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Maxillofacial Surgical Techniques for Hypopharyngeal Obstruction in Obstructive Sleep Apnea

1 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…

Multilevel Surgery With or Without Genioglossal Advancement

1 Introduction Severe obstructive sleep apnea syndrome (OSAS) is preferably treated by nasal continuous positive airway pressure (NCPAP). Unfortunately, 30% to 50% of patients refuse or cannot accept NCPAP for a variety of reasons. Approximately 25% of patients refuse it up front or cannot pass the test period; others cannot accept it or refuse it in the long run, or use it for only a few…

Transoral Robotic Surgery (TORS) for OSA

1 Introduction The importance of lingual tonsil hypertrophy has long been recognized as a significant factor in obstructive sleep apnea (OSA), but only recently with the advent of transoral robotic surgery (TORS) do sleep surgeons have a tool that can effectively and safely manage this pathology in the retrolingual region. Friedman and Myung Sung have recently provided details of lingual tonsil hypertrophy, including practical classification systems.…

Management of the Epiglottis

This chapter reviews the role of the epiglottis in obstructive sleep apnea (OSA) and surgical management of its obstructive capacity. Although it has been well recognized for years that multiple levels of obstruction are responsible for OSA, most authors focus on nasal, retropalatal, and retroglossal obstruction as the three major sites of collapse. Relatively little literature has been devoted to the role of the epiglottis in…

Hyoid Suspension as the Only Procedure

1 Introduction 1.2 Indications and Contraindications Obstruction of the airway at the retropalatinal and retropharyngeal airway is the key factor in the pathophysiology of obstructive sleep apnea syndrome (OSAS). Patient selection is crucial in successful surgery of the upper airway in OSAS. In addition to polysomnography, topical diagnostic workup is of paramount importance in this regard. We routinely perform polysomnography first and after that in cases…

Genioglossus Advancement in Sleep Apnea Surgery

1 Introduction The genioglossus muscle originates from the genial tubercle, inserts posteriorly at the tip of the tongue and the dorsum of the tongue, and into the body of the hyoid bone ( Fig. 52.1 ). The fibers retract the tip of the tongue, depress the dorsum of the tongue, and move the hyoid in an anterosuperior direction. The muscle receives the majority of its blood…

External Submucosal Glossectomy

1 Introduction The major contributing factors to retrolingual collapse in sleep apnea are macroglossia, hypotonia, retrognathia, and lingual tonsillar hyperplasia. Any or all of these may contribute to varying degrees in any given individual. All current low-morbidity options have limitations in treating the macroglossia component. The ideal procedure for macroglossia would have low morbidity, allow large tissue volume reduction, have low risk of alteration in tongue…

Multilevel Pharyngeal Surgery for Obstructive Sleep Apnea

1 Introduction Obstructive sleep apnea (OSA) is a common sleep disorder. It is characterized by repetitive apneas and hypopneas during sleep. These events are due to partial or complete collapse of the upper airway, resulting in decreased oxygenation and sympathetic overdrive. Frequent arousals occur, causing sleep fragmentation, which leads to excessive daytime sleepiness, morning headaches, poor concentration, memory loss, frustration, depression, and even marital discord. The…

Hypoglossal Nerve Stimulation: Targeted Neurostimulation Device for Treatment of Obstructive Sleep Apnea

1 Introduction Obstructive sleep apnea (OSA) is a multi-factorial disorder where state-dependent loss of upper airway muscle tone and neuromuscular dysfunction result in cyclical upper airway obstruction during sleep. Hypoglossal neurostimulation is a new, functional approach to treating OSA that specifically addresses neuromuscular dysfunction, as opposed to conventional therapies such as positive airway pressure, oral appliance therapy, and reconstructive upper airway surgery, that act via direct,…

Upper Airway Stimulation: Implanted Neurostimulation Device for Treatment of Obstructive Sleep Apnea

1 Introduction Upper airway stimulation is a novel approach to the management of obstructive sleep apnea (OSA). Hypoglossal nerve stimulation (HNS) therapy has been shown to improve objective respiratory and subjective quality-of-life outcomes and is well positioned as a new second-line treatment for moderate to severe OSA. 2 Scientific Rationale The development of HNS therapy has been driven by a need for new OSA treatments, as…

