Acta Oto-Laryngologica
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Glossopexia—Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome H. Faye‐Lund, G. Djupesland & T. Lyberg To cite this article: H. Faye‐Lund, G. Djupesland & T. Lyberg (1992) Glossopexia—Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome, Acta OtoLaryngologica, 112:sup492, 46-49, DOI: 10.3109/00016489209136808 To link to this article: http://dx.doi.org/10.3109/00016489209136808
Published online: 08 Jul 2009.
Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [RMIT University Library]
Date: 29 March 2016, At: 18:05
Acta Otolaryngol (Stockh) 1992; Suppl. 492: 46-49
Glossopexia- Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome H. FAYE-LUND,' G. DJUPESLAND' and T. LYBERQ From the Departments of 'Otorhinolaryngology and 2Maxillofacial surgery, Ullevdl Hospital, University of Oslo, Norway
Acta Oto-Laryngologica 1992.112:46-49.
Faye-Lund H, Djupesland G, Lyberg T. Glossopexia-evaluation of a new surgical method for treating obstructive sleep apnea syndrome. Acta Otolaryngol (Stockh) 1992; Suppl492: 46-49.
Uvulopalatopharyngoglossoplasty,UPPGP, is a modification of the uvulopalatopharyngoplasty, UPPP, technique, originally used for surgical treatment of the obstructive sleep apnea syndrome. The first method seems to be the more successful. However, polysomnography performed after UPPGP showed that about 35% of the patients still had obstructive apnea periods during sleep. Eight of these patients were reoperated with a new technique which is a combination of partial tongue resection and anterior suspension of the tongue (glossopexia). After glossopexia all the patients were subjectively relieved of their symptoms. However, polysomnography carried out postoperatively demonstrated that only 2 patients were objectively cured. The authors want to stress the necessity of meticulous polysomnographical registration pre- and postoperatively. Subjectiveand objective parameters recorded before and after surgery are discussed. Key words: sleep apnea, palato-pharyngo%lossoplasty, UPPP, UPPGP, glossopexia, objective improvement.
INTRODUCTION Obstructive sleep apnea syndrome, OSA, is caused by upper airway obstruction at several levels, and may lead to serious heart and lung failure in adults (1) as well as in children (2,3). During sleep the muscles relax and a collapse of the airways may be the result. It has been demonstrated by cephalometric recordings that patients with OSA have certain anatomical characteristics (4, 5). Uvulopalatopharyngoplasty, UPPP, as originally described by Fujita et al. (6), is the surgical procedure of choice for treatment of OSA. Most investigators using UPPP have experienced a marked discrepancy in subjective and objective response as substantiated by objective measures of sleep-related respiratory impairment. Simmons et al. (7) pointed out the importance of performing polysomnography postoperatively in order to evaluate the results objectively. A cure rate of 45% was obtained in their material, while Dickson & Blakmanis (8) demonstrated a cure rate of 77%, and Riley et al. (9) one of approximately 90%. Still a considerable number of OSA patients operated on with UPPP is not cured. Against this background we strongly felt a need for additional or alternative surgical methods for these patients. Based on the fact that the size and position of the tongue may play an important part in the syndrome we have developed a surgical approach combining a reduction of and an anterior suspension of the tongue. The technique is described and the results obtained in a study group of 8 patients evaluated. MATERIAL AND METHODS Eight patients with polysomnographicallydocumented OSA underwent another polysomnography which still revealed obstructive apnea episodes during sleep and low O2 saturation values (down to 64%). A high number of apneas and hypopneas was demonstrated (see
Glossopexia 47
Table I. Polysomnographic recordings in 8 patients with OSA syndrome treated with glossopexia. The j7gures show pre- and post- (in parentheses) operative values Obstructive apnea
Acta Oto-Laryngologica 1992.112:46-49.
Patient/Age
Obstructive hypapnea
No.
Duration
No.
