History

• 1.
  

  History of present illness

  
  
  
  
  • a.
    

    Sleep architecture: Assess hours of sleep per night, number of nighttime awakenings, and use of sleep medications.

    
    
  • b.
    

    Sleep-related symptoms: Evaluate for the presence of snoring, witnessed apneas, restless sleep, sleep maintenance or onset insomnia, perspiration during sleep, nocturnal enuresis, nighttime seizures, narcolepsy, and restless leg symptoms.

    
    
  • c.
    

    Daytime-related symptoms: Evaluate for the presence of excessive daytime sleepiness, morning headaches, and awakening feeling tired.

    
    
  • d.
    

    Changes in weight should be quantified over a defined period of time.

    
    
  • e.
    

    PSG: Has a PSG been obtained? If so, what are the results? When was the study done? Has there been any weight or health changes since the study? PSG should always be obtained prior to any surgical procedures.

    
    
  • f.
    

    CPAP use: Has this been trialed yet? If so, is the patient able to tolerate it? If the patient is not able to tolerate it, why? Has any other medical therapy been tried?

  
  
  
  
• 2.
  

  Past medical history

  
  
  
  
  • a.
    

    Medical comorbidities

    
    
    
    
    • 1)
      

      Hypertension (controlled?), cardiac arrhythmias (atrial fibrillation?), congestive heart failure, obesity hypoventilation syndrome, pulmonary hypertension, chronic obstructive pulmonary disease, neuromuscular/neurodegenerative disorder, additional sleep disorders

    
    
    
    
  • b.
    

    Surgical history

    
    
    
    
    • 1)
      

      Tonsillectomy, adenoidectomy, septoplasty, turbinate reduction, rhinoplasty, bariatric surgery

    
    
    
    
  • c.
    

    Family history

    
    
    
    
    • 1)
      

      Anesthesia-related complications

    
    
    
    
  • d.
    

    Medications

    
    
    
    
    • 1)
      

      Antiplatelet drugs

      
      
    • 2)
      

      Herbal products

      
      
    • 3)
      

      Alcohol

    
    
    
    
  • e.
    

    Social history

    
    
    
    
    • 1)
      

      Smoking status

      
      
    • 2)
      

      Caffeine intake per day

    
    

  
  
  
  
• 3.
  

  Epworth sleepiness scale

A subjective patient self-assessment tool to determine sleepiness level with various activities. Comparison of preoperative and postoperative scores may assist in the evaluation of subjective outcome measures.

Physical Examination

• 1.
  

  Vital signs

  
  

  Resting pulse oximetry and body mass index (BMI) should be recorded.

  
  
• 2.
  

  Nose

  
  

  Evaluate for deviated septum, inferior turbinate hypertrophy, and nasal valve collapse.

  
  
• 3.
  

  Oral cavity and oropharynx

  
  

  Note size and presence or absence of tonsils, ability to visualize the uvula, soft palate, and hard palate for determination of Friedman tongue position. This can be instrumental in guiding surgical management.

  
  
• 4.
  

  Neck

  
  

  Measure the circumference of the neck. Note whether there is a large amount of subcutaneous adipose tissue or musculature, especially over the hyoid, because this may limit surgical success. Palpate laryngeal landmarks (i.e., hyoid bone and thyroid cartilage).

  
  
• 5.
  

  Flexible supine nasopharyngoscopy

  
  

  Flexible supine endoscopy is the most important preoperative portion of the examination. This can be done awake in the office and/or under sedation in the operating suite. We prefer drug-induced sedation endoscopy in the operating suite because it best mimics the sleep state. If performed in the office, addition of the Müller maneuver (inhalation with nasal and oral passages closed) can help to simulate an obstructive event. During endoscopy, the level (velopharyngeal, oropharyngeal, or hypopharyngeal), degree, and pattern of upper airway collapse is noted to determine the most suitable surgical intervention. Perform a jaw thrust maneuver to evaluate whether collapse improves. Note VOTE (velum, oropharynx, tongue base, epiglottis) classification.

Procedures

• 
  

  Polysomnography

  
  
  
  
  • 
    

    Preoperative sleep testing with home portable monitoring or in-lab PSG is necessary for diagnosis of OSA. Medical necessity for treatment is often considered an apnea-hypopnea index (AHI) of greater than 15 or an AHI greater than 5 with sleep-related symptoms or comorbidities. Prior to surgical intervention, all patients should demonstrate inability to successfully use CPAP or other medical therapy options.

  
  

Imaging

No required imaging procedures, although lateral cephalometric radiograph may be considered for preoperative planning and documentation of hyoid position.

Indications

• 1.
  

  Patients with moderate-to-severe OSA (AHI of 15 or greater), who have failed adequate trial of CPAP or other medical therapy, with specific hypopharyngeal collapse at the base of tongue or epiglottis, as demonstrated on supine awake and/or sedated flexible endoscopy ( Fig. 57.2 )

  
  

  
  

  
  

  

  
  

  
  

  Collapse of the base of the tongue and epiglottis.

  
  
  
  
• 2.
  

  Often used as a multilevel treatment of OSA in conjunction with other sleep surgical interventions aimed at addressing nasal, velopharyngeal, and/or oropharyngeal collapse

Contraindications

• 1.
  

