Maxillofacial Surgical Techniques for Hypopharyngeal Obstruction in Obstructive Sleep Apnea

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Indications

From our first case report describing isolated mandibular advancement for the treatment of obstructive sleep apnea (OSA) in 1984, maxillofacial surgical interventions have played significant roles in sleep surgery. Single jaw advancement evolved to maxillary and mandibular advancement (MMA) surgery in the mid-1980s with consistently improved postoperative outcomes in OSA patients.

As an isolated or multilevel procedure, we also described the original genioglossus advancement (GGA) surgery for stabilization of the tongue base. As part of the original phased Stanford protocol, when the preoperative evaluation implicated the base of the tongue (Fujita type II–III) as a source of airway obstruction, GGA was performed as a conservative osteotomy to place the genioglossus, a primary protrusor tongue muscle, under direct tension. The increased tension on the tongue is proposed to resist the collapse of the tongue into the airway that can occur with sleep-induced hypotonia. Patients with residual OSA after phase 1 were then considered for phase 2 surgery: the MMA.

In the original protocol, presurgical evaluation consisted of a comprehensive medical history, head and neck examination, fiber-optic nasopharyngolaryngoscopy, radiographic cephalometric analysis, and polysomnography. Today, the lateral cephalometric analysis is largely replaced by a noncontrast fine-cut maxillofacial computed tomography (CT) scan that can be reconstructed to afford three-dimensional views of the maxillofacial skeleton and posterior airway space. It can also be used for virtual surgical planning (VSP).

The advent of drug-induced sedation endoscopy (DISE) has further augmented our ability to identify patients who would benefit from bypassing phase 1 and going directly to MMA. Liu et al. have identified two key predictive preoperative airway collapse patterns under DISE for surgical success with MMA first: (1) severe lateral pharyngeal wall collapse with (2) circumferential collapse of the velum ( Video 57.1 and Video 57.2 ).

We have also diversified our original GGA with a patient-specific GGA that is designed preoperatively with VSP. We typically include the inferior border of the mandible and the genial tubercle to capture both the genioglossus and suprahyoid muscles with improved accuracy.

In this chapter, we focus on technical nuances and contemporary refinements to our MMA and GGA techniques that have been cultivated since the previous edition.

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Contraindications

Age is a relative contraindication to skeletal surgery, although there are no reliable studies for determination of bone-healing capacity. The oldest patient who effectively underwent MMA to date is 67 years old with no adverse outcome. Patients with rheumatoid arthritis, temporomandibular joint derangement, history of intravenous bisphosphonate use, and connective tissue disorders require further evaluation to determine candidacy for maxillofacial surgery. Other contraindications include compromised lung function, unstable cardiac pathology, drug or alcohol addiction, and psychological instability. Dental limitations such as partial or complete edentulism, severe periodontal disease, and malocclusion are not absolute contraindications, but present challenges that warrant expert assessment.

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Alternative Treatment Options

Positive airway pressure (PAP) therapy, weight loss, positional therapy, and dental devices are nonsurgical treatments, with PAP being the mainstay. Palatopharyngoplasty, tongue base surgery, tongue suspension surgery, and upper airway stimulation can be effective surgical options, especially with multilevel treatment. Bariatric surgery and tracheostomy are options for specific patient phenotypes.

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Anesthesia