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Operative Techniques in Otolaryngology (2005) 16, 264-269

ypopharyngeal airway surgery in the pediatric patientith obstructive sleep apnea syndrome

erome E. Hester, MD,a Nelson B. Powell, MD,a,b Robert W. Riley, DDS, MDa,b

rom the aDepartment of Otolaryngology, Stanford School of Medicine, Palo Alto, California; and the

Department of Behavioral Sciences, Division of Sleep Disorders Medicine, Stanford School of Medicine, Palo Alto, California.

Although standard treatment of pediatric sleep apnea has been directed at the nasal and retropalatallevels, some patients will have persistent obstruction at the base of the tongue. Surgical approaches thattreat this area, many of which have been proven effective in the adult population, can be considered totreat these patients.© 2005 Elsevier Inc. All rights reserved.

KEYWORDSPediatric sleep apnea;Hypopharyngealairway;Genioglossusadvancement;Hyoid myotomy;Maxillary mandibular

advancement

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Standard treatment for the obstructive sleep apneayndrome or the upper airway resistance syndrome in theediatric age group has focused on the nasal and retro-alatal levels in the past.1 Certainly, these therapies haverovided reasonable success rates, especially in the pre-dolescent age group.2 However, as the awareness andubsequent diagnosis of the pediatric obstructive sleeppnea syndrome increases, identification of those indi-iduals who have either persistent or recurrent obstruc-ion will also increase. In some patients, this obstructionill likely involve the hypopharyngeal airway. At this

ime, the frequency of obstruction at this level in thedolescent age group is unknown.

Certainly, there must be concern regarding the pedi-tric age group when surgical changes are introduced intohe upper or lower jaws. Consideration of alteration in therowth of the jaws is a relative risk until full develop-ent and growth have occurred. Typically, 90% of

raniofacial development is present by age 12 years.3 Inddition, care to avoid damage to unerupted dentitionust be taken. Therefore, unless extraneous circum-

tances are present, genioglossus advancement and bi-axillary advancement would usually not be considered

ntil late adolescence. Before this time, recent studies

Address reprint requests and correspondence: Jerome E. Hester,D, Suite #317, 750 Welch Road, Palo Alto, CA 94303.

pE-mail address: jhester@sleepsurgery.com.

043-1810/$ -see front matter © 2005 Elsevier Inc. All rights reserved.oi:10.1016/j.otot.2005.07.001

uggest that the use of orthodontia, rapid maxillary ex-ansion, or distraction may be useful.4-6

The mechanisms to identify the severity and locationf obstruction have been described in the adult popula-ion.7 In those adolescents with suspected hypopharyn-eal obstruction, a complete physical examination andedical history are followed by fiberoptic nasopharyn-

oscopy and a cephalometric x-ray. These examinationsot only help define the patient’s anatomy but also assesshe presence of other potential causes, such as neoplasticr developmental etiologies. Although medical comor-idities are less common than in adults, these are fullyvaluated preoperatively, including a referral to the ap-ropriate specialist as indicated. Laboratory data, includ-ng a complete blood count and comprehensive metabolicurvey, are obtained.

All procedures are performed in the operating roomith an anesthesiologist trained in difficult airways and

he anesthetic treatment of sleep apnea. The surgeons areresent at the time of induction. Postoperatively, all pa-ients are admitted for observation with oxygen satura-ion monitoring. Those individuals who undergo multi-evel surgery or those with preexisting medicalorbidities are admitted to the intensive care unit. The

se of intravenous narcotics is only allowed in the inten-ive care unit setting and, even then, only with strictnstruction to the nursing staff to avoid them in the

resence of signs of sedation. Benzodiazepines are also

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265Hester et al Hypopharyngeal Airway Surgery in the Pediatric Patient

ontraindicated in this group. Table 1 compares the pro-edures discussed herein.

andibular osteotomyith genioglossus advancement

andibular osteotomy with genioglossus advancementelies on the firm attachment of the genioglossus muscleo the genial tubercle. Advancement of the segment of theandible places the muscle under tension, which limits

ts posterior displacement during sleep.8 In addition tohe preoperative evaluation described previously, a Pan-rex radiograph (Imaging Sciences, Int, Inc, Hatfield,A) is obtained to document the anatomy of the anterior

eeth, mandibular height, course of the inferior alveolarerve canal, and any pathologic process.

