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Usefulness of Uvulopalatopharyngoplasty With Genioglossus and Hyoid Advancement in the Treatment of Obstructive Sleep Apnea
Isabel Vilaseca, MD;
Antonio Morelló, MD;
Josep María Montserrat, MD;
Joan Santamaría, MD;
Alex Iranzo, MD
Arch Otolaryngol Head Neck Surg. 2002;128:435-440.
ABSTRACT
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Objective To evaluate the usefulness of uvulopalatopharyngoplasty plus mandibular
osteotomy with genioglossus and hyoid advancement in the treatment of obstructive
sleep apnea syndrome (OSAS).
Design Prospective study of 20 consecutive patients with OSAS.
Setting University medical center.
Patients and Interventions Twenty OSAS patients with multilevel upper airway obstruction who refused
continuous positive airway pressure treatment. All patients were evaluated
before and 6 months after surgery by clinical history, the Epworth Sleepiness
Scale, physical examination, fiberoptic nasopharyngoscopy combined with the
Müller maneuver, cephalometric analysis, nocturnal polysomnography, and
a second-night polysomnography with upper airway pressure recording during
sleep. Surgery procedures were uvulopalatopharyngoplasty plus mandibular osteotomy
with genioglossus and hyoid advancement. Surgical successful outcome was defined
as an apnea-hypopnea index (AHI) lower than 20 plus subjective resolution
of daytime symptoms.
Main Outcome Measure Surgical success rate.
Results Mean ± SD AHI decreased from 60.5 ± 16.5 to 44.6 ±
27 (P = .007), and CT90 (percentage of time with oxyhemoglobin
saturation below 90%) decreased from 39.5% ± 26% to 25.1% ±
26.4% (P = .002). The overall surgical success rate
was 35% but increased to 57% in patients with moderate OSAS (AHI, 41-60) and
to 100% in mild OSAS (AHI, 21-40). In the group of severe OSAS, the success
rate was 9%. Predictors of surgical outcome success were the AHI, CT90, stages
2 and 3-4 sleep percentages, and the cephalometric ANB angle (angle formed
from the deepest point on the maxillary outer contour to the nasion to the
deepest point on the outer mandibular contour).
Conclusion Patients with mild and moderate OSAS and multilevel obstruction in the
upper airway may benefit from uvulopalatopharyngoplasty plus genioglossus
and hyoid advancement.
INTRODUCTION
OBSTRUCTIVE sleep apnea syndrome (OSAS) is caused by repetitive occlusion
of the upper airway during sleep and may be treated with continuous positive
airway pressure (CPAP) or with several surgical techniques. Surgery is used
to correct any anatomic abnormality that potentially narrows the upper airway,
which may be disclosed clinically or by other means (eg, cephalometry and
fiberoptic nasopharyngoscopy).1
Uvulopalatopharyngoplasty (UPPP) is used to eliminate the upper airway
obstruction selectively at the level of the oropharynx by removing a portion
of the soft palate and the uvula; it is effective in 33% to 77% of patients.2 The association of UPPP plus mandibular osteotomy
with genioglossus and hyoid advancement (multi-level reconstruction phase
1) was introduced by Riley et al3 as a surgical
alternative to isolated UPPP in patients with multilevel obstruction. When
this procedure fails, maxillomandibular advancement (multi-level reconstruction
phase 2) may follow phase 1. This surgical strategy was adopted by several
centers maintaining the gradual 2-phase surgical procedure proposed by Riley
et al,3 who showed that the multi-level reconstruction
phase 2 success rate was similar to CPAP efficacy. However, the usefulness
of multi-level phase 1 reconstruction remains unclear because apart from those
by the Stanford group,3 the studies published
are few, with small numbers of patients and varying rates of success.4-10
The aim of our study was to evaluate the usefulness of a multilevel phase
1 surgical procedure in a group of OSAS patients with multilevel obstruction.
