Current surgical concepts for treating obstructive sleep apnea syndrome

Obstructive sleep apnea syndrome is a relatively common disorder with potentially serious psychologic and physiologic consequences. A comprehensive method of evaluation is described. Presurgical tests are mandatory in order to logically direct surgical treatment. Current surgical treatment and new techniques are discussed.

Maxillary, mandibular, and hyoid advancement: an alternative to tracheostomy in obstructive sleep apnea syndrome

Nine patients with severe obstructive sleep apnea syndrome (OSAS)--for whom several therapeutic approaches, including palatopharyngoplasty, had failed--were treated with a combined maxillary, mandibular, and hyoid advancement. Objective evaluation--performed before and 4 to 18 months after surgery, using nocturnal polysomography--indicated that the OSAS had improved or had disappeared. This surgical approach is beneficial for specific cases of OSAS, which can be identified by mandatory presurgical tests.

Inferior sagittal osteotomy of the mandible with hyoid myotomy-suspension: a new procedure for obstructive sleep apnea

Five patients were treated by inferior sagittal osteotomy and hyoid myotomy-suspension. In three of the patients, palatopharyngoplasty had previously failed. One of the patients was noted to have mandibular deficiency; the others had normal skeletal development. Nocturnal polysomnograms were performed preoperatively and postoperatively. All patients showed significant improvement.

Thyroglossal tract anomalies

Thyroglossal tract anomalies present most frequently before the second decade of life. Investigations should include ultrasound and thyroid isotope scan to demonstrate the presence of other functioning thyroid tissue prior to excision. Cysts demonstrating echogenic material centrally should be considered to be inflamed and surgical exploration carried out under antibiotic cover to minimize postoperative infection. Total excision of the thyroglossal tract anomaly must include the body of the hyoid bone to prevent recurrence and reduce the risk of further symptoms.

Diagnosis and management of obstructive sleep apnea. Part II

Snoring has been shown to be the primary sign of a potentially serious medical condition, ie, obstructive sleep apnea. Traditionally, the otolaryngologist has been the primary resource for patients with snoring problems although, until recently, little was known about the now-acknowledged serious complications of this phenomenon. Among the primary treatments for this condition, the most commonly used to-date involve surgical procedures routinely performed by the otolaryngologist, ie, tracheostomy and uvulopalatopharyngoplasty. Thus, the practicing otolaryngologist has been thrust into the forefront of diagnosis and management of obstructive sleep apnea, and it behooves the modern practitioner to be cognizant of the multidisciplinary approach to the diagnosis and management of this problem. The utilization of information obtained during the sleep study determines the management of the sleep apneic patient.

Elongated styloid process syndrome: intraoral versus external approach for styloid surgery

Elongated styloid process is a source of craniofacial and cervical pain. This condition is characterized by a dull, nagging, pharyngeal pain and a palpatory finding in the tonsillar fossa. Radiologic demonstration of styloid elongation is readily made in most instances. The incidence and pathogenesis of the styloid syndrome are discussed and the differential diagnosis detailed. The only effective treatment is surgical shortening of the styloid process. Eight patients undergoing surgery for elongated styloids are reported and the intraoral and external surgical approaches are presented. The external cervical approach is preferred since surgical visualization is optimal and the risk of deep cervical infection is minimal.

Reconstructive laryngectomy

Reconstructive laryngectomy, the aim of which is to leave the patient without a tracheostoma, thus preserving the normal pneumophonic function relative to vocal articulation, is a link between the various techniques suggested for conservative laryngeal surgery and classic total laryngectomy. The aim of this technique is to restore continuity to the airways, so that the patient is able to breathe naturally and subsequently can speak without having to resort to the use of esophageal voice.

Conservation surgery for cancer of the larynx in the elderly

The postoperative course was evaluated for 458 consecutive patients, all over the age of 56 years, who had undergone laryngeal conservation surgery in the last 10 years. One hundred seventy-one patients aged 66 and over made up the "elderly" group and 287 patients, aged between 56 and 65 years formed the control group. It was confirmed that cordectomy and frontolateral laryngectomy are feasible even in elderly patients. Bronchopneumonia is the most frequent and serious complication after supraglottic laryngectomy. Therefore this operation should be performed in the elderly patient only after a thorough evaluation of cardiac and respiratory function. Prophylactic neck dissection should not be done for N0 necks and the second therapeutic neck dissection in N2 cancers should be staged 6 or more weeks later. Hemilaryngopharyngectomy and subtotal reconstructive laryngectomy with cricohyoidpexis are not advisable in elderly patients.

