J Oral Maxillofac 4820-26,
Surg
1990
Maxillary, Mandibular, and Hyoid Advancement for Treatment of Obstructive Sleep Apnea: A Review
of 40 Patients
ROBERT W. RILEY, DDS, MD,* NELSON B. POWELL, CHRISTIAN GUILLEMINAULT, MDt
DDS, MD,* AND
Forty patients with documented obstructive sleep apnea syndrome (OSAS) were evaluated following maxillary and mandibular osteotomies (MMO). All patients were evaluated before and after surgery by a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polysomnography. Ninety-seven percent of the patients responded to the surgical treatment, based on the polysomnogram. The present indications for MM0 are severe OSAS, morbid obesity, and severe mandibular deficiency.
The pathogenesis of obstructive sleep apnea syndrome (OSAS) is well documented.’ Electromyograms and video pharyngoscopy have shown that the muscular atonia that develops in the upper airway during sleep can result in collapse or obstruction during inspiration.2,3 Repetitive apnea produces not only sleep fragmentation, which manifests itself as excessive daytime sleepiness (EDS),4 but also hypoxemia, which can produce hypertension and cardiac arrhythmia.5-7 In spite of the understanding of the systemic effects of OSAS, the long-term consequences have not been known, and treatment has been directed at correcting EDS. Two recent studies have documented a significantly increased mortality rate related to cardiovascular events in the untreated sleep apneic patient.8.9 The Stanford Study reviewed 200 untreated patients and concluded that those at risk included not only patients with severe OSAS, but patients with moderate disease as well. Surgery has been one of the primary forms of treatment, evolving from the early method of tra-
cheostomy. This was described by Kuhlo et al, who showed that in bypassing the upper airway, OSAS was controlled. lo Local problems associated with tracheostomy (infection, drainage, tracheal irritation) and psychological factors makes this an undesirable form of treatment. Fujita et al, hoping to eliminate the need for tracheostomy, described the use of uvulopalatopharyngoplasty (UPPP).” This was a modification of a surgical procedure published by Ikematsu to correct snoring.‘* The basic concept of UPPP was to remove excessive, redundant tissue from the posterior soft palate and lateral pharyngeal wall. Several retrospective reviews of unselected patients reported that the control rate of OSAS was at best 50%.‘3,‘4 We reviewed UPPP failures and concluded that the base of tongue was the cause of continued obstruction.i5 In fact, it is now generally accepted that there are several areas, including the soft palate, base of tongue, and pharyngeal walls of the hypopharynx that can contribute to the obstructive process.‘6*‘7 Sullivan et al reported on the use of nasal continuous positive airway pressure (CPAP) to pneumatically maintain upper airway patency.” This nonsurgical alternative, which uses a mask, valve, and pressure generator, is widely used today. It is dependent on patient compliance, and a recent report indicates that after only 5 months 35% of the patients have discontinued its use.19 Because of the varied acceptance of tracheostomy and nasal CPAP, and incomplete treatment from UPPP sec-
* In private practice, Reconstructive Surgery, Palo Alto, CA. t Sleep Disorders Center, Stanford University School of Medicine, Stanford, CA. Address correspondence and reprint requests to Dr Riley: 750 Welch Rd, Suite 317, Palo Alto, CA 94304. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4801-0004$3.00/O
20
RILEY,POWELL,
21
ANDGUILLEMINAULT
ondary to hypopharyngeal obstruction, we have explored the use of skeletal surgery to correct the obstruction. The surgical concept is based on the fact that the position of the base of tongue is dictated by the position of the mandible and hyoid bone. Surgical advancement results in expansion of the hypopharyngeal airway.20-2” Materials and Methods PATIENT
EVALUATION
AND
SURGICAL
CONCEPT
Treatment of the sleep apneic patient begins with the presurgical evaluation, which includes a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polysomnography.“3 The polysomnogram is initially performed to document the sleep-related breathing abnormalities.24,25 It is the objective method of establishing the diagnosis and assessing success of treatment. It includes the electroencephalogram, electro-oculogram, electromyogram. and electrocardiogram (lead V2). Respiration is monitored using respiratory inductive plethysmography, and nasal and oral flow is monitored by thermistors. Oxygen saturation (Sao,) is monitored by ear oximetry. The results are reported as the respiratory disturbance index (RDI), which is the number of abnormal respiratory events per hour of sleep and is calculated by using the following formula: Apnea + Hypopnea
x60/Total
lometric analysis confirms the physical examination and fiberoptic pharyngoscopy. Figure 1 shows a cephalometric tracing with its important anatomic landmarks. The usefulness of cephalometric analysis has recently been confirmed by deBarryBorowieki et al. 26 Following the evaluation, each patient is classified according to the site of obstruction (type I, oropharynx; type II, oropharynxhypopharynx; type III, hypopharynx). Once the diagnosis of OSAS has been made and the sites of obstruction identified, the reconstruction of the upper airway is staged to eliminate the sleep-related obstruction. The majority of our patients have a type II obstruction (soft palate and base of tongue). Oropharyngeal obstruction is corrected by UPPP. Two procedures have been used to advance the base of tongue and correct hypopharyngeal obstruction. One is a limited anterior mandibular osteotomy with hyoid suspension (AMO) (Fig 2), and the other is bimaxillary advancement (MMO) (Fig 3). The initial phase of surgery is the AM0 with or without UPPP. The hyoid advancement has been previously described.27 It is approached through a horizontal submental incision. The infrahyoid muscles are carefully dissected off the hyoid bone to avoid injury to the superior laryngeal nerve. The hyoid bone is suspended anteriorly-superiorly to the mandible with fascia lata har-
Sleep Time.