PATIENTS AND METHODS
STUDY DESIGN
We prospectively observed 20 consecutive OSAS patients with UPPP failure
and multilevel obstruction in the upper airway. Inclusion criteria were (1)
persistent symptoms suggestive of OSAS and post-UPPP apnea-hypopnea index
(AHI) (total number of apneas and hypopneas per hour of sleep) greater than
20, as determined by polysomnography (PSG); (2) obstruction in both the oropharynx
and the hypopharynx, and (3) CPAP refusal or intolerance. Exclusion criteria
were (1) age older than 65 years, (2) chronic pulmonary disease and/or (3)
poor health condition. Presurgical evaluation included clinical history, Epworth
Sleepiness Scale (ESS) evaluation,11 physical
examination, fiberoptic pharyngolaryngoscopy, cephalometry, nocturnal PSG,
and second-night PSG with upper airway pressure measurement during sleep.
In all patients, the surgical procedure included UPPP and hyoid advancement.
Inferior mandibular osteotomy with genioglossus advancement was also performed
in 11 subjects according to cephalometric criteria of mandibular deficiency.
To evaluate the effectiveness of the surgical procedure, we repeated the presurgical
evaluation 6 months after surgery. A procedure was considered successful (and
the patient, a responder) if the postoperative PSG
demonstrated an AHI lower than 20 and the patient reported significant clinical
improvement. This study was approved by the ethics committee at our institution
and written informed consent was obtained from each patient.
CLINICAL EVALUATION
Patients were evaluated by a comprehensive clinical history that covered
their sleep habits and the occurrence of sleep disturbances. Excessive daytime
sleepiness was estimated by the ESS: a score greater than 10 was considered
indicative of hypersomnia.11 Physical examination
included measurement of the body mass index (BMI) and neck circumference and
evaluation of the anatomic characteristics and abnormalities of the upper
airway. A combination of nasopharyngolaryngoscopy with the Müller maneuver12 was used to evaluate the upper airway compliance.
CEPHALOMETRIC ANALYSIS
Lateral cephalometric radiographs were performed according to standard
procedure.13 Before the exposure, patients
swallowed contrast to outline the pharynx soft structures. We determined and
evaluated the SNA angle (maxilla to cranial base, position of the maxilla),
SNB angle (mandible to cranial base, postion of the mandible), PAS (posterior
airway space, distance between the base of the tongue and the dorsal pharyngeal
wall), PNS-P (distance from the posterior nasal spine to the tip of the soft
palate, length of soft palate), point A (deepest point on the maxillary outer
contour), point B (deepest point on the outer mandibular contour), point G
(palate thickness), point P (inferior tip of the palate), ANB angle (angle
formed from point A to nasion to point B), and MP-H (distance from inferior
mandible plane to hyoid bone; position of the hyoid bone).14-15
Palatal obstruction was defined when cephalometric analysis showed a PNS-P
greater than 40 mm.16 Hypopharyngeal obstruction
was defined when cephalometric analysis showed mandibular deficiency (SNB 77°)
and narrowing of the airway space at the base of the tongue (PAS10 mm).17 After surgery, mandibular advancement was calculated
according to the depth of the mandibular osteotomy.
SLEEP EVALUATION
All night PSG studies included 4 electroencephalogram leads (C3-A1,
C4-A2, O1-A1, O2-A2), electrooculogram, chin and left and right anterior tibial
surface electromyogram, electrocardiogram, nasal and oral airflow measure
(thermistors), thoracic and abdominal movement determination, and continuous
oxyhemoglobin saturation evaluation by a pulse oximeter. Sleep stages were
scored according to criteria set out by Rechtschaffen and Kales.18
Obstructive apneas were defined as the absence of airflow with respiratory
effort for at least 10 seconds. Hypopneas were defined by a greater than 50%
reduction of airflow accompanied by an oxygen desaturation of more than 4
points or occurrence of an arousal from sleep. The percentage of time with
oxyhemoglobin saturation below 90% (CT90) and lowest saturation level were
also calculated.
Pressure recordings at the velopharynx, oropharynx, and hypopharynx
were evaluated during the PSG studies before and after surgery using the esophagus
pressure as reference. We used a 3-lumen catheter adapted to an esophageal
balloon that was connected to a pressure transducer. The right upper airway
catheter placement was checked under visual inspection using catheter marks.
The detection of changes and cessation of the signal during an obstructive
apnea allowed us to detect the precise location of the collapse in the pharynx.