Duration
Min. 0,saturation
150-(221) 78-(3) 119-(35) 19-(40) 181-(0) 64-(63) 274-( 70) 102-( 15)
24-(26) 26-( 55) 21-(15) 24-( 26) 22-(0) 24-(32) 44-(45) 30-( 13)
153-( 10) 334-(315) 79-( 59) 49-(16) 180-(0) 33-(40) 6-( 14) 130-(45)
22-( 12) 24-( 19) 19-( 15) 24-( 24) 22-(0) 21-(27) 3-(32) 9-(15)
85-(76) 70 80-( 84) 82-(86) 64-(80) 87( -84) (77) (75)
Table I). Cephalometry was performed using standard techniques in all patients pre- and postoperatively. Appreciating the size and position of the tongue as a potential cause of oropharyngeal obstruction we have developed a surgical technique which combines a tongue resection plasty and anterior suspension of the tongue (Fig. 1). The tongue reduction was done as a spindle-shaped/V-shaped excision in the midline starting 2-3 cm from the tip of the tongue and extending as far back as technically possible. Strips of fascia lata (1 x 25 cm) were harvested and applicated as a triangular sling in the body of the tongue with the base in the dorsal part of the tongue reduction area. The ends of the strip were passed through two bur holes in the mandible subdentally in the genial region and sutured to each other after maximal anterior suspension of the tongue. All patients were tracheotomized. The tracheostomas were closed successfully at the end of the hospital stay in all the patients. All the patients were reexamined 12-24 months postoperatively. The examination consisted of a questionnaire, clinical ENT examination, polysomnography and cephalometry. In the cephalometric analysis special references were made to the position of the hyoid bone and the posterior airway space which is measured at the narrowest dimension between the base of the tongue and the posterior pharyngeal wall. RESULTS Subjectively all patients reported substantial to moderate improvement regarding excessive daytime sleepiness. However, the polysomnograms showed reliable improvement in only 2 of the patients. The frequency and duration of apneas and hypopneas before and after surgery are shown in Table I. The cephalometry revealed that neither the vertical nor the horizontal position of the hyoid bone was significantly influenced by the glossopexia technique (minimal observation period being 12 months). Further, the posterior airway space was essentially the same pre- and postoperatively, 8, 0 3, 2 mm (SD) and 8, 2 f 3, 5 mm, respectively. Six patients had a weight loss during the treatment (range 8-20 kg). As the patients also had been tracheotomized it is difficult to relate the weight loss to the glossopexia. In only one of the patients the glossopexia operation changed their snoring habits. Two of the patients claimed that the negative side-effects were so troublesome that they had preferred not to be operated on. The negative side-effects were decreased sensitivity of the chin and the tongue,
Acta Oto-Laryngologica 1992.112:46-49.
48 H.Faye-Lund et al.
Fig. 1. Schematic illustration of the surgical technique of glossopexia. The area surrounded by the dotted line is removed. The fascia lata is applicated as a sling in the body of the tongue, the ends passed through two holes in the mandible and sutured to each other after maximal anterior suspension of the tongue.
immobility of the tongue, decreased sense of taste and slight difficulties of articulation. The ENT examination revealed satisfying conditions concerning the mouth and pharynx in 6 of the patients. One patient was not able to protrude his tongue in front of his teeth. The hospitalization time postoperatively vaned between 7 and 29 days. One patient had to stay for 29 days, because of a large edema of the tongue postoperatively. One patient was reoperated on after 6 months because the fascia lata was rejected. One patient was readmitted to hospital after 2 weeks because of a serious infection in the tracheostoma spreading to the mediastinum. DISCUSSION Obstructive sleep apnea syndrome is a complex condition with several anatomical structures in the upper airways involved. This has led to various modalities of treatment (for a review, see Moran & Orr, 1985 (10)). Presurgical tests are mandatory in order to logically direct treatment (4,9). Half of the patients do not benefit from uvulopalatopharyngoplasty,UPPP. The glossopexia is a surgical method where two aims are achieved: Firstly, a reduction, and
Acta Oto-Laryngologica 1992.112:46-49.
