Hyoid Suspension - Clinical Tree

It is estimated that adequate adherence to continuous positive airway pressure (CPAP) may vary from 28% to 80%. For patients with moderate-to-severe obstructive sleep apnea (OSA) who fail CPAP, a variety of surgical procedures are available. To determine the surgical intervention most suitable, the airway is fully evaluated for level, pattern, and degree of airway collapse. In a prospective study of 108 patients, Kezirian et al. found hypopharyngeal collapse in 83% to 84% of subjects undergoing sleep endoscopy. Treating the base of the tongue and epiglottis can be difficult, with a number of available procedures being invasive, thus requiring significant recovery time and the potential for complications.

Hyoid suspension (HS) is a relatively noninvasive technique with a low complication rate, often used to address anteroposterior (AP) collapse at the base of the tongue and epiglottic levels ( Fig. 57.1 ). It can be performed as an isolated procedure or in combination with those addressing velopharyngeal, oropharyngeal, or nasal obstruction.

Fig. 57.1, Hyoid to mandible suspension showing favorable expansion of the hypopharyngeal space.

Key Operative Learning Points

1.
Operative procedures for OSA should minimize morbidity and preserve function. Leave the stylohyoid muscles attached to the hyoid bone. This is the key mechanism that advances the base of the tongue when the hyoid is suspended to the mandible.
2.
When suspending the hyoid, make sure the patient’s head is in normal pillow supine position. Adequate suspension should be obtained without overtightening to avoid suture breakage or complications.
3.
The patient should be reevaluated with polysomnography (PSG) and long-term follow-up after HS is necessary, to evaluate for return of symptoms or signs of progression of OSA.

Preoperative Period

History

1.
History of present illness
- a.
  Sleep architecture: Assess hours of sleep per night, number of nighttime awakenings, and use of sleep medications.
- b.
  Sleep-related symptoms: Evaluate for the presence of snoring, witnessed apneas, restless sleep, sleep maintenance or onset insomnia, perspiration during sleep, nocturnal enuresis, nighttime seizures, narcolepsy, and restless leg symptoms.
- c.
  Daytime-related symptoms: Evaluate for the presence of excessive daytime sleepiness, morning headaches, and awakening feeling tired.
- d.
  Changes in weight should be quantified over a defined period of time.
- e.
  PSG: Has a PSG been obtained? If so, what are the results? When was the study done? Has there been any weight or health changes since the study? PSG should always be obtained prior to any surgical procedures.
- f.
  CPAP use: Has this been trialed yet? If so, is the patient able to tolerate it? If the patient is not able to tolerate it, why? Has any other medical therapy been tried?
2.
Past medical history
- a.
  Medical comorbidities
  - 1)
    Hypertension (controlled?), cardiac arrhythmias (atrial fibrillation?), congestive heart failure, obesity hypoventilation syndrome, pulmonary hypertension, chronic obstructive pulmonary disease, neuromuscular/neurodegenerative disorder, additional sleep disorders
- b.
  Surgical history
  - 1)
    Tonsillectomy, adenoidectomy, septoplasty, turbinate reduction, rhinoplasty, bariatric surgery
- c.
  Family history
  - 1)
    Anesthesia-related complications
- d.
  Medications
  - 1)
    Antiplatelet drugs
  - 2)
    Herbal products
  - 3)
    Alcohol
- e.
  Social history
  - 1)
    Smoking status
  - 2)
    Caffeine intake per day
3.
Epworth sleepiness scale

A subjective patient self-assessment tool to determine sleepiness level with various activities. Comparison of preoperative and postoperative scores may assist in the evaluation of subjective outcome measures.

Physical Examination

1.
Vital signs

Resting pulse oximetry and body mass index (BMI) should be recorded.
2.
Nose

Evaluate for deviated septum, inferior turbinate hypertrophy, and nasal valve collapse.
3.
Oral cavity and oropharynx

Note size and presence or absence of tonsils, ability to visualize the uvula, soft palate, and hard palate for determination of Friedman tongue position. This can be instrumental in guiding surgical management.
4.
Neck

Measure the circumference of the neck. Note whether there is a large amount of subcutaneous adipose tissue or musculature, especially over the hyoid, because this may limit surgical success. Palpate laryngeal landmarks (i.e., hyoid bone and thyroid cartilage).
5.
Flexible supine nasopharyngoscopy

Flexible supine endoscopy is the most important preoperative portion of the examination. This can be done awake in the office and/or under sedation in the operating suite. We prefer drug-induced sedation endoscopy in the operating suite because it best mimics the sleep state. If performed in the office, addition of the Müller maneuver (inhalation with nasal and oral passages closed) can help to simulate an obstructive event. During endoscopy, the level (velopharyngeal, oropharyngeal, or hypopharyngeal), degree, and pattern of upper airway collapse is noted to determine the most suitable surgical intervention. Perform a jaw thrust maneuver to evaluate whether collapse improves. Note VOTE (velum, oropharynx, tongue base, epiglottis) classification.

Procedures

Polysomnography
- Preoperative sleep testing with home portable monitoring or in-lab PSG is necessary for diagnosis of OSA. Medical necessity for treatment is often considered an apnea-hypopnea index (AHI) of greater than 15 or an AHI greater than 5 with sleep-related symptoms or comorbidities. Prior to surgical intervention, all patients should demonstrate inability to successfully use CPAP or other medical therapy options.

Imaging

No required imaging procedures, although lateral cephalometric radiograph may be considered for preoperative planning and documentation of hyoid position.

Indications

1.
Patients with moderate-to-severe OSA (AHI of 15 or greater), who have failed adequate trial of CPAP or other medical therapy, with specific hypopharyngeal collapse at the base of tongue or epiglottis, as demonstrated on supine awake and/or sedated flexible endoscopy ( Fig. 57.2 )
2.
Often used as a multilevel treatment of OSA in conjunction with other sleep surgical interventions aimed at addressing nasal, velopharyngeal, and/or oropharyngeal collapse

Contraindications

1.
Medical comorbidities presenting increased risk for undergoing general anesthesia or upper airway procedures
2.
Prior Sistrunk procedure

Preoperative Preparation

1.
Preoperative anesthesia visit should be performed on all patients due to their history of OSA. Bloodwork, chest radiograph, electrocardiogram, and additional preoperative testing are dictated by the patient age, comorbidities and symptoms, and factors as with any procedure using general anesthesia.
2.
Discontinue antiplatelet drugs.

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Introduction