Apnea is defined as cessation of breathing for longer than 10 seconds, and hypopnea is a 50% reduction in tidal volume for more than 10 seconds. Oxygen desaturations are continuously monitored and reported as the number of events below 90% and the lowest Sao, during nocturnal sleep. The body mass index (BMI, kg/m’) is determined at each study. The presurgical evaluation, performed by one surgeon, is one of the most important aspects in treating patients with OSAS. The goal is to identify sites of obstruction so that treatment can be logically directed. Failure to identify the site of obstruction will increase the risk of failure. The physical examination emphasizes evaluation of the head and neck, extending from the nasal cavity to the larynx. Emphasis is placed on identifying a potential nasal obstruction from a septal deformity or turbinate hypertrophy; oropharyngeal obstruction from a long, redundant soft palate or hypertrophic tonsils; and hypopharyngeal obstruction from the base of tongue. The fiberoptic pharyngoscope is positioned transnasally to examine the pharyngeal areas, and it supplements the physical examination. The cepha-
FIGURE 1. Cephalometric analysis used for evaluation of patients with OSAS. SNA 82” (SD i 2). maxilla to cranial base; SNB 80” (SD -t- 2), mandible to cranial base; PAS 11 mm (SD 2 l), posterior airway space; PNS-P 37 mm (SD 2 3). length of soft palate; MP-H 15.4 mm (SD -+ 3). distance of hyoid from inferior mandible.
MAXILLOFACIAL
FIGURE 2. Diagram of anterior mandibular osteotomy and hyoid suspension to advance the position of the tongue. (Modified with pennission.28)
vested from the thigh. The overall advancement is 1 to 2 cm. All patients are treated with this protocol, and after completing this initial phase, are reevaluated by a polysomnogram. In a recent review of 55 patients who underwent
SURGERY AND SLEEP APNEA
AM0 with or without UPPP, OSAS was eliminated in 70% of the patients.28 The failures were reevaluated, and hypopharyngeal or base of tongue obstruction was the cause for persistent OSAS. The most frequent failures were patients with severe mandibular deficiency (SNB < 74”) or morbid obesity (BMI > 33). The patients with failures of stage I were candidates for stage II, the MMO. The rationale of this progression was to avoid overtreatment and determine if a protocol of a staged reconstruction with AM0 (with or without UPPP) as stage I and MM0 as stage 2 was appropriate. We have previously reported the results of a small group of patients treated by advancement of the maxilla and mandible.29 The surgical concept is to advance the mandible maximally while maintaining function and esthetics (Fig 3). Because of this concept, the maxilla is advanced to allow greater overall advancement of the mandible. All patients are orthodontically coordinated. The Le Fort I osteotomy and sagittal split osteotomies utilize standard methods and techniques.” The fragments are rigidly fixed with titanium plates and bicortical screws. Because of the large movements of the mandible and maxilla, outer table cranial bone is grafted to the osteotomy sites. Maxillomandibular fixation is maintained for 1 to 3 weeks. Patients with a preexisting class II malocclusion are advanced to a class I relationship. Patients with class I occlusions are treated in two stages. A class II position is created in stage I by a total mandibular subapical osteotomy with bilateral repositioning of the inferior alveolar nerves (Fig 4). Stage 2 is the MMO, by which a class I occlusion is again achieved. This is done 3 months after the subapical osteotomy. Patient Population
FIGURE 3. Diagram showing advancement of the maxilla by Le Fort I osteotomy with rigid fixation, and of the mandible by a bilateral sagittal ramus split. Also note the hyoid advancement and suspension.
Forty patients who had failed phase I surgery were treated by MMO. Before the MMO, six patients had been treated with anterior subapical osteotomy, and 18 patients were treated by the previously described total mandibular subapical osteotomy. All patients underwent a presurgical evaluation to document the severity of OSAS, and the level of obstruction was isolated to the hypopharynx-base of tongue. The population had a mean age of 43.5 years, with a range of 18 to 63 years. Seven women were included in the study. The presurgical evaluation indicated that all patients complained of EDS, and 18 patients complained of moderate to severe snoring in spite of the fact that 14 had received UPPP. Twelve patients complained of poor memory. Thirteen patients had a history of hypertension requiring medication, and three patients had a history of cardiac arrhythmia
23
RILEY, POWELL, AND GUILLEMINAULT
which included at least a 50% reduction in the number of respiratory events, and normal or nearnormal Sao, . Snoring was eliminated in all but three patients, and they continue to complain of moderate snoring. All patients with complaints of poor memory reported marked improvement. Seven of the 13 patients with a history of hypertension reported improvement in blood pressure that allowed a reduction or elimination of their hypertensive medication. The three patients with a history of cardiac arrhythmia continued to require medication. No patients continued using CPAP, and all tracheostomies have been removed. Cephalometric Analysis
FIGURE 4. Diagram of total mandibular subapical osteotomy with retropositioning of the dentition prior to mandibular advancement by a sagittal ramus split.