Electrical Stimulation of the Upper Airway

1 Introduction Sleep-disordered breathing results from a combination of factors affecting upper airway patency and the control of ventilation. Although the mechanisms underlying upper airway collapse are incompletely understood, a decline in pharyngeal neuromuscular activity during sleep appears to play a critical role. This knowledge has supported the notion that stimulation of upper airway muscles may represent a specific approach to the treatment of obstructive sleep…

Endoscopic Coblation Lingual Tonsillectomy

1 Introduction For the clinician and surgeon treating patients with obstructed sleep apnea and related maladies, the retrolingual airway is of great importance. This area, often difficult to examine and identify as an area of concern, has recently been the site of much academic and surgical attention. For with its difficult location comes increased complexity in surgical cure, plagued with both intra-operative and postoperative challenges. Although…

Tongue Base Stabilization for Obstructive Sleep Apnea and Snoring

1 Introduction Obstructive sleep apnea syndrome (OSA) results from a complex scenario initiated with airway collapse and obstruction, loss of compensatory wake and sleep reflexes, increased ventilatory effort, arousal, hypoventilation, and asphyxia during sleep. In adults, a structurally small upper airway may be a primary contributing factor. Enlarging this airway may prevent the cascade into sleep apnea and snoring. The small upper airway in adults may…

Endoscopic Coblator Open Tongue Base Resection for Obstructive Sleep Apnea

As we trace the advancements of obstructive sleep apnea (OSA) surgery, it is important to realize that tongue base surgery has remained a challenge. Traditional hypopharyngeal/tongue base procedures for OSA are usually aggressive, time consuming, and technically advanced. Some previously reported cases even needed temporary postoperative tracheotomy. Kezirian et al. reported on the types of surgeries performed for OSA in four US states. They found that only…

Radiofrequency Tissue Effects

Radiofrequency (RF) energy has been used in medicine for numerous applications, including cutting tissue, vessel coagulation, and tissue volume reduction. There are unipolar, bipolar, and even multipolar devices in use at present. The goal of using RF in sleep-disordered breathing (SDB) would be the third application: tissue volumetric reduction. 1 Indications for Treatment Patients diagnosed with SDB may have obstruction at the following anatomic sites: the…

Fundamentals of Minimally Invasive Radiofrequency Applications in Ear, Nose, and Throat Medicine

Ear, nose, and throat (ENT) medicine currently has several different systems at its disposal for minimally invasive treatments that apply high-frequency electric current to achieve a therapeutic effect. This chapter is intended to provide a survey of the technical fundamentals and tissue effects of such systems. With the purpose of deepening the understanding of the use of high-frequency current for medical applications, an overview of the…

Barbed Snore Surgery (BSS)

1 Introduction It became clear at the dawn of the third millennium that the real origin of obstructive sleep-disordered breathing (OSDB), snoring, and obstructive sleep apnea/hypopnea syndrome (OSAHS) was the hypercollapsibility of the upper airway walls (UAWs), more frequently located at the retropalatal and/or retrolingual level. This is primarily resulting from the inability of neuromuscular structures to maintain sufficient parietal tension to resist the internal negative…

Lateral Pharyngoplasty

1 Introduction As new concepts have emerged in the medical literature for sleep apnea and also based on our own experience, lateral pharyngoplasty (LP) was developed and updated several times since we first published it in 2003 ( ; ; ; ; ; ; ; ). The main factors that have led to the evolution of our technique described here and wider applicability to patients are…

Expansion Sphincter Pharyngoplasty

1 Introduction Snoring results from the vibration of the soft tissues in the oral cavity: the soft palate, uvula, tonsils, base of tongue, epiglottis, and lateral pharyngeal walls. These may lead to collapse of the upper airway. It is known that when inspiratory transpharyngeal pressure exceeds the pharyngeal dilating muscle action, apneas and hypopneas occur. Collapse of the upper airway is usually multilevel, at the level…

Transpalatal Advancement Pharyngoplasty

Successful surgical treatment of obstructive sleep apnea (OSA) continues to be a challenging goal. Maxillomandibular advancement (MMA) remains the gold standard of surgical care, but its use is limited due to its perceived morbidity, associated cosmetic changes, frequent requirements for additional orthodontic treatment, and cost. No other surgical procedure demonstrates similar success for a broad spectrum of patients. There is a need for more selective surgical…