Hypopharyngeal Procedures and Jaw Advancement Surgery are some of the surgical options available for the treatment of obstructive sleep apnea. In this section, we will explain the procedures, and discuss how they work.
Hypopharyngeal procedures – Surgical Procedures for Sleep Apnea
Hypopharyngeal procedures include the following: tongue radiofrequency, genioglossus advancement, tongue stabilization, partial glossectomy, and hyoid suspension. These procedures treat the blockage of breathing that can occur in the lower part of the throat, often called the hypopharyngeal (or retroglossal or retrolingual) region through a combination of tissue repositioning, tightening, removal, or shrinkage. These procedures are generally performed under general anesthesia in the operating room. Hypopharyngeal procedures are mainly used to treat obstructive sleep apnea, and the procedures can be performed alone or in combination with palate procedures. Specific features of the procedures include the following:
Tongue radiofrequency involves a controlled cauterization of the tongue muscle. This creates small areas of damage in the tongue, leading to formation of a scar that shrinks the tongue slightly and makes the tongue less likely to fall back to block breathing during sleep. Most patients undergoing tongue radiofrequency should expect a total of 2-3 treatment sessions.
Genioglossus advancement takes advantage of the fact that the tongue is mainly muscle, with the largest being the genioglossus muscle that attaches over a relatively small area on the inside of the lower jaw. This procedure involves cutting the portion of the lower jaw where the muscle attaches, pulling the small piece of bone forward to bring the anchor point of the tongue forward and create more room for the tongue to relax during sleep without blocking breathing.
Tongue stabilization holds the tongue in a different way. Through a skin incision on the neck, a screw is placed on the inside of the central part of the lower jaw. A stitch is attached to this screw and is passed through the tongue on one side and brought back through the other side. As the stitch is tied down, it reduces the ability of the tongue to move around, especially to fall back and block breathing during sleep. There are two devices that can be used in tongue stabilization: Medtronic’s AIRvance and Siesta Medical’s Encore System that is part of the AirLift procedure.
Partial glossectomy refers to a number of procedures that involve removal of a portion of the tongue: midline glossectomy, submucosal lingualplasty, submucosal minimally invasive lingual excision (SMILE), and lingual tonsillectomy (often with extension of the tissue removal to include part of the tongue. These procedures are somewhat different, in that they involve physical removal of a portion of the tongue, and they are based on the observation that many patients with sleep apnea appear to have enlarged tongues, likely due not only to having more muscle mass but also to deposition of fat within the tongue. The procedures all differ in their techniques, and this is the procedure that has been performed using a surgical robot.
Hyoid suspension is based on the fact that the hyoid bone, a U-shaped bone in the neck located above the thyroid cartilage (Adam’s apple), has attachments to muscles of the tongue as well as other muscles and soft tissues around the throat. The hyoid bone is mobile in humans, perhaps allowing the structures that attach to it to collapse and cause airway blockage during sleep more easily. Through a neck incision, this procedure secures the hyoid bone either slightly downwards to the thyroid cartilage or upwards to the lower jaw.
Jaw advancement surgery
Jaw advancement surgery (called maxillomandibular advancement or bimaxillary advancement) includes moving the upper and lower jaws forward. It enlarges the space for breathing in the throat because the structures that surround the throat are effectively attached to the jaws. Advancing the jaws moves these structures forward, reducing their ability to produce blockage in the throat. Maxillomandibular advancement surgery has demonstrated better results than the procedures listed above, but this procedure has more substantial risks and recovery. Because it is more involved than other procedures, jaw advancement surgery is usually performed only in patients who have not responded to other procedures. However, in some patients with jaw abnormalities it can be a first-line surgical treatment. In patients with obstructive sleep apnea, this procedure is more complicated than in the typical patient with abnormal jaw positions without sleep apnea; it requires greater movements of the jaws, is technically more difficult for the surgeon, and has greater risks and a more difficult recovery.
Author: Eric Kezirian, MD, MPH