Glossopexia 49
secondly an anterior suspension of the tongue. Eight patients unsuccessfully treated by UPPGP underwent glossopexia. All the patients experienced a subjective improvement postoperatively. However, neither polysomnography (Table I) nor cephalometry showed any reliable improvement in more than 2 or 3 of 8 patients. From Table I it can be seen that the numbers and duration of the apnea and hypopnea episodes vary a great deal. Patients M54 and M50 had reliable improvement after the operation, and patients M46 and M63 may have been helped. The remaining 4 patients showed no alterations regarding their quality of sleep. The present investigation shows how unreliable subjective statements concerning improvements in the quality of sleep are. Polysomnography is an important diagnostic tool in the documentation of the results obtained by surgery. A comparison of the apnea/hypopnea index and the oxygen saturation, pre- and postoperatively is insufficient in order to evaluate the results of surgery. A commonly used criterion of success of UPPP is a 50% reduction of the apnea index. Fragmental sleep, daytime sleepiness and clinically significant deoxygenation may persist although the number of apneas is reduced by more than half ( 1 1). Attention to hypopneas postoperatively is also essential. A more precise measure of sleep fragmentation, with very brief arousals and awakenings, is perhaps necessary if sleep disturbance is to be quantified. The present study shows that not only the number of apneas and hypopneas but also the duration of these episodes are important factors in assessing the benefits of the treatment. REFERENCES 1. Buda AJ, Schroeder JS, Guilleminault C. Abnormalities of pulmonary artery wedge pressure in sleep
induced apnea. Int J Cardial 1981, 174. 2. Djupesland G, Godtliebsen OB, Langslet A, Nustad A. Sleep induced obstruction of the upper airways in children with congenital heart defects and epileptic seizures. Peadiatr Otorhinolaryngol 1988, 663-1. 3. Swift AC. Upper airway obstruction, sleep disturbances and adenotonsillectomy in children. J Laryngol Otol 1988; 102: 419-22. 4. Djupesland G, Lyberg T, Krogstad 0. Cephalometric analysis and surgical treatment of patients with obstructive sleep apnea syndrome. A preliminary report. Acta Otolaryngol (Stockh) 1987; 103: 551 -7. 5. Lyberg T, Krogstad 0, Djupesland G. Cephalometric analysis in patients with obstructive sleep apnea syndrome. I. Skeletal morphology and 11. Soft tissue morphology. J Laryngol Otol 1989; 103: 287-97. 6. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomical abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty.Otolaryngol Head Neck Surg 198I; 89: 804-10. 7. Simmons FG, Guilleminault C, Silvestri R. Snoring, and some obstructive sleep apnea, can be cured by oropharyngeal surgery: Palatopharyngoplasty. Arch Otolaryngol 1983; 109: 503-7. 8. Dickson RI, Blokmanis A. Treatment of obstructive sleep apnea by uvulopalatopharyngoplasty. Laryngoscope 1987; 97: 1054-59. 9. Riley RW, Powell N, Guilleminault C. Current surgical concepts for treating obstructive sleep apnea syndrome. J Oral Maxillofac Surg 1987; 45: 149-57. 10. Moran WB, Orr WC. Diagnosis and management of obstructive sleep apnea. Part 11. Arch Otolaryngol 1985; 111: 650-7. 11. Kavey NB, Whyte J, Blitzer A, Gidro-Frank S. Postsurgical evaluation of uvulopalatopharyngoplasty: Two case reports. Sleep 1990; 13: 79-84. Address for correspondence: H. Faye-Lund, Department of Otolaryngology, Ullevll Hospital, Oslo, Norway
ISSN: 0001-6489 (Print) 1651-2251 (Online) Journal homepage: http://www.tandfonline.com/loi/ioto20
Glossopexia—Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome H. Faye‐Lund, G. Djupesland & T. Lyberg To cite this article: H. Faye‐Lund, G. Djupesland & T. Lyberg (1992) Glossopexia—Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome, Acta OtoLaryngologica, 112:sup492, 46-49, DOI: 10.3109/00016489209136808 To link to this article: http://dx.doi.org/10.3109/00016489209136808
Published online: 08 Jul 2009.