requiring medication. Three patients had significant obstructive lung disease (forced expiratory volume in 1 second, ~70%; residual volume-total lung capacity, >40%). Thirty-six patients had previously received UPPP. Eleven patients had been treated by tracheostomy, and 18 were using nasal CPAP. The CPAP patients found this to be unacceptable and opted for a surgical alternative. One patient was initially referred for facial skeletal deformity. His history was consistent with OSAS, which was confirmed by polysomnography . Results The patients were reexamined 6 months following surgery. The reevaluation included polysomnographic testing and reassessment of physical symptoms. The polysomnographic testing systematically reevaluated the RDI, Sao, decreases below 90%, lowest Sao,, and BMI. Treatment results were based on the polysomnogram. Surgery was scored a success if the postsurgical RDI was less than 20,
The results of the cephalometric analysis are shown in Table 1. Eleven patients had normal mandibular skeletal development (SNB > 78”). Twelve patients had mild mandibular deficiency (SNB 74” to 78”), and 17 patients had significant mandibular deficiency (SNB < 74”). The mean change in SNB was from 75” to 79”. The mean change in posterior airway space (PAS) was from 4 mm to 10 mm. There was no direct relationship between the PAS distance gained measured by cephalometrics and the nocturnal polygraphic results. The average sagittal split advancement was 12 mm (SD 2.1), and the average advancement at the geniotubercle was 21 mm (SD 3.4). Polygraphic Results The polysomnographic results are shown in Table 2 and Fig 5. The earliest polysomnographic examination was at 6 months postsurgery, and the latest postsurgical results now extend to 4 years. There has been no significant change between the early and late results. The BMI results show no significant change in weight between the presurgical and postsurgical testing intervals. The presurgical and postsurgical RDIs were 66.8 (SD 19.4) and 9.1 (SD 6. l), respectively. The mean low Sao, and the number of Sao, events below 90% before surgery were 63.5 (SD 15.4) and 261 (SD 154). respectively. After surgery, the mean low Sao, and number of Sao,
Table 1. Cephalometric Analysis of Maxillary, Mandibular, and Hyoid Advancement and OSAS in 40 Patients
Preoperative Postoperative
SNA
SNB
(mm)
(mm)
Sagittal Split Advancement (mm)
79.0 2 3.8 82.5 2 2.9
74.5 k 3.7 79.0 ” 3.1
4.2 2 1.9 9.8 * 1.9
28.7 -+ 6.4 18.8 k 6.3
11.9 2 2.1
PAS
MP-H
Genioglossus Advancement (mm1 21.0 2 3.4
24
MAXILLOFACIAL
Table 2.
Polysomnographic Results for Maxillary, Mandibular, and Hyoid Advancement and OSAS No. of Sao z Events Below 90%
RDI Preoperative
2 3 4 6
8 9 10 II 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 SD Mean
SURGERY AND SLEEP APNEA
65 76 57 47 76 71 75 85 68 72 33 72 60 52 44 69 75 53 56 64 101 86 70 67 90 57 122 56 36 68 20 84 102 70 67 55 80 45 60 82 19.4 66.8
Postoperative
3 6 4 8 2 2 11 19 8 6 11 10 13 13 4 20 4 8 18 19 7 2 20 4
8 3 20 5 10 2 4 10 19 2 19 7 14 38 6.1 9.1
Preoperative
141 492 222 266 238 392 323 323 391 15 66 302 454 304 93 394 353 20 38 87 403 174 312 247 439 343 659 176 75 76 110 495 363 309 258 101 406 119 217 524 154.2 261.2
events below 90% were 87 (SD 3.2) and 13 (SD 19), respectively. When the polygraphic results of the patients who had initially used CPAP but then elected surgery were compared, there was no significant difference. It appears that in these 18 patients the surgery is equally effective as CPAP. The surgical success of correcting OSAS by MM0 was 97%. One patient showed improvement but did not meet our criteria for success (Table 2, patient 40). Obesity and the effects of chronic obstructive lung disease did not seem to affect surgical success. Morbidly obese patients have uniformly poor results with UPPP. The inferior sagittal osteotomy with hyoid myotomy and suspension has not
Lowest Sao,
Postoperative
8 7 0 0 2 0 48 5 5 0 0 10 26 87 0 76 4 0 12 7 14 0 0 0 10 20 32 14 23 0 6 18 22 22 4 30 0 10 155 19.5 13.4
Preoperative
74 48 78 42 76 61 60 70 70 82 87 54 57 46 75 65 35 83 82 75 56 80 80 62 62 64 69 63 60 56 60 10 63 67 51 80 56 74 44 29 15.4 63.5
Postoperative
84 85 90 90 88 90 84 88 88 92 90 83 88 85 90 80 81 90 86 88 86 90 90 90 88 84 88 84 88 80 90 86 86 84 88 86 84 90 84 82 3.2 86.6
proved successful in patients with significant chronic obstructive lung disease. The one patient who failed to show significant improvement seemed to have very poor advancement of the base of tongue with the mandibular advancement. However, he is early in treatment, and we have seen patients show continued improvement up to 1 year following surgery. Complications
There was one significant complication in this group. One patient had aggressive suspension of the hyoid bone, in which the thyrohyoid membrane was
25
RILEY, POWELL. AND GUILLEMINAULT
120 r SD 154 361
110 -
POLYSOMNOGRAM
100 90 80 70 60 FIGURE 5. Maxillary. mandibular, and hyoid advancement and OSAS (40 patients).
