|Year : 2018 | Volume
| Issue : 1 | Page : 244-249
Hyoid suspension versus laser midline glossectomy in the management of obstructive sleep apnea
Omar A Elbanhawy1, Ibrahim A Abd Elshafy1, Yasir A Khaleel1, Rana H Elhelbawy2, Ahmed F Abd Elhameed3
1 Department of Otolaryngology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Chest Diseases, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Otolaryngology, Shebin El-Kom Teaching Hospital, Shebin El-Kom, Egypt
|Date of Submission||28-Sep-2015|
|Date of Acceptance||15-Dec-2015|
|Date of Web Publication||14-Jun-2018|
Ahmed F Abd Elhameed
Department of Otolaryngology, Shebin El-Kom Teaching Hospital, Yassin Abd-Alghafar Street, Shebin El-Kom
Source of Support: None, Conflict of Interest: None
The base of the tongue and the hypopharynx are the major sites of obstruction in up to 50% of patients with obstructive sleep apnea (OSA) possibly explaining the cause of failure in palatal surgery. Hyoid suspension and laser midline glossectomy can be used as a surgical treatment for tongue base and hypopharyngeal collapse.
The aim of this study was to compare hyoid suspension type I and laser midline glossectomy in the management of OSA as regards safety, efficiency, and postoperative morbidity and mortality.
Patients and methods
In this study, 30 patients were diagnosed as having OSA by means of polysomnography with retrolingual collapse using Muller maneuver. Fifteen patients were operated upon using hyoid suspension type I and the other 15 patients were operated upon using laser midline glossectomy.
In hyoid suspension type I, the incidence of responder patients [50% or more reduction in their apnea–hypopnea index (AHI) plus reduction in the AHI below 20] was 66.67%, with reduction in the AHI by 77.2%, and the incidence of nonresponder patients was 33.33%, with reduction in the AHI by 36.17%. However, in midline laser glossectomy, the incidence of responder patients was 53.34% with reduction in the AHI by 73.87%, and the incidence of nonresponder patients was 46.67% with reduction in the AHI by 40.79%. Complications were higher in laser midline glossectomy compared with hyoid suspension type I.
Our data indicate that hyoid suspension type I may be safer and more effective with lesser morbidity compared with laser midline glossectomy.
Keywords: hyoid suspension, laser midline glossectomy, obstructive sleep apnea
|How to cite this article:|
Elbanhawy OA, Abd Elshafy IA, Khaleel YA, Elhelbawy RH, Abd Elhameed AF. Hyoid suspension versus laser midline glossectomy in the management of obstructive sleep apnea. Menoufia Med J 2018;31:244-9
|How to cite this URL:|
Elbanhawy OA, Abd Elshafy IA, Khaleel YA, Elhelbawy RH, Abd Elhameed AF. Hyoid suspension versus laser midline glossectomy in the management of obstructive sleep apnea. Menoufia Med J [serial online] 2018 [cited 2020 Feb 22];31:244-9. Available from: http://www.mmj.eg.net/text.asp?2018/31/1/244/234213
| Introduction|| |
Obstructive sleep apnea (OSA) is a common disorder, characterized by recurrent narrowing and closure of the upper airway accompanied by intermittent oxyhemoglobin desaturation and sympathetic activation . Sequelae include excessive sleepiness and impaired quality of life. Moderate-to-severe OSA, defined as an apnea–hypopnea index (AHI) score of 15, or more apnea or hypopnea events per hour, is an independent risk factor for insulin resistance, dyslipidemia, vascular disease, and death,,,,,.
Continuous positive airway pressure is the first-line treatment modality for patients with moderate-to- severe sleep apnea. Long-term compliance with continuous positive airway pressure, however, is estimated to only be 50–70% .
Surgical treatment of OSA begins with evaluation of site (s) of the upper airway narrowing or collapse. Surgical approaches for OSA patients functionally target the retropalatal and the hypopharyngeal region . Fujita and Simmons  described three types of upper airway collapse: retropalatal collapse alone (type I), both retropalatal and hypopharyngeal collapse (type II), and hypopharyngeal collapse alone (type III).
