Hyoid suspension

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Hyoid suspension also known as hyoid myotomy and suspension or hyoid advancement, is a surgical procedure or sleep surgery in which the hyoid bone and its muscle attachments to the tongue and airway are pulled forward with the aim of increasing airway size and improving airway stability in the retrolingual and hypopharyngeal airway (airway behind and below the base of tongue). The horseshoe shaped hyoid bone sits directly below the base of tongue with the arms of the bone flanking the airway. Hyoid suspension is typically performed as a treatment for obstructive sleep apnea (OSA). This procedure is frequently performed with a uvulopalatopharyngoplasty (UPPP) which targets sites of obstruction higher in the airway. Typically, a hyoid suspension is considered successful when the patient’s apnea-hypopnea index is significantly reduced after surgery.

Sleep surgery is a surgery performed to treat sleep disordered breathing. Sleep disordered breathing is a spectrum of disorders that includes snoring, upper airway resistance syndrome, and obstructive sleep apnea. These surgeries are performed by surgeons trained in otolaryngology, oral maxillofacial surgery, and craniofacial surgery.

Hyoid bone horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage

The hyoid bone is a horseshoe-shaped bone situated in the anterior midline of the neck between the chin and the thyroid cartilage. At rest, it lies at the level of the base of the mandible in the front and the third cervical vertebra (C3) behind.

Obstructive sleep apnea repeated collapse and obstruction of the upper airway during sleep, which results in reduced airflow (hypopnea) or complete airflow cessation (apnea), oxygen desaturation, and arousals from sleep.

Obstructive sleep apnea (OSA) is the most common type of sleep apnea and is caused by complete or partial obstructions of the upper airway. It is characterized by repetitive episodes of shallow or paused breathing during sleep, despite the effort to breathe, and is usually associated with a reduction in blood oxygen saturation. These episodes of decreased breathing, called "apneas", typically last 20 to 40 seconds.

Contents

Background

The American Academy of Otolaryngology Head and Neck Surgery position statement considers hyoid suspension “effective and non-investigational with proven clinical results when considered as part of the comprehensive surgical management of symptomatic adult patients with mild obstructive sleep apnea (OSA) and adult patients with moderate and severe OSA assessed as having tongue base or hypopharyngeal obstruction.”

The American Sleep Apnea Association (ASAA) website describes hyoid suspension as a minimally invasive procedure where: “Success from this procedure has been outstanding and is becoming a valuable tool in the surgeon’s armamentarium.”

The American Sleep Apnea Association (ASAA) is a non-profit organization founded in 1990 by persons with sleep apnea and concerned health care providers and researchers.

Hyo-mandibular advancement along with genioglossus advancement was originally described by in 1984. [1] Published clinical experience with hyoid suspension can be summarized into three different approaches to the hyoid suspension procedure: hyo-mandibular suspension, hyo-thyroid suspension, and genioglossus advancement and hyoid myotomy.

Hyo-mandibular suspension

In hyo-mandibular suspension, sutures are looped around the anterior section of the hyoid bone, the hyoid is advanced typically 2 - 3 centimeters (until the muscle attachments to the hyoid are tensioned) using the sutures, and the hyoid advancement is locked into place and secured via bone anchors on the front lower inside portion of the jaw. This procedure is typically performed with two incisions, one incision under the chin for placement of bone anchors into the jaw and one incision directly over the hyoid bone for the most direct access to the bone. Some surgeons perform the procedure from only the single incision below the chin. Potential complications and side effects from the procedure include neck seromas, edema, and surgical site infection.

Hyo-mandibular suspension: Base hyoid position before advancement. Hyoid suspension with base hyoid position.png
Hyo-mandibular suspension: Base hyoid position before advancement.
Hyo-mandibular suspension: Hyoid advanced with ghost image of original hyoid position. Shown using Encore hyoid system by Siesta Medical. Hyoid suspension with advanced hyoid with ghost of base position.png
Hyo-mandibular suspension: Hyoid advanced with ghost image of original hyoid position. Shown using Encore hyoid system by Siesta Medical.
Hyo-mandibular suspension: Completed suspension. Hyoid suspension with advanced hyoid.png
Hyo-mandibular suspension: Completed suspension.