50 40 30 20 IO o-
RDI
# SaOz Events Below 90% 0
Lowest sao,
Preop
totally sectioned in the suspension procedure. This resulted in severe aspiration for 10 days in a patient who was in maxillomandibular fixation. The suspension was partially released, and reattachment of the hyoid bone to the thyroid cartilage was achieved with Vicryl (Ethicon, Somerville, NJ) sutures. The aspiration resolved in 2 to 3 days. There has been no significant bleeding or infection in any of the patients. All patients developed transient anesthesia of the inferior alveolar nerve associated with a total mandibular subapical osteotomy and the sagittal ramus osteotomies. There has been 87% resolution between 6 and 12 months. Rigid skeletal fixation has been used in 24 patients, with only minimal surgical relapse in spite of the large skeletal movements. Three patients who have been followed for a period of 36 months have had a mandibular relapse of approximately 20%. They remain free of symptoms, and their OSAS remains controlled, as evidenced by polysomnography. The mean hospital stay has been 3.2 days. Conclusions Maxillofacial surgery has proven to be an effective method for controlling OSAS, and its results are equally effective as those obtained with nasal CPAP. The presurgical evaluation, which includes polysomnography, physical examination, fiberoptic pharyngoscopy, and cephalometric analysis, is essential in directing surgical therapy. Our protocol of staged reconstruction of the upper airway is necessary to avoid overtreatment. The present indications for MM0 are as follows: severe OSAS, morbid obesity, severe mandibular deficiency, and fail-
m
BMI Postop ure of other forms of treatment. We are continuing to evaluate patients on a long-term basis. At present, it appears that patients continue symptom free. References I. Guilleminault C, Tilkian AG, Dement WC: Sleep apnea syndromes. Ann Rev Med 21~465, 1953 2. Guilleminault C. Hill MW, Simmons FB: Obstructive sleep apnea: Electromyelographic and fiberoptic studies. Exp Neurol 62:48, 1978 3. Rojewski TE, Schuller DE, Clark RW: Video endoscopic determinations of the mechanism of obstruction in obstructive sleep apnea. Otolaryngol Head Neck Surg 92:127. 1984 4. Guilleminault C, Tilkian AC, Eldridge FL: Sleep apnea syndrome upper airway obstruction: A review of 25 cases. Arch Intern Med 137:296, 1977 5. Tilkian AC. Guilleminault C, Schroeder JS: Hemodynamics in sleep induced apnea, studies during wakefulness and sleep. Ann Intern Med 85:714, 1976 6. Miller WP: Cardiac arrhythmias and conduction disturbance in sleep apnea syndrome: Prevalence and significance. Am J Med 173:317, 1982 7. Tilkian AG, Guilleminault C, Schroeder JS: Sleep induced apnea syndrome: Prevalence of cardiac arrhythmias and their reversal after tracheostomy. Am J Med 63:348. 1977 8. He J. Kryger M. Zorick F, et al: Mortality and apnea index in obstructive sleep apnea. Chest 1:9, 1988 9. Partinen M, Jamieson A, Guilleminault C: Long-term outcome for obstructive sleep apnea syndrome patients: Mortality. Chest 94:1200, 1988 10. Kuhlo W, Doll E, Franck MD: Erfolgreiche behandlung eines Pickwick-syndroms durch eine dauertrachealkanule. Dtsch Med Wochenschr 94:1286. 1969 11. Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities of obstructive sleep apnea syodrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 89:923, 1981
26 12. Ikematsu T: Study of snoring-Fourth report: Snoring. J Jpn Otorhinolaryngol64:434, 1964 13. Guilleminault C, Hayes B, Smith FB: Palatopharyngoplasty and obstructive sleep apnea: A review of 35 cases. Bull Eur Phvsionathol Resnir 19:595. 1983 14. Conway W, Fujita S, Zohck F, et al: Uvulopalatopharyngoplasty: One year follow-up. Chest 88:385, 1985 15. Riley R, Guilleminault C, Powell N: Palatopharyngoplasty failure, cephalometric roentgenograms and obstructive sleen annea. Otolarvneol Head Neck Sure 93:240. 1985 16. Rivlin’J, ‘Hoffstein V: Kalbfleisch J, et al: Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis 129:355, 1984 17. Crumley RL, Stein S, Ganser G, et al: Determination of obstructive sites in obstructive sleep apnea. Laryngoscope 97:301, 1987 18. Sullivan CE, Berthon-Jones M, Issa FG, et al: Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1:862, 1981 19. Nino-Murcia G, Crowe C, Bliwise D, et al: Nasal CPAP: Follow-up of compliance and adverse effects. Sleep 16:398, 1987 (abstr) 20. Patten TJ, Thawley SE, Rotters RC: Expansion hyoidplasty: A potential surgical procedure designed for selective patients with obstructive sleep apnea syndrome (experimental canine results). Laryngoscope 93: 1387, 1983 21. Powell NB, Guilleminault C, Riley RW: Mandibular advancement and obstructive sleep apnea syndrome. Bull Eur Physiopathol Respir 19:607, 1983 22. Kuo PC, West RA, Bloomquist DS: The affect of mandibular
MAXILLOFACIAL
23.
24.
25.
26.
27.
28.
29.
30.
SURGERY AND SLEEP APNEA
osteotomy in three patients with hypersomnia and sleep apnea. J Oral Surg 48:385, 1979 Riley RW, Powell NB, Guilleminault C: Current surgical concepts for treating obstructive sleep apnea syndrome. J Oral Maxillofac Surg 45: 149, 1987 Rechtschaffen A, Kales A: A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. University of California, Los Angeles, Brain Information/Brain Research Institution, 1968 Guilleminault C (ed): Sleeping and Waking Disorders: Indications and Techniques. Menlo Park, CA, AddisonWesley, 1983 deBerry-Borowieki B, Kukwa A, Banks R: Cephalometric analysis for diagnosis and treatment of obstructive sleep apnea. Laryngoscope 98:226, 1988 Riley RW, Powell NB, Guilleminault C: Inferior sagittal osteotomy of the mandible with hyoid myotomy suspension: A new procedure for obstructive sleep apnea. Otolaryngol Head Neck Sum 94:589. 1986 Riley RW, Powell NB, Guilleminault C: Inferior mandibular osteotomy and hyoid myotomy suspension for obstructive sleep apnea: A review of 55 patients. J Oral Maxillofac Surg 47: 159, 1989 Riley RW, Powell NB, Guilleminault C, et al: Maxillarymandibular and hyoid advancement: An alternative to tracheostomy in obstructive sleep apnea. Otolaryngol Head Neck Surg 94:584, 1986 Bell W, Profftt W, Wright R: Surgical Correction of Dental Facial Deformities. Philadelphia, PA, Saunders, 1980
Surg
1990
Maxillary, Mandibular, and Hyoid Advancement for Treatment of Obstructive Sleep Apnea: A Review
of 40 Patients
ROBERT W. RILEY, DDS, MD,* NELSON B. POWELL, CHRISTIAN GUILLEMINAULT, MDt
DDS, MD,* AND
Forty patients with documented obstructive sleep apnea syndrome (OSAS) were evaluated following maxillary and mandibular osteotomies (MMO). All patients were evaluated before and after surgery by a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polysomnography. Ninety-seven percent of the patients responded to the surgical treatment, based on the polysomnogram. The present indications for MM0 are severe OSAS, morbid obesity, and severe mandibular deficiency.