Uvulopalatopharyngoplasty (UPPP), first described by Fujita et al. , is used for the treatment of the retropalatal collapse. For type II and type III collapses, the response rate of UPPP alone, for the surgical treatment of OSA, is shown to be only 5.3% . Therefore, several procedures have been developed to achieve successful response rates in OSA patients with hypopharyngeal obstruction. Among these procedures are hyoid suspension and laser midline glossectomy. There are two types of hyoid suspensions: type I, which is our modification (suturing the hyoid bone to the mandible), and type II (hyoidothreoidepexy). In this study we compare hyoid suspension type I and laser midline glossectomy as regards safety, efficiency, and postoperative morbidity and mortality.
| Patients and Methods|| |
This retrospective cohort study was conducted on 30 patients (18 male and 12 female). Their ages ranged from 32 to 60 years, with a mean age of 45.33 ± 7.77 years selected from the outpatient clinic, Menoufia University Hospital, from May 2014 to May 2015.
The study was conducted after obtaining approval of the Medical Ethical Committee of Menoufia University and after obtaining consent from patients. These 30 patients were diagnosed as having OSA using polysomnography. The site of obstruction, which was hypopharyngeal, was determined by means of flexible fiberoptic nasopharyngoscopy with Muller maneuver. Fifteen patients were operated upon using hyoid suspension type I procedure ( first group) and the other 15 patients were operated upon using laser midline glossectomy (second group). Patients with failure of prior proper UPPP, moderate or severe OSA, and obstructive tongue base anatomy (type III) airway were included in this study. Patients with mild OSA, clinically obvious maxillofacial abnormalities (e.g., retrognathia, AHI >60/h, BMI >34, coagulation disorders, central apnea, and pregnancy) were excluded.
All patients underwent preoperative history taking (partner must be present), and general, nasal, oral cavity, and oropharyngeal examination.
Polysomnography and flexible fiberoptic nasopharyngoscopy with Muller maneuver were performed for all patients before and after surgery.
As regards operative techniques, patients were informed about all possible complications and consent was obtained from all participants.
Surgical technique of hyoid suspension type I applied in this study (without using Repose system)
The Repose system is expensive and sophisticated. It was modified in this study to be feasible in any operating room. The instruments used in Repose system are disposable and inaccessible in Egypt. Our modification depends on making two burr holes using the electric drill with a 1.0-mm surgical cutting burr in the anterior mandible.
Under general anesthesia, the patient is placed supine with hyperextended neck. The position of the hyoid bone is identified and lidocaine 1% with 1:100 000 epinephrine solution is injected in the skin. A horizontal 4–5 cm skin incision is made directly over the hyoid bone and the platysma muscle is split in the midline. Allis clamp is used to grasp the hyoid and a blunt dissection is continued to the posterior aspect of the inferior border of the anterior mandible. Using an electric drill, two burr holes are created below the root of the teeth (incisors) beside the midline and separated by 5 mm. Complete skeletonization of the central segment of the hyoid is carried out by releasing the infrahyoid and the suprahyoid musculature between the lesser cornua. Using prolene 1 suture loaded onto a half curved needle [Figure 1], the needle is passed from the inferior musculature, ∼1 cm from midline, and then retrieved from the superior or suprahyoid muscles. The needle is then passed through the burr hole previously made on that side in the mandible. The suture is then passed a second time around the hyoid bone, inferior to superior just slightly medial of the first pass, and again through the burr hole on the mandible on the same side. Thereafter, a second suture needle is passed superior to inferior ∼1 cm lateral of the midline. The needle is passed through the burr hole on the mandible on the same side and the suture is passed a second time around the hyoid bone, superior to inferior, just slightly medial of the first pass and again through the burr hole of that side. The two ends of each suture is then pulled and knotted on each side; therefore, the hyoid bone will be drawn anterosuperior toward the mandible until the inferior midline muscles become drum tight. A suction drain can be placed, and the incision is appropriately closed and dressed.
Surgical technique of laser midline glossectomy applied in this study
The procedure was performed under general anesthesia, which was delivered using a laser-safe nasoendotracheal tube, using standard laser safety precautions. Hypotensive technique was compulsory. The patient was placed in the tonsillectomy position and the tongue protected with dental wax or wet gauze. The midline of the dorsum of the tongue base was identified using a bifid tongue blade, and marked with methylene blue injection behind the circumvallate papillae. Care must be taken to stick to the midline. Mucosal incision was marked for glossectomy on both sides of the midline by means of cautery. It should be 2–2.5 cm in width. The tongue may be folded on itself, and hence care must be taken to avoid excessive tension. The CO2 laser was used to excise 4–5 cm along the midline portion of the tongue. Excision was carried out as deeply as possible and assisted by vigorous countertraction on the excised segment using an Allis or similar clamp [Figure 2]. Initial incision should be deep to provide a firm grasp with the clamp because the strong countertraction needed cannot be performed with mucosa alone and requires a solid portion of the tongue muscle. After removal of the midline segment with the mouth gag in place, the prolapsed part of tongue tissues may prevent further excision of the redundant midline tissues. Hence, at this stage the mouth gag was removed and we use the hypopharyngoscope to expose the most posterior aspect of the tongue. The CO2 laser is connected to surgical microscope to reach the deeper redundant midline tissues.