Submit your article to this journal
Article views: 9
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ioto20 Download by: [RMIT University Library]
Date: 29 March 2016, At: 18:05
Acta Otolaryngol (Stockh) 1992; Suppl. 492: 46-49
Glossopexia- Evaluation of a New Surgical Method for Treating Obstructive Sleep Apnea Syndrome H. FAYE-LUND,' G. DJUPESLAND' and T. LYBERQ From the Departments of 'Otorhinolaryngology and 2Maxillofacial surgery, Ullevdl Hospital, University of Oslo, Norway
Acta Oto-Laryngologica 1992.112:46-49.
Faye-Lund H, Djupesland G, Lyberg T. Glossopexia-evaluation of a new surgical method for treating obstructive sleep apnea syndrome. Acta Otolaryngol (Stockh) 1992; Suppl492: 46-49.
Uvulopalatopharyngoglossoplasty,UPPGP, is a modification of the uvulopalatopharyngoplasty, UPPP, technique, originally used for surgical treatment of the obstructive sleep apnea syndrome. The first method seems to be the more successful. However, polysomnography performed after UPPGP showed that about 35% of the patients still had obstructive apnea periods during sleep. Eight of these patients were reoperated with a new technique which is a combination of partial tongue resection and anterior suspension of the tongue (glossopexia). After glossopexia all the patients were subjectively relieved of their symptoms. However, polysomnography carried out postoperatively demonstrated that only 2 patients were objectively cured. The authors want to stress the necessity of meticulous polysomnographical registration pre- and postoperatively. Subjectiveand objective parameters recorded before and after surgery are discussed. Key words: sleep apnea, palato-pharyngo%lossoplasty, UPPP, UPPGP, glossopexia, objective improvement.
INTRODUCTION Obstructive sleep apnea syndrome, OSA, is caused by upper airway obstruction at several levels, and may lead to serious heart and lung failure in adults (1) as well as in children (2,3). During sleep the muscles relax and a collapse of the airways may be the result. It has been demonstrated by cephalometric recordings that patients with OSA have certain anatomical characteristics (4, 5). Uvulopalatopharyngoplasty, UPPP, as originally described by Fujita et al. (6), is the surgical procedure of choice for treatment of OSA. Most investigators using UPPP have experienced a marked discrepancy in subjective and objective response as substantiated by objective measures of sleep-related respiratory impairment. Simmons et al. (7) pointed out the importance of performing polysomnography postoperatively in order to evaluate the results objectively. A cure rate of 45% was obtained in their material, while Dickson & Blakmanis (8) demonstrated a cure rate of 77%, and Riley et al. (9) one of approximately 90%. Still a considerable number of OSA patients operated on with UPPP is not cured. Against this background we strongly felt a need for additional or alternative surgical methods for these patients. Based on the fact that the size and position of the tongue may play an important part in the syndrome we have developed a surgical approach combining a reduction of and an anterior suspension of the tongue. The technique is described and the results obtained in a study group of 8 patients evaluated. MATERIAL AND METHODS Eight patients with polysomnographicallydocumented OSA underwent another polysomnography which still revealed obstructive apnea episodes during sleep and low O2 saturation values (down to 64%). A high number of apneas and hypopneas was demonstrated (see
Glossopexia 47
Table I. Polysomnographic recordings in 8 patients with OSA syndrome treated with glossopexia. The j7gures show pre- and post- (in parentheses) operative values Obstructive apnea
Acta Oto-Laryngologica 1992.112:46-49.
Patient/Age
Obstructive hypapnea
No.
Duration
No.