The pathogenesis of obstructive sleep apnea syndrome (OSAS) is well documented.’ Electromyograms and video pharyngoscopy have shown that the muscular atonia that develops in the upper airway during sleep can result in collapse or obstruction during inspiration.2,3 Repetitive apnea produces not only sleep fragmentation, which manifests itself as excessive daytime sleepiness (EDS),4 but also hypoxemia, which can produce hypertension and cardiac arrhythmia.5-7 In spite of the understanding of the systemic effects of OSAS, the long-term consequences have not been known, and treatment has been directed at correcting EDS. Two recent studies have documented a significantly increased mortality rate related to cardiovascular events in the untreated sleep apneic patient.8.9 The Stanford Study reviewed 200 untreated patients and concluded that those at risk included not only patients with severe OSAS, but patients with moderate disease as well. Surgery has been one of the primary forms of treatment, evolving from the early method of tra-
cheostomy. This was described by Kuhlo et al, who showed that in bypassing the upper airway, OSAS was controlled. lo Local problems associated with tracheostomy (infection, drainage, tracheal irritation) and psychological factors makes this an undesirable form of treatment. Fujita et al, hoping to eliminate the need for tracheostomy, described the use of uvulopalatopharyngoplasty (UPPP).” This was a modification of a surgical procedure published by Ikematsu to correct snoring.‘* The basic concept of UPPP was to remove excessive, redundant tissue from the posterior soft palate and lateral pharyngeal wall. Several retrospective reviews of unselected patients reported that the control rate of OSAS was at best 50%.‘3,‘4 We reviewed UPPP failures and concluded that the base of tongue was the cause of continued obstruction.i5 In fact, it is now generally accepted that there are several areas, including the soft palate, base of tongue, and pharyngeal walls of the hypopharynx that can contribute to the obstructive process.‘6*‘7 Sullivan et al reported on the use of nasal continuous positive airway pressure (CPAP) to pneumatically maintain upper airway patency.” This nonsurgical alternative, which uses a mask, valve, and pressure generator, is widely used today. It is dependent on patient compliance, and a recent report indicates that after only 5 months 35% of the patients have discontinued its use.19 Because of the varied acceptance of tracheostomy and nasal CPAP, and incomplete treatment from UPPP sec-
* In private practice, Reconstructive Surgery, Palo Alto, CA. t Sleep Disorders Center, Stanford University School of Medicine, Stanford, CA. Address correspondence and reprint requests to Dr Riley: 750 Welch Rd, Suite 317, Palo Alto, CA 94304. 0 1990 American
Association
of Oral
and Maxillofacial
Sur-
geons 0278-2391/90/4801-0004$3.00/O
20
RILEY,POWELL,
21
ANDGUILLEMINAULT
ondary to hypopharyngeal obstruction, we have explored the use of skeletal surgery to correct the obstruction. The surgical concept is based on the fact that the position of the base of tongue is dictated by the position of the mandible and hyoid bone. Surgical advancement results in expansion of the hypopharyngeal airway.20-2” Materials and Methods PATIENT
EVALUATION
AND
SURGICAL
CONCEPT
Treatment of the sleep apneic patient begins with the presurgical evaluation, which includes a physical examination, fiberoptic pharyngoscopy, cephalometric analysis, and polysomnography.“3 The polysomnogram is initially performed to document the sleep-related breathing abnormalities.24,25 It is the objective method of establishing the diagnosis and assessing success of treatment. It includes the electroencephalogram, electro-oculogram, electromyogram. and electrocardiogram (lead V2). Respiration is monitored using respiratory inductive plethysmography, and nasal and oral flow is monitored by thermistors. Oxygen saturation (Sao,) is monitored by ear oximetry. The results are reported as the respiratory disturbance index (RDI), which is the number of abnormal respiratory events per hour of sleep and is calculated by using the following formula: Apnea + Hypopnea
x60/Total
lometric analysis confirms the physical examination and fiberoptic pharyngoscopy. Figure 1 shows a cephalometric tracing with its important anatomic landmarks. The usefulness of cephalometric analysis has recently been confirmed by deBarryBorowieki et al. 26 Following the evaluation, each patient is classified according to the site of obstruction (type I, oropharynx; type II, oropharynxhypopharynx; type III, hypopharynx). Once the diagnosis of OSAS has been made and the sites of obstruction identified, the reconstruction of the upper airway is staged to eliminate the sleep-related obstruction. The majority of our patients have a type II obstruction (soft palate and base of tongue). Oropharyngeal obstruction is corrected by UPPP. Two procedures have been used to advance the base of tongue and correct hypopharyngeal obstruction. One is a limited anterior mandibular osteotomy with hyoid suspension (AMO) (Fig 2), and the other is bimaxillary advancement (MMO) (Fig 3). The initial phase of surgery is the AM0 with or without UPPP. The hyoid advancement has been previously described.27 It is approached through a horizontal submental incision. The infrahyoid muscles are carefully dissected off the hyoid bone to avoid injury to the superior laryngeal nerve. The hyoid bone is suspended anteriorly-superiorly to the mandible with fascia lata har-
Sleep Time.