When no obstruction was demonstrated, all registers were parallel to the esophagus
signal.
SURGICAL PROCEDURE
All 20 patients had experienced UPPP failures. A second surgical phase
included hyoid advancement in all 20 patients and mandibular osteotomy with
genioglossus advancement in the 11 patients in whom the SNB angle was less
than 78°, indicating a retroposition of the mandible.
The UPPP was performed as previously described by Simmons et al.19 Hyoid advancement technique differed from the original
description by Riley et al20 in that we advanced
the hyoid bone to an anterior and downward direction over to the thyroid laminae
where it was fixed with Gore-Tex (WL Gore & Associates, Flagstaff, Ariz)
pushing the tongue ahead and consequently increasing the PAS. The mandibular
osteotomy with genioglossus advancement procedure was performed as described
by Riley et al3 advancing the tongue at the
genioid tubercle of the mandible to relieve the obstruction at the hypopharyngeal
level. Surgery was performed under general anesthesia, and during the 24 hours
following surgery patients were monitored in the intensive care unit.
STATISTICAL ANALYSIS
Data are presented as mean ± SD. The Wilcoxon test was used to
compare the preoperative and postoperative results. The Mann-Whitney test
was used to analyze the differences between responders and nonresponders.
Differences were also tested with analysis of covariance, with disease severity
as covariable. Data were analyzed using SPSS, Windows version 6.1.3 (SPSS
Inc, Chicago, Ill), establishing P<.05 as statistically
significant.
RESULTS
PREOPERATIVE AND POSTOPERATIVE EVALUATION
The main clinical, polysomnographic, and cephalometric characteristics
before and after surgery are summarized in Table 1. All 20 patients were men with a mean ± SD age of
44.7 ± 5.7 years (range, 34-58 years). The BMI was 27.8 ± 3.3
kg/m2, and neck circumference, 40.9 ± 2.1 cm. After 6 months
of follow-up, the BMI and neck circumference showed no significant differences.
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Table 1. Change in Key Patient Parameters After Surgery*
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All 20 patients were habitual and heavy snorers and reported daytime
fatigue and somnolence; 16 (80%) felt not refreshed on awakening. Postoperatively,
snoring was eliminated in 15 patients (75%), decreased in 5 (25%), and early
morning fatigue persisted in 6 (30%).
Before surgery, the ESS score was greater than 10 in 11 subjects, and
following treatment the score improved in all but 1 (Table 2). The ESS score improved from 12 ± 5.8 (range, 0-24)
to 7.9 ± 5 (range, 0-18) but this difference was not statistically
significant (P = .64).
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Table 2. Change in Apnea-Hypopnea Index (AHI) and Epworth Sleepiness
Scale (ESS) Scores After Survey*
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Mean baseline PSG parameters were characteristic of severe OSAS, showing
a high AHI (60.5 ± 16.5), severe oxygen desaturation (mean CT90, 39.6%
± 26.0%; lowest mean saturation, 68.3% ± 10.1%), and sleep fragmentation
induced by a high number of arousals and brief awakenings. Total sleep time
and sleep efficiency did not differ between preoperative and postoperative
studies. There was a statistically significant reduction in the AHI (P<.001), with a trend toward a decrease in the apnea
index and an increase in the hypopnea index. Postoperative studies showed
a reduction in the AHI in 16 patients (80%), with an AHI lower than 20 in
7, and 50% or more AHI reduction in 8 (Table 2). In 4 patients, the postoperative AHI was slightly higher
than before surgery. Oximetric analysis showed a significant decrease in CT90
(P = .002) and increase in lowest oxyhemoglobin saturation
(P = .001) between preoperative and postoperative
studies. After surgery, sleep architecture improved, showing a significant
decrease in stage 2 sleep (P = .01) and a tendency
toward an increase in slow-wave sleep (P = .06) and
REM (rapid eye movement) sleep (P = .07).
Before surgery, cephalometric analysis showed long and thick soft palates,
narrowing in the PAS behind the tongue, mild mandibular and maxillar deficiency,
and lowered position of the hyoid bone. Eleven patients (55%) had mandibular
deficiency (SNB<78°).