The procedure may be performed with the patient undereneral anesthesia or, in appropriate cases, under intrave-ous sedation. The incision is intraoral in the anterior gin-ival buccal sulcus, taking care to leave a cuff of mucosa toacilitate closure and maintain the integrity of the sulcusostoperatively. Dissection is performed submucoperioste-lly to expose the inferior border of the mandible. Theocation of the genial tubercle is identified by the radio-raphs and then palpated in the floor of the mouth (FigureA). The osteotomy is then outlined using a sagittal sawhrough the outer cortex. The outline is typically 9 � 18

m, and centered 5-mm inferior to the root apices and0-mm above the inferior border of the mandible, incorpo-ating the previously identified geniotubercle. A titaniumcrew is placed in the center of the osteotomy to facilitateanipulation of the fragment. The cuts are then completed

Table 1 Comparison of surgical techniques

Genioglossus advancement

Indications ● Persistent OSA aftertraditional soft tissuesurgery and examinationdocumenting base of tongueobstruction

Contraindications ● Unerupted dentition● Inadequate mandibular

heightSpecial instruments ● Sagittal saw

● Titanium screwTips and pearls ● Careful placement of

osteotomy to avoid roottips, incorporate tubercle,and stay above mandibularborder by 10 mm

Abbreviations: OSA, obstructive sleep apnea; RDI, Respiratory Distur

hrough the inner cortex, taking care to maintain parallel t

alls. The fragment is then displaced medially into the floorf the mouth. Hemostasis is obtained using electrocauteryr, where indicated, Gelfoam (Pharmacia Corp, Kalamazoo,I). The mandibular fragment is advanced and rotated

lightly (Figure 1B). The outer cortex and marrow are re-oved, and a titanium screw is placed inferiorally to fixate

he fragment. A pear-shaped bur may then be used to con-our the fragment (Figure 1C). The wound is then closedith absorbable suture.Overall, complication rates are low.9 It is possible to

ave mild-to-moderate edema or ecchymosis in the floorf the mouth. This typically resolves but needs to beonitored closely. The patient should be counseled that

ypesthesia or paresthesia of the anterior chin or lowereeth likely will be present but should resolve over a feweeks to months. Injury to the tooth roots and mandibular

racture generally can be avoided by correct placement ofhe osteotomy.

yoid myotomy suspension

he hyoid is integrally associated with the hypopharyn-eal airway. Anterior advancement results in wideninghe posterior airway space.10 For this reason, the hyoiddvancement was initially described as a traditional com-onent of phase I surgery in the Riley-Powell surgicalrotocol in those individuals with documented hypopha-yngeal involvement.11 However, it has been our obser-ation that in many patients, the advancement providedy the genioglossus procedure alone, or more recently,hen combined with radiofrequency, may provide ade-uate treatment of the hypopharyngeal airway. In addi-

myotomy andsion

Maxillary mandibularadvancement

stent OSA aftertional soft tissuery and examinationmenting base of tongueruction

● Persistent OSA aftercompleting palatal surgeryand genioglossusadvancement

● Severe OSA (RDI �40) afterpalatal surgery

● Untreated OSA withcraniofacial deformityamenable to bimaxillarysurgery

perative dysphagia ● Preadolescent

onabsorbable suture oncurved needle

● Rigid fixation system

lute hemostasisment of draindissection medial tor cornu

● Aggressive advancement● Meticulous attention to

fixation and occlusion

ndex.

Hyoidsuspen

● Persitradisurgedocuobst

● Preo

● “0” nlarge

● Abso● Place● Keep

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ion, the hyoid advancement does leave an external scar,

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266 Operative Techniques in Otolaryngology, Vol 16, No 4, December 2005

hich may be of particular concern in the adolescentopulation.