Hyo-thyroid suspension

In hyo-thyroid suspension, sutures are looped around the hyoid, and the hyoid bone is advanced using the sutures to the upper edge of the thyroid cartilage where it is sutured and tied to the top of the thyroid cartilage. This procedure is typically performed from a single incision directly over the hyoid bone. Potential complications and side effects from the procedure include neck seromas, edema, transient dysphagia, and surgical site infection.

Genioglossus advancement and hyoid myotomy (GAHM)

In genioglossus advancement and hyoid myotomy (GAHM), a genioglossus advancement is performed at the same time as either a hyo-mandibular or hyo-thyroid suspension. Potential complications and side effects from the procedure include lip and chin hypoanesthesia, seromas, edema, transient dysphagia and aspiration, and surgical site infection.

Clinical results

Published clinical results for hyoid suspension performed with a UPPP are presented in the table below. [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] Surgical success typically means that the AHI is reduced at least 50% and that the post-operative AHI is less than 20.

Hyo-mandibular suspension Hyo-thyroid suspension GAHM
AHI improvement 60% 48% 58%
Surgical success 71% 58% 61%

Published clinical information for the three hyoid suspension variations without a UPPP is very limited. [19] [20] [21]

For many years, a genioglossus advancement was consistently performed with a hyoid suspension where the more invasive and morbid genioglossus advancement was considered a necessary component for the overall success of the tongue base intervention. Hyo-thyroid suspension published evidence comes entirely from Europe where the low cost, reduced morbidity, and nearly equivalent results to GAHM have made it the preferred technique. Recent publications have suggested that hyo-mandibular suspension may be the most effective hyoid suspension technique in treating tongue base and hypopharyngeal obstructions. [22] The technique is similarly invasive to hyo-thyroid suspension and available clinical data shows 25% greater efficacy for the reduction of AHI when compared to hyo-thyroid suspension. Data available for hyo-mandibular suspension also shows similar superior efficacy to the GAHM procedure. Hyo-mandibular suspension requires a surgical kit and implants (Siesta Medical Encore or Medtronic Airvance) which make the procedure marginally more expensive than hyo-thyroid suspension.

Related Research Articles

Otorhinolaryngology study of ear, nose, and throat conditions

Otorhinolaryngology is a surgical subspecialty within medicine that deals with conditions of the ear, nose, and throat (ENT) and related structures of the head and neck. Doctors who specialize in this area are called otorhinolaryngologists, otolaryngologists, ENT doctors, ENT surgeons, or head and neck surgeons. Patients seek treatment from an otorhinolaryngologist for diseases of the ear, nose, throat, base of the skull, and for the surgical management of cancers and benign tumors of the head and neck.

Sleep apnea sleep disorder characterized by repeated cessation and commencing of breathing that repeatedly disrupts sleep

Sleep apnea, also spelled sleep apnoea, is a sleep disorder characterized by pauses in breathing or periods of shallow breathing during sleep. Each pause can last for a few seconds to a few minutes and they happen many times a night. In the most common form, this follows loud snoring. There may be a choking or snorting sound as breathing resumes. As the disorder disrupts normal sleep, those affected may experience sleepiness or feel tired during the day. In children it may cause problems in school, or hyperactivity.

Palatine uvula fleshy appendage that hangs from the back of the palate

The palatine uvula, usually referred to as simply the uvula , is a conic projection from the posterior edge of the middle of the soft palate, composed of connective tissue containing a number of racemose glands, and some muscular fibers. It also contains a large number of serous glands that produce a lot of thin saliva.

Snoring is the vibration of respiratory structures and the resulting sound due to obstructed air movement during breathing while sleeping. In some cases, the sound may be soft, but in most cases, it can be loud and unpleasant. Snoring during sleep may be a sign, or first alarm, of obstructive sleep apnea (OSA). Research suggests that snoring is one of the factors of sleep deprivation.

Adenoidectomy surgical removal of the adenoids

Adenoidectomy is the surgical removal of the adenoid for reasons which include impaired breathing through the nose, chronic infections, or recurrent earaches. The surgery is less commonly performed in adults in whom the adenoid is much smaller and less active than it is in children. It is most often done on an outpatient basis under general anesthesia. Post-operative pain is generally minimal and reduced by icy or cold foods. The procedure is often combined with tonsillectomy and recovery time can range from several hours to two or three days.