Duration
Min. 0,saturation
150-(221) 78-(3) 119-(35) 19-(40) 181-(0) 64-(63) 274-( 70) 102-( 15)
24-(26) 26-( 55) 21-(15) 24-( 26) 22-(0) 24-(32) 44-(45) 30-( 13)
153-( 10) 334-(315) 79-( 59) 49-(16) 180-(0) 33-(40) 6-( 14) 130-(45)
22-( 12) 24-( 19) 19-( 15) 24-( 24) 22-(0) 21-(27) 3-(32) 9-(15)
85-(76) 70 80-( 84) 82-(86) 64-(80) 87( -84) (77) (75)
Table I). Cephalometry was performed using standard techniques in all patients pre- and postoperatively. Appreciating the size and position of the tongue as a potential cause of oropharyngeal obstruction we have developed a surgical technique which combines a tongue resection plasty and anterior suspension of the tongue (Fig. 1). The tongue reduction was done as a spindle-shaped/V-shaped excision in the midline starting 2-3 cm from the tip of the tongue and extending as far back as technically possible. Strips of fascia lata (1 x 25 cm) were harvested and applicated as a triangular sling in the body of the tongue with the base in the dorsal part of the tongue reduction area. The ends of the strip were passed through two bur holes in the mandible subdentally in the genial region and sutured to each other after maximal anterior suspension of the tongue. All patients were tracheotomized. The tracheostomas were closed successfully at the end of the hospital stay in all the patients. All the patients were reexamined 12-24 months postoperatively. The examination consisted of a questionnaire, clinical ENT examination, polysomnography and cephalometry. In the cephalometric analysis special references were made to the position of the hyoid bone and the posterior airway space which is measured at the narrowest dimension between the base of the tongue and the posterior pharyngeal wall. RESULTS Subjectively all patients reported substantial to moderate improvement regarding excessive daytime sleepiness. However, the polysomnograms showed reliable improvement in only 2 of the patients. The frequency and duration of apneas and hypopneas before and after surgery are shown in Table I. The cephalometry revealed that neither the vertical nor the horizontal position of the hyoid bone was significantly influenced by the glossopexia technique (minimal observation period being 12 months). Further, the posterior airway space was essentially the same pre- and postoperatively, 8, 0 3, 2 mm (SD) and 8, 2 f 3, 5 mm, respectively. Six patients had a weight loss during the treatment (range 8-20 kg). As the patients also had been tracheotomized it is difficult to relate the weight loss to the glossopexia. In only one of the patients the glossopexia operation changed their snoring habits. Two of the patients claimed that the negative side-effects were so troublesome that they had preferred not to be operated on. The negative side-effects were decreased sensitivity of the chin and the tongue,
Acta Oto-Laryngologica 1992.112:46-49.
48 H.Faye-Lund et al.
Fig. 1. Schematic illustration of the surgical technique of glossopexia. The area surrounded by the dotted line is removed. The fascia lata is applicated as a sling in the body of the tongue, the ends passed through two holes in the mandible and sutured to each other after maximal anterior suspension of the tongue.
immobility of the tongue, decreased sense of taste and slight difficulties of articulation. The ENT examination revealed satisfying conditions concerning the mouth and pharynx in 6 of the patients. One patient was not able to protrude his tongue in front of his teeth. The hospitalization time postoperatively vaned between 7 and 29 days. One patient had to stay for 29 days, because of a large edema of the tongue postoperatively. One patient was reoperated on after 6 months because the fascia lata was rejected. One patient was readmitted to hospital after 2 weeks because of a serious infection in the tracheostoma spreading to the mediastinum. DISCUSSION Obstructive sleep apnea syndrome is a complex condition with several anatomical structures in the upper airways involved. This has led to various modalities of treatment (for a review, see Moran & Orr, 1985 (10)). Presurgical tests are mandatory in order to logically direct treatment (4,9). Half of the patients do not benefit from uvulopalatopharyngoplasty,UPPP. The glossopexia is a surgical method where two aims are achieved: Firstly, a reduction, and
Acta Oto-Laryngologica 1992.112:46-49.