Apnea is defined as cessation of breathing for longer than 10 seconds, and hypopnea is a 50% reduction in tidal volume for more than 10 seconds. Oxygen desaturations are continuously monitored and reported as the number of events below 90% and the lowest Sao, during nocturnal sleep. The body mass index (BMI, kg/m’) is determined at each study. The presurgical evaluation, performed by one surgeon, is one of the most important aspects in treating patients with OSAS. The goal is to identify sites of obstruction so that treatment can be logically directed. Failure to identify the site of obstruction will increase the risk of failure. The physical examination emphasizes evaluation of the head and neck, extending from the nasal cavity to the larynx. Emphasis is placed on identifying a potential nasal obstruction from a septal deformity or turbinate hypertrophy; oropharyngeal obstruction from a long, redundant soft palate or hypertrophic tonsils; and hypopharyngeal obstruction from the base of tongue. The fiberoptic pharyngoscope is positioned transnasally to examine the pharyngeal areas, and it supplements the physical examination. The cepha-
FIGURE 1. Cephalometric analysis used for evaluation of patients with OSAS. SNA 82” (SD i 2). maxilla to cranial base; SNB 80” (SD -t- 2), mandible to cranial base; PAS 11 mm (SD 2 l), posterior airway space; PNS-P 37 mm (SD 2 3). length of soft palate; MP-H 15.4 mm (SD -+ 3). distance of hyoid from inferior mandible.
MAXILLOFACIAL
FIGURE 2. Diagram of anterior mandibular osteotomy and hyoid suspension to advance the position of the tongue. (Modified with pennission.28)
vested from the thigh. The overall advancement is 1 to 2 cm. All patients are treated with this protocol, and after completing this initial phase, are reevaluated by a polysomnogram. In a recent review of 55 patients who underwent
SURGERY AND SLEEP APNEA
AM0 with or without UPPP, OSAS was eliminated in 70% of the patients.28 The failures were reevaluated, and hypopharyngeal or base of tongue obstruction was the cause for persistent OSAS. The most frequent failures were patients with severe mandibular deficiency (SNB < 74”) or morbid obesity (BMI > 33). The patients with failures of stage I were candidates for stage II, the MMO. The rationale of this progression was to avoid overtreatment and determine if a protocol of a staged reconstruction with AM0 (with or without UPPP) as stage I and MM0 as stage 2 was appropriate. We have previously reported the results of a small group of patients treated by advancement of the maxilla and mandible.29 The surgical concept is to advance the mandible maximally while maintaining function and esthetics (Fig 3). Because of this concept, the maxilla is advanced to allow greater overall advancement of the mandible. All patients are orthodontically coordinated. The Le Fort I osteotomy and sagittal split osteotomies utilize standard methods and techniques.” The fragments are rigidly fixed with titanium plates and bicortical screws. Because of the large movements of the mandible and maxilla, outer table cranial bone is grafted to the osteotomy sites. Maxillomandibular fixation is maintained for 1 to 3 weeks. Patients with a preexisting class II malocclusion are advanced to a class I relationship. Patients with class I occlusions are treated in two stages. A class II position is created in stage I by a total mandibular subapical osteotomy with bilateral repositioning of the inferior alveolar nerves (Fig 4). Stage 2 is the MMO, by which a class I occlusion is again achieved. This is done 3 months after the subapical osteotomy. Patient Population
FIGURE 3. Diagram showing advancement of the maxilla by Le Fort I osteotomy with rigid fixation, and of the mandible by a bilateral sagittal ramus split. Also note the hyoid advancement and suspension.
Forty patients who had failed phase I surgery were treated by MMO. Before the MMO, six patients had been treated with anterior subapical osteotomy, and 18 patients were treated by the previously described total mandibular subapical osteotomy. All patients underwent a presurgical evaluation to document the severity of OSAS, and the level of obstruction was isolated to the hypopharynx-base of tongue. The population had a mean age of 43.5 years, with a range of 18 to 63 years. Seven women were included in the study. The presurgical evaluation indicated that all patients complained of EDS, and 18 patients complained of moderate to severe snoring in spite of the fact that 14 had received UPPP. Twelve patients complained of poor memory. Thirteen patients had a history of hypertension requiring medication, and three patients had a history of cardiac arrhythmia
23
RILEY, POWELL, AND GUILLEMINAULT
which included at least a 50% reduction in the number of respiratory events, and normal or nearnormal Sao, . Snoring was eliminated in all but three patients, and they continue to complain of moderate snoring. All patients with complaints of poor memory reported marked improvement. Seven of the 13 patients with a history of hypertension reported improvement in blood pressure that allowed a reduction or elimination of their hypertensive medication. The three patients with a history of cardiac arrhythmia continued to require medication. No patients continued using CPAP, and all tracheostomies have been removed. Cephalometric Analysis
FIGURE 4. Diagram of total mandibular subapical osteotomy with retropositioning of the dentition prior to mandibular advancement by a sagittal ramus split.