Patients received antibiotics, analgesics, and antiedematous drugs for 10 days after surgery and routine follow-up during the postoperative period to monitor surgical healing and manage any complications. All patients were encouraged to undergo a repeat polysomnography and flexible fiberoptic nasopharyngoscopy with Muller maneuver 12 weeks after surgery to document the presence of improvement in sleep-related respiratory parameters.
| Results|| |
Thirty patients with OSA were included in this study. The age of patients ranged from 32 to 60 years, with a mean age of 45.33 ± 7.77 years. Male patients represented 60% (18) and female patients represented 40% (12) of the studied groups.
Patients were divided into two groups. Each group comprised 15 age-matched and sex-matched patients, with a predominance of male patients in both groups. The first group was operated upon by means of hyoid suspension type I, and thesecondgroup was operated upon using laser midline glossectomy.
According to the degree of the postoperative changes in the number of apneas–hypopneas per hour of sleep (AHI), patients were divided into responders and nonresponders. Patients who showed 50% or more reduction in their AHI plus reduction in AHI below 20 were considered responders, whereas patients who did not reach this level of reduction were considered nonresponders according to Sher's criteria .
Ten (66.67%) patients in the first group were responders and eight (53.33%) patients in the second group were responders. In the first group, the mean AHI preoperatively was 38.40 ± 10.54 and decreased to 15.47 ± 12.61 postoperatively with a statistically significant (P < 0.05). The AHI reduced by 63.6%. The mean oxygen saturation preoperatively was 73 and increased to 83.7 postoperatively with a statistically significant (P < 0.05) [Table 1]. In the second group the mean AHI preoperatively was 40.07 ± 13.46 and decreased to 18.47 ± 12.40 postoperatively with a statistically significant (P < 0.05). The AHI reduced by 58.4%. The mean oxygen saturation preoperatively was 75 and was increased to 82.26 postoperatively with a statistically significant (P < 0.05) [Table 2], [Figure 3], [Figure 4].
|Table 1: Comparison of mean preoperative and postoperative apnea-hypopnea index and oxygen saturation in Group I|
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|Table 2: Comparison of mean preoperative and postoperative apnea-hypopnea index and oxygen saturation in Group II|
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|Figure 3: Mean preoperative and postoperative apnea–hypopnea index (AHI) in the first and second group.|
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|Figure 4: Mean preoperative and postoperative oxygen saturation in the first and second group.|
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| Discussion|| |
The use of hyoid suspension (type I) for OSA was initially described by Riley et al. , who described suspending the hyoid with fascia lata passed around the hyoid and sutured to the mandibular periosteum.
The same group of authors later proposed a revised technique, in which the hyoid was brought anteriorly and secured to the superior border of the thyroid cartilage with permanent suture through a single cervical incision (type II).
The Repose suspension suture system was first introduced in the late 1990s as a device to provide stabilization to the tongue during sleep. The Repose system is expensive and not routinely available in Egypt.
Therefore, in our study, instead of using the Repose system, our modification depends on making two burr holes using the electric drill with a 1.0-mm surgical cutting burr in the anterior mandible.
The use of the other technique (laser midline glossectomy) in the second group, as an example of reduction surgery, was chosen to compare it with type I hyoid suspension.
Fujita et al.  described laser midline glossectomy and extended to the epiglottis. Woodson and Fujita  suggested performing lingualoplasty by suturing the tongue furrow in the midline after wedge resection to stretch the tongue and advance it. In our study, laser midline glossectomy without lingualoplasty was performed.
In the first group, the mean AHI preoperatively was 38.40 ± 10.54 and decreased to 15.47 ± 12.61 postoperatively with a statistically significant (P < 0.05). The AHI reduced by 63.6%. The mean oxygen saturation preoperatively was 73.07 ± 4.99 and was increased to 83.73 ± 7.19 postoperatively with a statistically significant P- value.
