Clin Exp Otorhinolaryngol.  2020 Aug;13(3):225-233. 10.21053/ceo.2020.00360.

Maxillomandibular Advancement and Upper Airway Stimulation: Extrapharyngeal Surgery for Obstructive Sleep Apnea

• Yu MS
• Ibrahim B
• Riley RW
• Liu SYC

• KMID: 2504916
• DOI: http://doi.org/10.21053/ceo.2020.00360

Abstract

There are many ways to categorize surgery for obstructive sleep apnea (OSA), one of which is to distinguish between intrapharyngeal and extrapharyngeal procedures. While the general otolaryngologist treating OSA is familiar with intrapharyngeal procedures, such as uvulopalatopharyngoplasty and tongue base reduction, extrapharyngeal sleep operations such as maxillomandibular advancement (MMA) and upper airway stimulation (UAS) have evolved rapidly in the recent decade and deserve a dedicated review. MMA and UAS have both shown predictable high success rates with low morbidity. Each approach has unique strengths and limitations, and for the most complex of OSA patients, the two in combination complement each other. Extrapharyngeal airway operations are critical for achieving favorable outcomes for sleep surgeons.

Keyword

Obstructive Sleep Apnea; Sleep Surgery; Maxillomandibular Advancement; Facial Skeletal Surgery; Hypoglossal Nerve Stimulation; Upper Airway Stimulation

Figure

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  Fig. 1. Virtual surgical planning (VSP) of maxillomandibular advancement with counterclockwise rotation: preoperative VSP (A), postoperative VSP (B), and postoperative computed tomography scan (C).

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  Fig. 2. Schematic drawing of maxillomandibular advancement. LeFort I osteotomy. (A) Exposure of the piriform aperture and nasal floor. Le Fort I osteotomy and wedges (dotted lines) for counterclockwise rotation. (B) Maxilla mobilization via traction with wire through the anterior nasal spine. (C) Fixation with titanium plates. Virtual surgical planning-guided genioglossus and geniohyoid advancement. (D) The anterior mandible is exposed and the osteotomy guide is designed to capture the genial tubercle (dotted line) while avoiding dental roots and mental nerves. (E) The osteotomy is made using a reciprocating saw. The genial tubercles (dotted line) are preserved. (F) The mobilized graft is moved forward and fixed with a plate. Sagittal split mandibular osteotomy. (G) The mandibular ramus and body are exposed by subperiosteal dissection. (H) The horizontal osteotomy is made through the lingula and the anterior osteotomy split sequentially with three osteotomes. (I) The mandible is advanced, and fixation is performed with positional screws and titanium plates.

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  Fig. 3. Tongue muscles and branches of the hypoglossal nerve (CN XII). The medial branches of CN XII (med CN-XII) and first cervical spinal nerve (C1) selectively innervate the primary upper airway dilators: the genioglossus (GG) and geniohyoid (GH) muscles, respectively. The lateral branches of the hypoglossal nerve (lat CN-XII) innervate the retrusor muscles: the hyoglossus (HG) and styloglossus (SG). The ideal placement of the stimulation cuff electrode is distal to the lateral branch of CN XII, thereby including the medial branch and C1 nerve. T/V, transverse and vertical; SL, superior longitudinal; IL, inferior longitudinal; GGo, genioglossus oblique; GGh, genioglossus horizontal.

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  Fig. 4. Hypoglossal nerve stimulation system. (A) Stimulation cuff lead placement. To identify the medial branch (br) of the hypoglossal nerve, the anterior belly of the digastric muscle and mylohyoid muscle (m) are identified and retracted inferiorly and anteriorly, respectively. (B) The implantable pulse generator delivers electric pulses through a stimulation lead to the hypoglossal nerve synchronous with respiratory cycles detected by a sensing lead. (C) Sensing lead placement. The distal end of the sensing lead is placed between internal and external intercostal muscles parallel to the adjacent ribs.

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