There were significant differences between preoperative and postoperative
findings in the palate parameters PNS-P and point G, the hyoid bone position
MP-H, and the SNB angle. Seventeen patients (85%) experienced significant
increase in MP-H from 35.3 ± 9.7 mm to 42.5 ± 8.7 mm (P = .005). In those with mandibular osteotomy with genioglossus
advancement, the mean depth of osteotomy was 11.5 ± 2.4 mm, resulting
in a significant SNB angle increase of 9.4° ± 2.1°. Preoperative
PAS was less than 11 mm in 7 subjects (35%), and after surgery increased from
10.9 ± 4.1 mm to 12.8 ± 3.8 mm (P =
.07) and enlarged in 14 patients (70%). The 6 subjects who had no increase
in their PAS had undergone mandibular osteotomy with genioglossus advancement,
and only 1 of them had a preoperative PAS smaller than 11 mm (Table 3).
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Table 3. Change in Posterior Airway Space (PAS) After Surgery*
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Preoperative pressures of the upper airway during sleep showed multilevel
obstruction in all patients, although a reduced sleep efficiency related to
discomfort was disclosed in 2. Postoperative pressure could not be assessed
in 8 patients because they refused the procedure. Complete preoperative and
postoperative studies to measure pressures were done and well tolerated in
10 nonresponders. In these 10 patients, multilevel obstruction was still demonstrated
after surgery.
There was no correlation between postoperative AHI changes and postoperative
variations in BMI, neck circumference, ESS score, sleep stage percentages,
and the cephalographic parameters PNS-P, point G, PAS, and MP-H. Changes in
AHI were correlated with postoperative changes in ANB (P = .01) and SNB (P = .01).
SURGICAL OUTCOME
Seven patients (35%) met our polysomnographic and clinical criteria
for surgical success. Statistical analysis identified AHI, CT90, stages 2
and 3-4 percentages (sleep quality), and the ANB angle as predictors of surgical
outcome. Before surgery, the successful group had significantly fewer apneas
and oxyhemoglobin desaturations, lower stage 2 sleep percentage, higher slow-wave
sleep percentages, and lower maxillary/mandible discrepancy. Patients with
severe OSAS (AHI, >60) had a low incidence of success. Surgical outcome rate
was higher in patients with moderate (AHI, 41-60) and mild (AHI, 21-40) OSAS:
Patients who were not successfully treated tended to have bigger neck
circumferences (P = .09) and higher ESS scores (P = .08) than responders. There were no statistical differences
between the 2 groups in BMI, age, and all the cephalometric parameters except
ANB angle (Table 4).
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Table 4. Preoperative Comparison of Key Patient Parameters Between
Success and Failure Groups
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None of the patients in this series had postoperative bleeding, infection,
difficulty swallowing, persistent rhinolalia and nasal regurgitation, or significant
pain. Two days after surgery, 1 patient with a preoperative history of coronary
heart disease had an angina pectoris, which resolved with adequate medical
treatment.
COMMENT
This study showed that UPPP plus mandibular osteotomy with genioglossus
and hyoid advancement was effective in 35% of OSAS patients with multilevel
obstruction. Patients in the successful group reported elimination of snoring
and were free of daytime symptoms. Treatment success predictors were AHI,
oxyhemoglobin saturation, sleep architecture, and the ANB angle. The highest
treatment effect was obtained in patients with mild to moderate AHI, no significant
desaturations, no sleep disruption, and slight mandibular deficiency.
Our success rate is similar to that in 2 previous publications, which
showed a success rate between 27% and 42%,8-9
but is lower than that of the Stanford group3
and other researchers who reported a 50% to 78% rate of success.4-7,10
There are several possible explanations for these differences in results.
First, our patients might have changed weight during the 6 months after surgery
and subsequently increased their AHIs and CT90s. However, this speculation
was not confirmed; statistical analysis showed that there were no differences
between BMI and neck circumference before and 6 months after surgery.
Second, our patients had moderately severe OSAS with a mean AHI of 60,
while other studies selected patients with lower AHIs (range, 45-58).4-5,7-8 Because
success rate is predicted by the AHI, it can be speculated that our surgical
success would have been higher if we had selected patients with lower severity.