Expansion hyoidplasty. 1983 First-Place Resident Research Award: clinical category

An inspiratory, circumferential, passive collapse of the hypopharyngeal lumen is the mechanism of airway obstruction in some patients with "idiopathic" obstructive sleep apnea syndrome. While permanent tracheotomy has resolved the obstruction and reversed the associated cardiopulmonary sequelae, it is not without complications. The expansion hyoidplasty was conceived as an alternative. The hyoid bone is trisected just medial to each lesser cornu, then held in an expanded position by a permanent brace. The greater cornua with attached middle constrictor and hyoglossus are moved laterally, while the body of the hyoid with attached geniohyoid and genioglossus shifts the base of tongue anteriorly. The procedure is potentially reversible. Twenty dogs were studied before and after hyoid expansion, 10 for superior hypopharyngeal pressure-volume measurements and 10 for the closing-pressure study. Pressure-volume studies demonstrated a consistent expansion of the superior hypopharynx. Deglutition and laryngeal competence wee not grossly affected. Reexamination of four animals in the closing-pressure group 1 year postoperatively demonstrated stability of the hyoid expansion and no evidence of serious parahyoid tissue complications.

Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: a case report

A 24-year-old man with obstructive sleep apnea syndrome and secondary daytime somnolence and nocturnal arrhythmias underwent palatopharyngoplasty. When he did not improve significantly, he underwent a new surgical procedure combining hyoid bone and mandibular horizontal sliding osteotomy.

Sectioning the hyoid bone as a therapeutic approach for obstructive sleep apnea

After research studies, including systematic lateral x-rays, of normal controls and obstructive sleep apnea syndrome (OSAS) patients, we decided to perform a medial resection of the hyoid bone in OSAS patients. The procedure is similar to that performed for ductus thyreoglossus. To date, three patients have undergone the operation under anesthesia. The two cases have been followed for several months (the third underwent surgery only recently) and have improved, indicating that this procedure can be beneficial for OSAS.

The problem of recurrent thyroglossal duct remnants

The removal of a thyroglossal duct or sinus is a common pediatric surgical operation. It has been taught that if the duct remnant is removed down to and including the middle third of the hyoid bone, the "correct" operation has been done. The three authors have an experience totaling over 60 years in pediatric surgery during which time they operated on 270 thyroglossal duct cysts and sinuses. In this group were 27 recurrences of which three belonged to the authors. Most recurrent thyroglossal duct remnants were found to have the middle third of the hyoid bone still in place, and with its removal the patients were cured. However, during this period of time, there were thyroglossal duct cysts and sinuses which recurred in spite of the "correct" surgical procedure having been done. These patients had all been operated on between three and five times thus creating a difficult and unusual problem. The solution to these recurrent thyroglossal duct cysts and sinuses were deeper excisions to remove residual tracts deep to the previously removed hyoid bone, and/or wider excisions to excise previously missed respiratory epithelial remnants which deviated laterally from the midline. The latter tissue was found to be a more centrally directed branchial cleft sinus.

Expansion hyoidplasty: a potential surgical procedure designed for selected patients with obstructive sleep apnea syndrome. Experimental canine results

Some patients with "idiopathic" obstructive sleep apnea syndrome have an inspiratory, circumferential, passive collapse of the hypopharyngeal lumen as the mechanism of airway obstruction. Permanent tracheotomy has offered documented dramatic resolution of the airway obstruction with reversal of the associated cardiopulmonary sequelae. Tracheotomy is not, however, without psychological and physical complications detracting from its use. In hope of developing a surgical alternative, the expansion hyoidplasty was conceived. The hyoid bone is transected just medial to each lesser cornu. The trisected hyoid bone is then held in an expanded position by a permanent stainless steel brace. The greater cornua with attached middle constrictor and hyoglossus are moved laterally, while the body of the hyoid with attached geniohyoid and genioglossus shift the base of tongue anteriorly. The procedure is potentially reversible. Twenty dogs were studied pre and posthyoid expansion. Superior hypopharyngeal pressure-volume and closing pressures were obtained on 10 dogs. The pressure-volume studies demonstrate a consistent expansion of the superior hypopharynx. The average drop in pressure varied from 2.9 to 12.4 cm H2O in different animals. All posthyoid expansion dogs showed an average increase in closing pressure ranging from -4.4 to -28.3 cm H2O. Deglutition and laryngeal competence were not grossly effected. These results support the continued experimentation towards implementation of the expansion hyoidplasty in humans.

Conjoint hyoid bone segments for the repair of severe laryngeal stenosis

We discuss and show by illustrations a surgical technique for the management of severe combined laryngeal and subglottic stenosis using multiple pieces of hyoid bone. No serious problems resulted from the removal of the entire hyoid bone. All patients have maintained a good airway, despite the possibility of absorption of a free bone graft. Although it is reasonable to try to use the hyoid bone with a strap muscle pedicle, it is impossible to reconstruct the subglottic and laryngeal area without multiple pieces. Our experience encourages us to use multiple pieces of free hyoid bone for laryngotracheal reconstruction.

Severe laryngeal stenosis repair: long-term follow-up using conjoint hyoid bone segments

In early 1983 the authors presented an innovative procedure for the management of severe laryngeal stenosis. Because of the severity of the stenosis and the large surgical defect created by excision of the stenosis, multiple pieces of the hyoid bone were sewn together conjointly to bridge the surgical defect. The authors are now able to report follow-up in 6 patients ranging from 11 to 60 months and discuss their favorable experience with this procedure.