The procedure is performed through a horizontal in-ision typically placed in a neck crease. Dissection isontinued to identify the hyoid (Figure 2A). Hemostasiss absolutely maintained. Removing the infrahyoid mus-ulature isolates the body of the hyoid. The suprahyoidusculature is left intact. Further mobility can be ob-

ained by transecting the stylohyoid ligament (FigureB). The hyoid itself is then advanced and stabilized byassing permanent sutures around the hyoid and throughhe superior aspect of the thyroid cartilage, which haseen carefully cleared of soft tissue (Figure 2C). Theound is then closed in a layered fashion, and a passiverain is placed.

Meticulous hemostasis, the use of a drain, and the place-ent of a light pressure dressing for 24 hours markedly

educe the chance of seroma or hematoma. Perioperativentibiotics are used. By keeping the dissection medial to the

igure 1 (A) Identification of the geniotubercle. (B) Advancemosition of the advancement.

esser cornu, injury to the superior laryngeal nerve can be s

voided. Dysphagia may occur postoperatively but is gen-rally only significant in the elderly.

axillary mandibular advancement

t is very important that the treating physician acknowledgehe limitations of even a complete diagnostic work-up inelineating the level and severity of obstruction. Ignoringhis limitation may lead the surgeon to recommend a moreggressive treatment plan than may be otherwise indicated.ertainly, recent reports documenting increased success us-

ng bimaxillary advancement as a first stage have been useds evidence that this is a reasonable approach.12 However,e believe it should be reserved in most patients for thoseho have completed the phase I protocol and have persis-

ent disease.13

Besides the standard preoperative evaluation or allatients, careful attention is paid to the patient’s occlu-

fixation of the mandibular fragment and genioglossus. (C) Final

ent and

ion. One goal of the procedure should be to maintain the

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267Hester et al Hypopharyngeal Airway Surgery in the Pediatric Patient

xisting occlusion. However, in those individuals with alass II occlusion, the lower jaw may be corrected moreggressively to obtain normal occlusion. It is advised toave 2 units of autologous-packed red blood cells avail-ble at surgery. The patient is nasally intubated with theurgical team in attendance. Arch bars are typicallylaced to facilitate postoperative maintenance of occlu-ion. Alternatively, orthodontic bands can be placed pre-peratively. The LeFort I maxillary osteotomy is per-ormed first. The incision is made through the mucosa,nd a submucoperiosteal flap is elevated. Full exposurerom the nasal fossae to the root of the zygoma is im-ortant (Figure 3). Special care must be taken not toiolate the nasal mucosa medially. The horizontal osteot-my is placed above the root apices using a sagittal saw.terygomaxillary separation is performed using a curved

igure 2 (A) Isolation of the hyoid and thyroid cartilage. (B) Adf the thyroid cartilage.

igure 3 Advancement and fixation of maxillary and mandibu-

ar osteotomies. (Reprinted with permission.13) w

steotome (Figure 4). The descending palatine arteries aredentified and preserved if possible. If necessary, control of theessels is obtained with surgical clips. Close attention to theaxilla is mandatory to identify any signs of vascular insuffi-

iency. Immediate replacement of the maxilla is performed ifny signs of ischemia are present. Aggressive advancementetween 8 and 12 mm is then performed. Rigid fixation isccomplished with stainless steel 24-gauge wires and 4 tita-ium miniplates.

The mandible is then addressed through a posteriorncision that allows identification of the external obliqueidge and lingula, and extends anteriorally to the canine.he periosteum is then elevated to expose both the me-ial and lateral surfaces. Identification of the lingula on

ment of the hyoid. (C) Fixation of the hyoid to the superior aspect

igure 4 Posterior view of the LeFort osteotomy. (Reprinted

vance

ith permission.13)

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268 Operative Techniques in Otolaryngology, Vol 16, No 4, December 2005

he medial surface allows identification and protection ofhe neurovascular bundle (Figure 5). A pear-shaped bur issed to make a trough just above and just past the lingula.