Third, our definition of surgical success included not only an AHI lower
than 20, but also daytime clinical resolution. Because some studies considered
an AHI lower than 20 as the sole indicative parameter of surgical success,
some of our patients with AHIs lower than 20 but without complete disappearance
of daytime symptoms would have been classified as responders. However, all
patients with remaining postsurgery symptoms in our study also showed AHIs
higher than 20 and hypersomnia, and consequently were classified in the failure
group. Furthermore, if our definition of success had included a 50% reduction
in the AHI,4 then the success rate of our study
would have increased to 40%.
Fourth, we found a postoperative reduction in the number of apneas at
the expense of an increase in the number of hypopneas. This finding was also
observed by Bettega et al.8 Because the definition
criteria for a hypopnea and the methods used to register the oral and nasal
airflow may differ depending on the sleep laboratory,21
a meticulous measurement of respiratory events is necessary to avoid underestimation
of residual hypopneas after surgery.
Finally, our surgical protocol differed slightly from that of previous
studies,3 and the procedures were not the same
for all the patients in our series. For example, we performed hyothyropexia
instead of hyoid suspension, and genioglossus advancement was only performed
in 11 patients (55%). However, our cephalometric analysis showed significant
differences (as have previous publications4, 9-10)
in most of the parameters between preoperative and postoperative studies,
suggesting a significant effect of our surgical protocol in the anatomic structures
responsible for the obstruction during sleep. Six of the 7 patients in the
successful group showed an increase in PAS. Furthermore, postoperative changes
in AHI were significantly correlated with postoperative changes in ANB and
SNB angles. However, while all patients with isolated hyoid advancement experienced
increased PAS, 6 (55%) of 11 patients with genioglossus plus hyoid advancement
did not, suggesting that the combination of genioglossus and hyoid advancement
may not always reduce the hypopharyngeal obstruction (Table 3).
In all of our patients, clinical examination, fiberoptic nasopharyngoscopy,
cephalometry, and upper airway manometry during sleep disclosed preoperative
obstruction in both the soft palate and the base of the tongue. Since all
patients were symptomatic and rejected CPAP, the multilevel surgery approach
was proposed and accepted. The procedure was designed to remove the obstruction
in the oropharynx by UPPP and increase the size of the airway at the hypopharnyx
by mandibular osteotomy with genioglossus advancement and hyoid advancement.
After 6 months of follow-up, 66% of patients with preoperative mild to moderate
sleep apnea (mean AHI, 46) had successful outcome, while most subjects with
severe sleep apnea (mean AHI, 68) were still symptomatic and had an AHI higher
than 20, continued desaturations, altered sleep architecture, and remnant
oropharyngeal and hypopharyngeal obstruction demonstrated by endoscopy and
upper airway manometry recording during sleep.
Our study shows the importance of routine postoperative PSG studies
and clinical follow-up. The finding that only OSAS severity predicted the
surgical outcome in our study suggests that genioglossal and hyoid advancement
cannot be recomended on the basis of cephalometrics alone. Patients for whom
phase 1 failed were still symptomatic, had a significant number of apneas,
retained multilevel obstruction, and consequently required additional treatment.
Therapeutic alternatives in these patients may be bimaxillary advancement22-23 and another nasal CPAP attempt. In
conclusion, although limited by the small number of patients, our study suggests
that after UPPP, only patients with mild to moderate OSAS with oropharyngeal
and hypopharyngeal obstruction may benefit from a multi-level reconstruction
phase 1 surgical approach.
AUTHOR INFORMATION
Accepted for publication September 14, 2001.
This work was supported by grant FISS 94/0434 from the Fondo de Investigaciones
Sanitarias, Madrid, Spain (Dr Morelló).
Corresponding author and reprints: Isabel Vilaseca, MD, Otorhinolaryngology
Service, Hospital Clínic de Barcelona, C/ Villarroel 170, Barcelona
08036, Spain (e-mail: ivilasecag{at}seorl.org).
From the Services of Otorhinolaryngology (Drs Vilaseca and Morelló),
Pneumology (Dr Montserrat), and Neurology (Drs Santamaría and Iranzo),
University of Barcelona, Hospital Clínic, Barcelona, Spain.
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