Sternohyoid myo-osseous flap for acquired subglottic stenosis in children

Endotracheal intubation can occasionally result in acquired subglottic stenosis (ASGS) in infants and children. Twenty-one consecutive patients, ages 3 months to 13 years, with ASGS secondary to endotracheal intubation and severe enough to require tracheotomy, are reviewed. Of this population, eight cases of ASGS were refractory to endoscopic excision and dilatation. These eight patients, five of whom had complete stenosis, underwent subglottic reconstruction using a sternohyoid myo-osseus flap. Six of the eight patients had been successfully decannulated with no evidence of recurrent stenosis at the time of this report.

The hyoid bone syndrome

Various causes of head and neck pain have been described in the literature. In 1954 Brown described a so-called hyoid bone syndrome, ie, tenderness at the site of the greater cornu of the hyoid bone. His paper, however, did not offer any definitive treatment. In 1968 Steinmann reported the hyoid bone syndrome as a form of "insertion tendinois," for which he recommended the use of procaine hydrochloride injection with corticosteroid at the tip of the greater hyoid cornu for relief of pain. The relief, however, was temporary. The purpose of this paper is to present the symptom complex of the hyoid bone syndrome, its diagnosis by exclusion, and excision of the greater cornu in 18 patients for permanent relief of head and neck pain.

Excision of the greater cornu of the hyoid in hyoid syndrome

The results of excision of the greater cornu of the hyoid bone in cases diagnosed as 'Hyoid Syndrome' are discussed. The possible aetiopathology of its vague symptoms is discussed in the light of available literature. The line of demarcation between the styloid and the hyoid syndromes is identified.

Hyoid arch transposition

The historical aspects of the use of hyoid bone autografts are reviewed. The technique of hyoid bone transposition is described. The graft has proved to be an excellent adjunct in the repair of glottic and subglottic stenosis and for the reconstruction of small anterior tracheal defects.

[Intraoral support prosthesis of the laryngohyoid complex and of the chin after complete removal of the mandible]

The various methods proposed to date for supporting the glossohyoid-laryngeal complex after removal of the mandibular arch have been examined. A new type of intra-oral maxillofacial prosthesis for supporting the soft lining tissues of the lower 3rd of the face is then described. This has made it possible to avoid final tracheostomy in spite of total mandible removal.

[Laryngeal release for tracheal resection (author's transl)]

Mobilization of the larynx resulting in a 2 to 2.5 cm gain of length can be used in tracheal resection as an alternative to more extensive procedures within the thorax with their specific complications. In the method of Dedo and Fishman the cranial insertions of the thyrohyoid muscle are resected, the thyrohyoid membrane is divided and the two horns of the thyrohyoid cartilage are cut. Difficulties in swallowing may persist for long periods of time but usually can be overcome. In the suprahyoideal method of Montgomery the cranial muscle-insertions at the hyoid are divided and the hyoid bone is transsected leaving the small and large horns. Disturbances of swallowing are not to be expected with this method. Likewise postoperative tube-feeding is not required. The suprahyoid method probably is to be preferred.

Chemodectoma of the larynx. A clinico-pathological study

The present case report is concerned with a clinico-pathological study, including ultrastructural investigation, of a rare and uncommon laryngeal tumour, a chemodectoma, in a 62 year old patient. There have been 23 cases of laryngeal chemodectomas reported in the literature, and only three of them, including our own report, were investigated by electron microscopy. The tumours arise from the superior and inferior larynegeal nonchromaffin paraganglia or possibly from Kultschitzky-cells of the normal bronchial mucosa. Ultrastructurally they have all the characteristics of apudomas whose parent cells (APUD-cells), usually show endocrine function and probably have their origin in the neural crest. The tumours show an aggressive type of behaviour, despite usually benign histological features when compared to chemodectomas at other sites in the head and neck region. Surgery is thus the therapy of choice.

[Management of median cysts and fistulae (author's transl)]

The total extirpation of thyroglossal duct remnants with resection of the mid hyoid bone is reported as the only method for successful surgical therapy. Convoluted ducts of cysts and fistulae must be dissected to the base of the tongue and excised. As our cases demonstrate, recurrences will be avoided and revision surgery, when required, will be most successful.

Functional laryngectomy (cricohyoidopexy)

Two techniques of subtotal functional laryngectomy are described: cricohyoidopexy which is used for supraglottic tumours, and cricohyoidoepiglottopexy for glottic tumours. These operations have been carried out on 61 patients, with tumours too extensive to be managed by the usual partial laryngectomy. The functional results are good, and 94% of the patients have been decannulated.

Hyoid syndrome

A hitherto unreported treatment for one of the manifestations of the hyoid syndrome is excision of the tip of the hyoid greater cornu. A greater "index of suspicion" for the hyoid syndrome is urged.

Radical total glossectomy

A study of 26 cases of advanced carcinoma of the tongue treated by radical total glossectomy is presented. The selection of cases, the operative technique and the postoperative management are described. As seen from the follow-up of this series this procedure is able to effect a cure in some cases and give good palliation in the majority of cases of localized advanced carcinoma of the tongue. None of our patients needed postoperative laryngectomy for the complication of aspiration pneumonia.