Thyroglossal cyst A congenital benign cyst arising from the remnants of the thyroglossal duct. It is usually located in the midline of the neck.

A thyroglossal cyst is a fibrous cyst that forms from a persistent thyroglossal duct. Thyroglossal cysts can be defined as an irregular neck mass or a lump which develops from cells and tissues left over after the formation of the thyroid gland during developmental stages.

Upper airway resistance syndrome is a common sleep disorder characterized by the narrowing of the airway that can cause disruptions to sleep. The primary symptoms include excessive fatigue and chronic insomnia. UARS can be diagnosed by polysomnography, and can be treated with lifestyle changes, dental devices, or CPAP therapy. UARS is similar to certain types of sleep apneas.

Mandibular advancement splint

A mandibular splint or mandibular advancement splint is a device worn in the mouth that is used to treat orofacial disorders including: obstructive sleep apnea (OSA), snoring, and TMJ disorders. These devices are also known as mandibular advancement devices, sleep apnea oral appliances, oral airway dilators and sleep apnea mouth guards. The American Academy of Sleep Medicine (AASM) and the American Academy of Dental Sleep Medicine (AADSM) recommend that sleep physicians should prescribe sleep apnea oral appliances for the adult patients who need treatment for their primary snoring rather than no treatment and for the patients who have obstructive sleep apnea but are intolerant to the CPAP therapy, or for those who prefer alternate therapy.

Uvulopalatopharyngoplasty

Uvulopalatopharyngoplasty is a surgical procedure or sleep surgery used to remove tissue and/or remodel tissue in the throat. This could be because of sleep issues. Tissues which may typically be removed include:

Genioglossus

The genioglossus is one of the paired extrinsic muscles of the tongue. The genioglossus is the major muscle responsible for protruding the tongue.

Maxillomandibular advancement (MMA) or orthognathic surgery, also sometimes called bimaxillary advancement (Bi-Max), or maxillomandibular osteotomy (MMO), is a surgical procedure or sleep surgery which moves the upper jaw (maxilla) and the lower jaw (mandible) forward. The procedure was first used to correct deformities of the facial skeleton to include malocclusion. In the late 1970s advancement of the lower jaw was noted to improve sleepiness in three patients. Subsequently, maxillomandibular advancement was used for patients with obstructive sleep apnea.

Genioglossus advancement (GA) also known as Genial Tubercle Advancement (GTA), is a surgical procedure or sleep surgery in which the base of the tongue is pulled forward, usually to increase airway size due to deformity or a sleep breathing disorder. This procedure is frequently performed with either uvulopalatopharyngoplasty or Maxillomandibular advancement surgeries.

Velopharyngeal insufficiency is a disorder of structure that causes a failure of the velum to close against the posterior pharyngeal wall during speech in order to close off the nose during oral speech production. This is important because speech requires sound and airflow to be directed into the oral cavity (mouth) for the production of all speech sound with the exception of nasal sounds. If complete closure does not occur during speech, this can cause hypernasality and/or audible nasal emission during speech. In addition, there may be inadequate airflow to produce most consonants, making them sound weak or omitted.

The Stanford Protocol is a combination of surgeries that are undertaken to treat obstructive sleep apnea. The Protocol involves two phases, the first of which involves UPPP and one or more of Genioglossus Advancement or Hyoid Suspension. The Second Phase of the operation involves maxillomandibular advancement.

Eric M. Genden is an American otolaryngological surgeon at the Icahn School of Medicine at Mount Sinai and Mount Sinai Health System in New York City.

TransOral Robotic Surgery (TORS) is a modern surgical technique used to treat tumors of the mouth and throat via direct access through the mouth. TransOral Robotic Sleep Apnea (TORSA) surgery utilizes the same approach to open the upper airway of patients with obstructive sleep apnea. In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth) and pharynx without any incisions through the neck, chin or lip. Current TORS techniques include radical tonsillectomy, resection of palate and base of skull tumors, hemiglossectomy and resection of tumors above and involving the larynx. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

References

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