requiring medication. Three patients had significant obstructive lung disease (forced expiratory volume in 1 second, ~70%; residual volume-total lung capacity, >40%). Thirty-six patients had previously received UPPP. Eleven patients had been treated by tracheostomy, and 18 were using nasal CPAP. The CPAP patients found this to be unacceptable and opted for a surgical alternative. One patient was initially referred for facial skeletal deformity. His history was consistent with OSAS, which was confirmed by polysomnography . Results The patients were reexamined 6 months following surgery. The reevaluation included polysomnographic testing and reassessment of physical symptoms. The polysomnographic testing systematically reevaluated the RDI, Sao, decreases below 90%, lowest Sao,, and BMI. Treatment results were based on the polysomnogram. Surgery was scored a success if the postsurgical RDI was less than 20,
The results of the cephalometric analysis are shown in Table 1. Eleven patients had normal mandibular skeletal development (SNB > 78”). Twelve patients had mild mandibular deficiency (SNB 74” to 78”), and 17 patients had significant mandibular deficiency (SNB < 74”). The mean change in SNB was from 75” to 79”. The mean change in posterior airway space (PAS) was from 4 mm to 10 mm. There was no direct relationship between the PAS distance gained measured by cephalometrics and the nocturnal polygraphic results. The average sagittal split advancement was 12 mm (SD 2.1), and the average advancement at the geniotubercle was 21 mm (SD 3.4). Polygraphic Results The polysomnographic results are shown in Table 2 and Fig 5. The earliest polysomnographic examination was at 6 months postsurgery, and the latest postsurgical results now extend to 4 years. There has been no significant change between the early and late results. The BMI results show no significant change in weight between the presurgical and postsurgical testing intervals. The presurgical and postsurgical RDIs were 66.8 (SD 19.4) and 9.1 (SD 6. l), respectively. The mean low Sao, and the number of Sao, events below 90% before surgery were 63.5 (SD 15.4) and 261 (SD 154). respectively. After surgery, the mean low Sao, and number of Sao,
Table 1. Cephalometric Analysis of Maxillary, Mandibular, and Hyoid Advancement and OSAS in 40 Patients
Preoperative Postoperative
SNA
SNB
(mm)
(mm)
Sagittal Split Advancement (mm)
79.0 2 3.8 82.5 2 2.9
74.5 k 3.7 79.0 ” 3.1
4.2 2 1.9 9.8 * 1.9
28.7 -+ 6.4 18.8 k 6.3
11.9 2 2.1
PAS
MP-H
Genioglossus Advancement (mm1 21.0 2 3.4
24
MAXILLOFACIAL
Table 2.
Polysomnographic Results for Maxillary, Mandibular, and Hyoid Advancement and OSAS No. of Sao z Events Below 90%
RDI Preoperative
2 3 4 6
8 9 10 II 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 SD Mean
SURGERY AND SLEEP APNEA
65 76 57 47 76 71 75 85 68 72 33 72 60 52 44 69 75 53 56 64 101 86 70 67 90 57 122 56 36 68 20 84 102 70 67 55 80 45 60 82 19.4 66.8
Postoperative
3 6 4 8 2 2 11 19 8 6 11 10 13 13 4 20 4 8 18 19 7 2 20 4
8 3 20 5 10 2 4 10 19 2 19 7 14 38 6.1 9.1
Preoperative
141 492 222 266 238 392 323 323 391 15 66 302 454 304 93 394 353 20 38 87 403 174 312 247 439 343 659 176 75 76 110 495 363 309 258 101 406 119 217 524 154.2 261.2
events below 90% were 87 (SD 3.2) and 13 (SD 19), respectively. When the polygraphic results of the patients who had initially used CPAP but then elected surgery were compared, there was no significant difference. It appears that in these 18 patients the surgery is equally effective as CPAP. The surgical success of correcting OSAS by MM0 was 97%. One patient showed improvement but did not meet our criteria for success (Table 2, patient 40). Obesity and the effects of chronic obstructive lung disease did not seem to affect surgical success. Morbidly obese patients have uniformly poor results with UPPP. The inferior sagittal osteotomy with hyoid myotomy and suspension has not
Lowest Sao,
Postoperative
8 7 0 0 2 0 48 5 5 0 0 10 26 87 0 76 4 0 12 7 14 0 0 0 10 20 32 14 23 0 6 18 22 22 4 30 0 10 155 19.5 13.4
Preoperative
74 48 78 42 76 61 60 70 70 82 87 54 57 46 75 65 35 83 82 75 56 80 80 62 62 64 69 63 60 56 60 10 63 67 51 80 56 74 44 29 15.4 63.5
Postoperative
84 85 90 90 88 90 84 88 88 92 90 83 88 85 90 80 81 90 86 88 86 90 90 90 88 84 88 84 88 80 90 86 86 84 88 86 84 90 84 82 3.2 86.6
proved successful in patients with significant chronic obstructive lung disease. The one patient who failed to show significant improvement seemed to have very poor advancement of the base of tongue with the mandibular advancement. However, he is early in treatment, and we have seen patients show continued improvement up to 1 year following surgery. Complications
There was one significant complication in this group. One patient had aggressive suspension of the hyoid bone, in which the thyrohyoid membrane was
25
RILEY, POWELL. AND GUILLEMINAULT
120 r SD 154 361
110 -
POLYSOMNOGRAM
100 90 80 70 60 FIGURE 5. Maxillary. mandibular, and hyoid advancement and OSAS (40 patients).
