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6 Advancements andInnovations inSleep Surgery
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Nasal Surgeries
The internal nasal valve represents the area of highest resistance in the upper airway. The internal nasal valve is composed of the nasal septum, the upper lateral
cartilage, the head of the inferior turbinate, and the nasal oor. Airway patency can
be enhanced by correcting a septal deviation, upper lateral stabilization, inferior
turbinate reduction, or expansion of the nasal oor. Improving nasal patency
decreases the associated sequence of mouth breathing, posterior tongue collapse,
and hypopharyngeal narrowing. Treating nasal obstruction does not cure
OSA.However, it improves continuous positive airway pressure (CPAP) compliance and sleep quality of life (QoL) [5]. A narrow nasal oor is a previously underrecognized cause of nasal obstruction and failure of nasal surgeries [6]. Nasal
obstruction early on in life leads to a facial growth pattern characterized by transverse maxillary deciency. This is associated with nasal obstruction later in life and
predisposes to sleep-disordered breathing, nasal surgery failure, and CPAP
intolerance.
Maxillary Expansion—“Rhinognathic Surgery”
The dissociation of adult and pediatric OSA is articial. The underpinnings and
development of OSA follow a continuum across age. Orofacial growth is inuenced
by many upper airway variables with nasal airow playing a critical role. Mouth
breathing and an abnormal position of the tongue in the oral cavity occurs when
skeletal growth is at a maximum early in life, leading to a decrease in growth stimulation of intermaxillary cartilage [7]. That, in turn, leads to a high-arched palate and
predisposes to sleep apnea later in life [8]. Furthermore, the dysfunction in facial
growth has secondary consequences on the maxillomandibular position, and such
changes have a negative feedback impact on the support of the muscles of the upper
airway. Hence, skeletal development inuences dental occlusal angle, facial aesthetics, and upper airway patency [9].
Ideally, transverse maxillary hypoplasia (TMH) is addressed while facial growth
is still active [10]. There is strong evidence demonstrating the resolution of persistent pediatric OSA post adenotonsillectomy with maxillary expansion [11]. The
need for a similar treatment in adults was observed by Christian Guilleminault of
Stanford University [12, 13]. However, such as the cribriform plate, parts of the
temporal bone, and zygoma. Excessive force applied to these areas can result in
cerebrospinal uid leakage, transient hearing loss, and facial asymmetry.
Craniomaxillofacial surgeons conventionally perform surgically assisted rapid
palatal expansion (SARPE) for adult TMH, which combines LeFort I level osteotomies, pterygoid disjunction, and a tooth-anchored expander. However, there
are a couple of drawbacks to this technique: [1] the LeFort I osteotomies are not
enough for transverse expansion; therefore, a midpalatal suture split is required.
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S. Y.-C. Liu and A. A. Al-Sayed
However, [2] even with multipiece osteotomies, the tooth-anchored expander
exerts the lateralizing forces on the dentoalveolar segments, thus lateralizing the
teeth more so than the split maxilla. Consequently, the SARPE does not adequately address the nasal oor, the key area in sleep-disordered breathing in
adults [14].
The need to expand the maxilla of adults in a predictable, fast, and stable manner is clear. In fact, most surgical interventions for OSA focus on the AnteriorPosterior (AP) dimension of the airway. Even with expansion pharyngoplasty,
where the goal is to expand the palatopharyngeus and palatoglossus muscles, the
expansion is limited by the width of the maxilla. Hence, skeletal maxillary expansion would be the only procedure that addresses the lateral dimension of the skeleton. Physiologically, the improvement in nasal breathing during sleep expands
upper airway dilator muscles (Fig.6.2) [6, 15]. Maxillary expansion has both struc-
tural and physiological contributions to a wider airway during sleep. It is important
to note distraction osteogenesis maxillary expansion (DOME) is not meant to be a
single procedure. Rather, in a patient- specic fashion, DOME has continually
evolved to convert a high-arched palate to a dome-shaped palate [13]. Over time,
with virtual surgical planning, Lefort guides to be used for nasal endoscopic
approaches, and improved orthodontic anchorage devices, DOME is a patient-specic approach to address nasal breathing during sleep. DOME has become an integral part of the revised Stanford sleep surgery protocol. As the technique was
rened over time, it is possible nowadays to perform the procedure in a minimally
invasive nasal endoscopic approach (MINI- DOME) [16].
In this section, we will be reviewing the indications, contraindications, patient
selection, diagnostic workup, specic risks, patient consent, anesthetic considerations, required equipment, procedural steps, complications, and postoperative care
of DOME and MINI-DOME.
Fig. 6.2 Distraction Osteogenesis Maxillary Expansion (DOME) increases the transverse dimension of the maxilla, which provides more space for the tongue to rest in the oral cavity. Additionally,
it allows for greater pharyngoplasty expansion
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Indications andContraindications
DOME is recommended generally for adults with OSA who have any or more of the
following features: (1) TMH with or without crossbite, (2) persistent nasal obstruction after nasal surgery with mild OSA and a high-arched palate, and (3) moderate
to severe OSA with a high-arched palate as a phased procedure preceding further
interventions. Contraindications to the procedure are relative and include: (1) periodontal disease, (2) inability or unwillingness to undergo perioperative orthodontic
care, and (3) difculty adhering to distraction.