Ten (66.67%) patients in the first group were responders. These results are in agreement with a study by Riley et al.  on 55 patients with OSA syndrome evaluated following inferior mandibular osteotomy with hyoid myotomy and suspension type I using fascia lata strands. Thirty-seven (67%) patients had a good response from surgery, and 18 (33%) patients were considered nonresponders.
However, Bowden et al.  did not find such good results in a study conducted on 29 patients who underwent hyoid suspension type II; only five of 29 patients achieved a successful outcome. The AHI did not change significantly for the group as a whole, although the lowest oxygen saturation did show some improvement. The mean preoperative AHI was 36.5 ± 27.6. The mean postoperative AHI was unchanged. The mean oxygen saturation before surgery was 72.7% and improved to 78%. However, in a study by Stuck et al. , 15 patients received isolated hyoid suspension type I; the AHI was reduced from 35.2 ± 19.1 to 27.4 ± 26.2, and only 40% of the patients were classified as responders. Moreover, daytime sleepiness improved significantly.
In another study by Riley et al. , 15 patients underwent isolated hyoid suspension type II procedure to correct hypopharyngeal obstruction. Postoperative sleep studies and subjective symptomatology revealed that 75% achieved correction of their excessive daytime sleepiness and marked improvement in their sleep disorder. The mean preoperative and postoperative AHI were 44.7 ± 22.6 and 12.8 ± 6.9, respectively, whereas the mean preoperative and postoperative oxygen saturation were 82 ± 6% and 86 ± 5%, respectively. Neruntarat  reported successful outcomes in 78%.
In the second group, the mean AHI preoperatively was 40.07 ± 13.46 and decreased to 18.47 ± 12.40 postoperatively, with statistically significant P- value. The mean oxygen saturation preoperatively was 75.07 ± 3.33 and was increased to 82.27 ± 4.13 postoperatively, with statistically significant P value. Eight (53.33%) patients in the second group were responders.
Fujita et al.  in their initial experience on 12 patients found that laser midline glossectomy was the sole procedure performed in 11 patients who had failed UPPP and one patient diagnosed with primarily hypopharyngeal narrowing. The results of their study revealed five (42%) patients who were considered responders with improvement in mean apnea index from 37.6 apnea events per hour preoperatively to 6.2 apnea events per hour postoperatively (>80% reduction).
However, two different studies used Sher's criteria of success ,; on combining UPPP and midline glossectomy a success rate of 60% was achieved, defined as a reduction in the AHI of more than 50%.
In the first group, there was no intraoperative bleeding in all cases but there was pain and mild dysphagia in the first week for all patients, which subsided with analgesics. There was no postoperative infection in any patient. Five (33.3%) patients developed neck seroma in the week following surgery. The seromas responded to serial aspirations and pressure dressings.
Among 39 patients who underwent hyoid suspension type II in a study of hyoid suspension complications by Richard et al. , one patient had a deviated tongue for a short period, which resolved within a few weeks postoperatively. Minor complications occurred in six patients. The following infections were observed in two patients: a wound abscess in one case and fistula in two cases. One patient underwent a tracheotomy within a few hours after surgery because of an imminent compromised airway due to postoperative bleeding. After 2 days, the tracheotomy was closed again. No major complications were seen.
In the second group, there was no intraoperative bleeding in 12 (80%) patients. The laser can act as a hemostatic tool. Three (20%) patients had bleeding during operation that was controlled with electrocautery, which was essential. There was severe pain and dysphagia in the first 2 weeks for all patients, which subsided with analgesics. Four (26.6%) patients had persistent pain for 3 weeks; three (20%) patients had fungal infection in their oral cavity from severe pain and dysphagia. Oral antifungal gel and efficient analgesics improved the condition.
However, in a study by Hou et al. , two participants experienced perioperative tongue swelling. These participants were transferred to the ICU and extubated the day after surgery. After extubation, three participants experienced a decrease in oxygen saturation. All three participants recovered after insertion of an oropharyngeal catheter, which was removed the following day once respiration had been stabilized after combined UPPP and laser midline glossectomy.
| Conclusion|| |
Our data indicate that hyoid suspension type I may be safer and more effective with lesser morbidity compared with laser midline glossectomy.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]