50 40 30 20 IO o-
RDI
# SaOz Events Below 90% 0
Lowest sao,
Preop
totally sectioned in the suspension procedure. This resulted in severe aspiration for 10 days in a patient who was in maxillomandibular fixation. The suspension was partially released, and reattachment of the hyoid bone to the thyroid cartilage was achieved with Vicryl (Ethicon, Somerville, NJ) sutures. The aspiration resolved in 2 to 3 days. There has been no significant bleeding or infection in any of the patients. All patients developed transient anesthesia of the inferior alveolar nerve associated with a total mandibular subapical osteotomy and the sagittal ramus osteotomies. There has been 87% resolution between 6 and 12 months. Rigid skeletal fixation has been used in 24 patients, with only minimal surgical relapse in spite of the large skeletal movements. Three patients who have been followed for a period of 36 months have had a mandibular relapse of approximately 20%. They remain free of symptoms, and their OSAS remains controlled, as evidenced by polysomnography. The mean hospital stay has been 3.2 days. Conclusions Maxillofacial surgery has proven to be an effective method for controlling OSAS, and its results are equally effective as those obtained with nasal CPAP. The presurgical evaluation, which includes polysomnography, physical examination, fiberoptic pharyngoscopy, and cephalometric analysis, is essential in directing surgical therapy. Our protocol of staged reconstruction of the upper airway is necessary to avoid overtreatment. The present indications for MM0 are as follows: severe OSAS, morbid obesity, severe mandibular deficiency, and fail-
m
BMI Postop ure of other forms of treatment. We are continuing to evaluate patients on a long-term basis. At present, it appears that patients continue symptom free. References I. Guilleminault C, Tilkian AG, Dement WC: Sleep apnea syndromes. Ann Rev Med 21~465, 1953 2. Guilleminault C. Hill MW, Simmons FB: Obstructive sleep apnea: Electromyelographic and fiberoptic studies. Exp Neurol 62:48, 1978 3. Rojewski TE, Schuller DE, Clark RW: Video endoscopic determinations of the mechanism of obstruction in obstructive sleep apnea. Otolaryngol Head Neck Surg 92:127. 1984 4. Guilleminault C, Tilkian AC, Eldridge FL: Sleep apnea syndrome upper airway obstruction: A review of 25 cases. Arch Intern Med 137:296, 1977 5. Tilkian AC. Guilleminault C, Schroeder JS: Hemodynamics in sleep induced apnea, studies during wakefulness and sleep. Ann Intern Med 85:714, 1976 6. Miller WP: Cardiac arrhythmias and conduction disturbance in sleep apnea syndrome: Prevalence and significance. Am J Med 173:317, 1982 7. Tilkian AG, Guilleminault C, Schroeder JS: Sleep induced apnea syndrome: Prevalence of cardiac arrhythmias and their reversal after tracheostomy. Am J Med 63:348. 1977 8. He J. Kryger M. Zorick F, et al: Mortality and apnea index in obstructive sleep apnea. Chest 1:9, 1988 9. Partinen M, Jamieson A, Guilleminault C: Long-term outcome for obstructive sleep apnea syndrome patients: Mortality. Chest 94:1200, 1988 10. Kuhlo W, Doll E, Franck MD: Erfolgreiche behandlung eines Pickwick-syndroms durch eine dauertrachealkanule. Dtsch Med Wochenschr 94:1286. 1969 11. Fujita S, Conway W, Zorick F, et al: Surgical correction of anatomic abnormalities of obstructive sleep apnea syodrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 89:923, 1981
26 12. Ikematsu T: Study of snoring-Fourth report: Snoring. J Jpn Otorhinolaryngol64:434, 1964 13. Guilleminault C, Hayes B, Smith FB: Palatopharyngoplasty and obstructive sleep apnea: A review of 35 cases. Bull Eur Phvsionathol Resnir 19:595. 1983 14. Conway W, Fujita S, Zohck F, et al: Uvulopalatopharyngoplasty: One year follow-up. Chest 88:385, 1985 15. Riley R, Guilleminault C, Powell N: Palatopharyngoplasty failure, cephalometric roentgenograms and obstructive sleen annea. Otolarvneol Head Neck Sure 93:240. 1985 16. Rivlin’J, ‘Hoffstein V: Kalbfleisch J, et al: Upper airway morphology in patients with idiopathic obstructive sleep apnea. Am Rev Respir Dis 129:355, 1984 17. Crumley RL, Stein S, Ganser G, et al: Determination of obstructive sites in obstructive sleep apnea. Laryngoscope 97:301, 1987 18. Sullivan CE, Berthon-Jones M, Issa FG, et al: Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet 1:862, 1981 19. Nino-Murcia G, Crowe C, Bliwise D, et al: Nasal CPAP: Follow-up of compliance and adverse effects. Sleep 16:398, 1987 (abstr) 20. Patten TJ, Thawley SE, Rotters RC: Expansion hyoidplasty: A potential surgical procedure designed for selective patients with obstructive sleep apnea syndrome (experimental canine results). Laryngoscope 93: 1387, 1983 21. Powell NB, Guilleminault C, Riley RW: Mandibular advancement and obstructive sleep apnea syndrome. Bull Eur Physiopathol Respir 19:607, 1983 22. Kuo PC, West RA, Bloomquist DS: The affect of mandibular
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osteotomy in three patients with hypersomnia and sleep apnea. J Oral Surg 48:385, 1979 Riley RW, Powell NB, Guilleminault C: Current surgical concepts for treating obstructive sleep apnea syndrome. J Oral Maxillofac Surg 45: 149, 1987 Rechtschaffen A, Kales A: A Manual of Standardized Terminology, Techniques and Scoring System for Sleep Stages of Human Subjects. University of California, Los Angeles, Brain Information/Brain Research Institution, 1968 Guilleminault C (ed): Sleeping and Waking Disorders: Indications and Techniques. Menlo Park, CA, AddisonWesley, 1983 deBerry-Borowieki B, Kukwa A, Banks R: Cephalometric analysis for diagnosis and treatment of obstructive sleep apnea. Laryngoscope 98:226, 1988 Riley RW, Powell NB, Guilleminault C: Inferior sagittal osteotomy of the mandible with hyoid myotomy suspension: A new procedure for obstructive sleep apnea. Otolaryngol Head Neck Sum 94:589. 1986 Riley RW, Powell NB, Guilleminault C: Inferior mandibular osteotomy and hyoid myotomy suspension for obstructive sleep apnea: A review of 55 patients. J Oral Maxillofac Surg 47: 159, 1989 Riley RW, Powell NB, Guilleminault C, et al: Maxillarymandibular and hyoid advancement: An alternative to tracheostomy in obstructive sleep apnea. Otolaryngol Head Neck Surg 94:584, 1986 Bell W, Profftt W, Wright R: Surgical Correction of Dental Facial Deformities. Philadelphia, PA, Saunders, 1980