reciprocating saw is used to cut through the outerortex, from the midline cut to the lateral aspect of thelveolus. The cut extends to the mesial of the first molar.

vertical cut is then made from the inferior border toonnect to the previous osteotomy (Figure 6). It is rec-mmended that the inferior 5-7 mm of this cut would beicortical, then superiorally includes only the outer cor-ex. The osteotomy is then completed carefully withsteotomes. The inferior alveolar nerve is then identifiednd preserved. Once these osteotomies have been com-leted bilaterally, the mandible is advanced and broughtnto occlusion using the previously made methylmethac-ylate splint. Rigid fixation is obtained with percutaneousitanium screws and mandibular plates (Figure 7). Allounds are copiously irrigated and closed with absorb-

ble suture. Intermaxillary fixation can be used postop-ratively at the surgeon’s discretion.

As previously mentioned, these patients are monitored inhe intensive care unit. Airway compromise can occur as aesult of postoperative edema. The careful monitoring oflood pressure is important to help control this edema as

igure 5 Identification of the lingual. (Reprinted with permis-ion.13)

igure 6 Outline of the vertical osteotomy. (Reprinted with

ermission.13)

ell as limit the chance of hemorrhage. Postoperative mal-cclusion or malunion can occur, but the use of rigid fixa-ion, attention to occlusion intraoperatively, and mainte-ance of a soft diet for approximately 6 weeks limit theseccurrences.

onclusion

he identification of obstructive sleep apnea in the pediatricge group will increase as public and physician awarenessncreases. This result will lead to the treatment of thosendividuals with hypopharyngeal obstruction. Careful ex-mination of these patients, and a stepwise approach to theirroblem should provide the safest and most efficaciousethod of treatment.

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2. Suen JS, Arnold JE, Brooks LJ: Adenotonsillectomy for treatment ofobstructive sleep apnea in children. Arch Otolaryngol Head Neck Surg121:525-530, 1995

3. Guilleminault C, Khramtsov A: Upper airway resistance syndrome inchildren: A clinical review. Semin Pediatr Neurol 8:207-215, 2001

4. Guilleminault C, Li K, Quo S, et al: A prospective study on thesurgical outcomes of children with sleep-disordered breathing. Sleep27:95-100, 2004

5. Pirelli P, Saponara M, Guilleminault C: Rapid maxillary expansion inchildren with obstructive sleep apnea syndrome. Sleep 27:761-766,2004

6. Li K, Powell N, Riley RW, et al: Distraction osteogenesis in adultobstructive sleep apnea surgery: A preliminary report. J Oral Maxil-lofac Surg 60:6-10, 2002

7. Shepard JW Jr, Gefter WB, Guilleminault C, et al: Evaluation of theupper airway in patients with obstructive sleep apnea. Sleep 14:361-371, 1991

8. Riley RW, Powell NB, Li KK, et al: Surgical therapy for obstructive

igure 7 Final appearance of the advancement with rigid fixa-ion. (Reprinted with permission.13)

sleep apnea-hypopnea syndrome, in Kryger MH, Roth T, Dement WC

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9. Troell RJ, Powell NB, Riley RW: Hypopharyngeal airway surgery forobstructive sleep apnea syndrome. Semin Respir Crit Care Med 19:175-183, 1998

0. Riley RW, Powell NB, Guilleminault C: Maxillary, mandibular,and hyoid advancement for treatment of obstructive sleep apnea:A review of 40 patients. J Oral Maxillofac Surg 48:20-26,

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1. Riley RW, Powell NB, Guilleminault C: Obstructive sleep apneasyndrome: A review of 306 consecutively treated surgical patients.Otolaryngol Head Neck Surg 108:117-125, 1993

2. Hochban W, Conradt R, Brandenburg U, et al: Surgical maxillofacialtreatment of obstructive sleep apnea. Plast Reconstr Surg 99:619-626,1997

3. Hester JE, Powell NB, Riley RW, et al: Maxillary-mandibular ad-vancement for obstructive sleep apnea. Oper Tech Otolaryngol Head

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