  Medical comorbidities presenting increased risk for undergoing general anesthesia or upper airway procedures

  
  
• 2.
  

  Prior Sistrunk procedure

Preoperative Preparation

• 1.
  

  Preoperative anesthesia visit should be performed on all patients due to their history of OSA. Bloodwork, chest radiograph, electrocardiogram, and additional preoperative testing are dictated by the patient age, comorbidities and symptoms, and factors as with any procedure using general anesthesia.

  
  
• 2.
  

  Discontinue antiplatelet drugs.

Anesthesia

• 
  

  General

  
  
  
  
  • 
    

    Dependent on technique and surgeon preference, the type of anesthesia will vary. We prefer general anesthesia for patient comfort.

  
  
  
  
• 
  

  Awake sedation

  
  
  
  
  • 
    

    Awake sedation may also be used as an alternative. One advantage is to allow for better postoperative evaluation of hypopharyngeal airway collapse with drug-induced supine sleep endoscopy. This should be used with caution in patients with severe OSA or those suspected to be difficult to intubate.

  
  
  
  
• 
  

  Local

  
  
  
  
  • 
    

    Local anesthetic has been described as a viable technique for patients undergoing isolated HS to the thyroid cartilage.

  
  

Positioning

• 
  

  Supine

  
  
  
  
  • 
    

    The head of the bed should be rotated 90 to 180 degrees away from the anesthesiologist. This will vary depending on surgeon preference and room setup. This is done to allow room for one or two assistants who are placed directly opposite the surgeon and/or at the patient’s head.

  
  

Perioperative Antibiotic Prophylaxis

• 
  

  First-generation cephalosporin

  
  
  
  
  • 
    

    Cefazolin is often used in the our institution because this provides adequate gram-negative and gram-positive coverage. The typical dose is 2 g given intravenously prior to incision.

  
  
  
  
• 
  

  Clindamycin

  
  
  
  
  • 
    

    Clindamycin is used if the patient is allergic to penicillin. The typical dose is 600 mg given intravenously prior to incision.

  
  

Monitoring

• 
  

  Routine general anesthesia monitoring

Instruments and Equipment to Have Available

• 1.
  

  Standard soft tissue neck instrument set

  
  

  This should include knife handle, Senn retractors, Army-Navy retractors, Molt elevator #9, hemostat or other blunt dissecting instruments, Lahey or Allis clamp, toothed forceps, and needle driver.

  
  
• 2.
  

  Monopolar electrocautery: for division of subcutaneous tissues and musculature

  
  
• 3.
  

  Bipolar electrocautery: for control of bleeding around nerves. Can be used instead of monopolar electrocautery in the event of a pacemaker or defibrillator device.

  
  
• 4.
  

  For hyoid to mandible suspension, specific equipment will be needed. Two systems are currently available on the market.

  
  
  
  
  • a.
    

    Encore (Siesta Medical, Los Gatos, CA) system

    
    
    
    
    • 1)
      

      A drill is necessary with this system.

    
    
    
    
  • b.
    

    AIRvance (Medtronic, Dublin, Ireland) system

  
  

Key Anatomic Landmarks

• 1.
  

  Hyoid Bone: A horseshoe-shaped bone in the anterior midline of the neck situated between the base of the mandible and the thyroid cartilage that aids in tongue movement and elevation of the larynx anteriorly and superiorly in swallowing for airway protection. An inferiorly positioned hyoid is strongly associated with hypopharyngeal collapse.

  
  
• 2.
  

  Thyroid cartilage: A shield-shaped cartilage that protects the vocal cords and whose movement produces a change in vocal pitch. Its easily palpable superior thyroid notch marks midline, and it is attached to the hyoid via the thyrohyoid membrane.

  
  
• 3.
  

  Stylohyoid muscle: A slender muscle attaching at the junction of the lesser and greater cornu of the hyoid bone originating from the styloid process. It acts to elevate the hyoid bone during swallowing. This should be preserved to ensure proper advancement of the base of the tongue.

  
  
• 4.
  

  The inferior border of the mandible.

Prerequisite Skills

• 1.
  

  Familiarity with midline neck and floor of mouth anatomy to be able to correctly identify the hyoid bone and associated musculature

  
  
• 2.
  

  Efficiency in drug-induced sleep endoscopy and ability to discern the level, pattern, and severity of airway collapse

Operative Risks

• 1.
  

  Injury to the hypoglossal nerve

  
  

  If dissection around the hyoid is carried out too far laterally or superiorly, the hypoglossal nerve may be damaged. This can be avoided by staying in the midline, identifying the hyoid bone with blunt dissection, and carefully skeletonizing only the central portion of the hyoid bone.

  
  
• 2.
  

  Injury to the internal branch of the superior laryngeal nerve

  
  

  Limiting the dissection near the lesser cornu will minimize the risk of injury to the superior laryngeal nerve.

  
  
• 3.
  

  Dental injury

  
  

  Placement of bone screws in the mandible is performed along the posterior lingual surface of the mandible at the level of the canines. If the screw is placed too far superiorly, injury to the tooth roots can occur. Screws are typically placed 1 cm superior from the inferior border of the mandible.

  
  
• 4.
  

  Bleeding

  
  

  Bleeding is managed in standard fashion with bipolar electrocautery and suture ligation.

Surgical Technique