent scarring are located adjacent to this area, and contractures may result in unaesthetic gingival recession around the mandibular incisors.

Imaging

• 1.

  Panoramic Radiograph —To visualize the periodontal tissues, dentition, height of the anterior mandible, mental foramina, inferior alveolar nerve canal, and temporomandibular joints

• 2.

  Lateral Cephalometric Radiograph —Evaluate the presence and severity of maxillary, mandibular, and genial hypoplasia, all of which can contribute to various levels of obstruction in the airway during sleep.

• 3.

  CBCT Scan or Maxillofacial CT Scan —Maxillofacial CT scans, and more recently CBCT scans, have been incorporated into the planning stages of various sleep surgeries, including GA. This is a proven technology that has been used for years and has been shown to have a high degree of accuracy. CBCT scans are advantageous in that they provide useful data regarding the volumetric aspects of the airway. The technology also facilitates the ability to make precise measurements to aid in planning osteotomies, avoiding critical structures such as the mental foramina, and to locate crucial aspects of the patient’s anatomy, such as the genial tubercles in this case. In addition, surgical models of the patient’s anatomy can be printed and studied along with the fabrication of surgical stents and guides to assist with various osteotomies to be certain that critical structures are included or avoided and that the specific surgical goal that was planned is accomplished. Postoperatively, the patient can be scanned again, and volumetric data can be generated about the increase in airway size and capacity.

Indications

Mild-moderate OSA with failure or inadequate adherence with medical therapy:

• 1.

  Retrolingual or hypopharyngeal location of collapse

• 2.

  Fujita type 2 or 3

• 3.

  Microgenia or mandibular hypoplasia. GA for these patients may have both airway and aesthetic benefits.

Contraindications

• 1.

  Significant medical comorbidities prohibiting operative intervention

• 2.

  Severe obesity likely to decrease GA effectiveness and increase perioperative risk

• 3.

  Airway obstruction localized to Fujita Level 1

• 4.

  Severe OSA

• 5.

  Severe periodontal disease

• 6.

  Patients concerned about transient or permanent V3 paresthesia

Preoperative Preparation

• 1.

  Discontinue any antiplatelet and anticoagulant medications if possible.

• 2.

  Oxymetazoline nasal spray prior to the induction of nasal endotracheal anesthesia.

• 3.

  Consider perioperative course of high-dose steroids to minimize postsurgical edema of the floor of the mouth, tongue, and airway.