Glossopexia 49
secondly an anterior suspension of the tongue. Eight patients unsuccessfully treated by UPPGP underwent glossopexia. All the patients experienced a subjective improvement postoperatively. However, neither polysomnography (Table I) nor cephalometry showed any reliable improvement in more than 2 or 3 of 8 patients. From Table I it can be seen that the numbers and duration of the apnea and hypopnea episodes vary a great deal. Patients M54 and M50 had reliable improvement after the operation, and patients M46 and M63 may have been helped. The remaining 4 patients showed no alterations regarding their quality of sleep. The present investigation shows how unreliable subjective statements concerning improvements in the quality of sleep are. Polysomnography is an important diagnostic tool in the documentation of the results obtained by surgery. A comparison of the apnea/hypopnea index and the oxygen saturation, pre- and postoperatively is insufficient in order to evaluate the results of surgery. A commonly used criterion of success of UPPP is a 50% reduction of the apnea index. Fragmental sleep, daytime sleepiness and clinically significant deoxygenation may persist although the number of apneas is reduced by more than half ( 1 1). Attention to hypopneas postoperatively is also essential. A more precise measure of sleep fragmentation, with very brief arousals and awakenings, is perhaps necessary if sleep disturbance is to be quantified. The present study shows that not only the number of apneas and hypopneas but also the duration of these episodes are important factors in assessing the benefits of the treatment. REFERENCES 1. Buda AJ, Schroeder JS, Guilleminault C. Abnormalities of pulmonary artery wedge pressure in sleep
induced apnea. Int J Cardial 1981, 174. 2. Djupesland G, Godtliebsen OB, Langslet A, Nustad A. Sleep induced obstruction of the upper airways in children with congenital heart defects and epileptic seizures. Peadiatr Otorhinolaryngol 1988, 663-1. 3. Swift AC. Upper airway obstruction, sleep disturbances and adenotonsillectomy in children. J Laryngol Otol 1988; 102: 419-22. 4. Djupesland G, Lyberg T, Krogstad 0. Cephalometric analysis and surgical treatment of patients with obstructive sleep apnea syndrome. A preliminary report. Acta Otolaryngol (Stockh) 1987; 103: 551 -7. 5. Lyberg T, Krogstad 0, Djupesland G. Cephalometric analysis in patients with obstructive sleep apnea syndrome. I. Skeletal morphology and 11. Soft tissue morphology. J Laryngol Otol 1989; 103: 287-97. 6. Fujita S, Conway W, Zorick F, Roth T. Surgical correction of anatomical abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty.Otolaryngol Head Neck Surg 198I; 89: 804-10. 7. Simmons FG, Guilleminault C, Silvestri R. Snoring, and some obstructive sleep apnea, can be cured by oropharyngeal surgery: Palatopharyngoplasty. Arch Otolaryngol 1983; 109: 503-7. 8. Dickson RI, Blokmanis A. Treatment of obstructive sleep apnea by uvulopalatopharyngoplasty. Laryngoscope 1987; 97: 1054-59. 9. Riley RW, Powell N, Guilleminault C. Current surgical concepts for treating obstructive sleep apnea syndrome. J Oral Maxillofac Surg 1987; 45: 149-57. 10. Moran WB, Orr WC. Diagnosis and management of obstructive sleep apnea. Part 11. Arch Otolaryngol 1985; 111: 650-7. 11. Kavey NB, Whyte J, Blitzer A, Gidro-Frank S. Postsurgical evaluation of uvulopalatopharyngoplasty: Two case reports. Sleep 1990; 13: 79-84. Address for correspondence: H. Faye-Lund, Department of Otolaryngology, Ullevll Hospital, Oslo, Norway
![[Surgical treatment of Obstructive Sleep Apnea Syndrome. Functional assessment].](/assets/img/hold.png)