Diagnostic Workup
We strongly recommend a preoperative attended polysomnography (PSG), with
attention to airow limitation. Maxillofacial computed tomography (CT) is necessary for virtual surgical planning (VSP) and assessment of surgical landmarks (premaxilla thickness, nasopalatine nerve position, and distance between central incisors
roots). The thickness of the maxilla dictates the length of screws used on the
expander. Pre- and posttreatment photos are recommended. It is important to note
that one’s facial appearance does not change signicantly posttreatment.
Specic Risks, Patient Information, andConsent
Patients must be counseled about the goals of treatment. The most signicant and
reproducible outcome is the subjective decrease in nasal obstruction as measured by
the nasal obstruction symptom evaluation (NOSE) scale and the functional component of the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS).
For severe OSA, surgical success is approximately 70%, and these patients will
continue to receive further interventions either in the form of other surgical procedures or CPAP.For patients with upper airway resistance syndrome (UARS), the
reduction in the apnea-hypopnea index (AHI) is signicant, but surgical success
cannot be dened by the Sher’s criteria because pretreatment AHI is usually less
than ten events per hour.
Surgical risks include loss of dental vitality, particularly of the central incisors;
asymmetric maxillary expansion; inadequate expansion; and persistent paresthesia
from the vestibular incision. VSP has signicantly reduced these risks. Moreover,
the MINI-DOME approach signicantly reduces the risk of paresthesia and swelling [16]. Pain is minimal post procedure and could be managed with over-thecounter analgesia. A minority may require narcotics for the rst few days
postoperatively. The risk of palatal stula is around 2% and most self-resolve.
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Anesthesia andPatient Positioning
Oral intubation with total intravenous anesthesia is preferred to reduce postoperative nausea and vomiting. A exible reinforced tube is secured to one side of the oral
commissure. The patient is turned 180° away from the anesthesia cart. Hypotensive
anesthesia is rarely required as only Lefort level 1 osteotomies are performed. If
both anterior and posterior maxilla need expansion (posterior for occlusion indications), then the pterygoid junctions are separated.
Equipment
A standard head and neck or maxillofacial set including Bovie electrocautery, Molt
periosteal elevators, toe-out retractors, curved Freer elevator, reciprocating saw,
piezoelectric saw (optional), several straight osteotomes, and 3–0 and 4–0 chromic
sutures. For MINI-DOME, a 0° rigid endoscope and a surgical assistant are required.
Patient-specic cutting guides are recommended to reduce the chances of asymmetrical osteotomies, particularly in minimally invasive approaches.
Surgical Steps withFocus onEndoscopic Approach
Prior to surgery, the collaborating orthodontist has designed and sometimes placed
the expander with the transpalatal implants. It is crucial that the implants are placed
as medially as possible, straddling the midpalatal suture. Additional implants can be
placed against the sides of the alveolus bilaterally near the molar region.
In the MINI-DOME approach, needle tip cautery is used to make a 1–1.5cm
incision parallel to the piriform rim at the level of the head of inferior turbinate, and
toward the anterior maxilla. This helps with closure at the end of the procedure.
Molt periosteal elevator is used initially to obtain a subperiosteal pocket. Once an
adequate pocket is developed, 0° endoscope is introduced to visualize the remainder
of the inferolateral dissection toward the lateral maxillary buttress. Subperiosteal
dissection can be quite limited because with guides, there is not a need to expose the
infraorbital nerve and inferiorly to identify the canine eminence (Fig.6.3). A small
malleable blade is fashioned to rest against the lateral buttress to retract the soft tissue away from the bony structures. It is helpful to rst cut at the middle of the classic Lefort osteotomy, where the anterior maxillary wall is located. This would allow
a natural drainage hole for the irrigation from ultrasonic cutting blades. This allows
one less instrument in the nasal cavity (suction tip). After this drainage hole is created, the osteotomy is carried forward past the buttress and then outwards toward
the piriform rim. The nasal incisions are closed on each side with 4–0 chromic
sutures.
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Fig. 6.3 (a) Depicts the extent of dissection in a MINI-DOME.The Lefort I osteotomy. ION
infraorbital nerve. (b) A custom made cutting-guide is inserted and secured. The bony cut is made
with a piezoelectric saw
The primordial groove of the midpalatal suture is seen inferior to the anterior
nasal spine, and between the apices of the maxillary central incisors. A piezoelectric saw, which does not cut the mucosa of the palate across the maxillary alveolus, is used to deepen the groove. Osteotomes are used in sequential fashion to
wedge open the midpalatal suture from the groove. A diastema between the central incisors is seen immediately as the suture opens. The expander is then turned
to ensure easy and symmetric separation of the maxilla bilaterally, until a 2mm
separation is created. In adults, it is generally advisable to place a cancellous or a
bone progenitor bone graft between the separated maxillae and not activate the
expansion for about 10–14days. This will allow improved bony healing, which is
not a concern in children. Closure of the vestibular wound is performed by 3–0
chromic sutures.
Complications
Major complications include bone healing issues such as malunion, nonunion, and
asymmetric expansion. Minor asymmetric expansion can be corrected with orthodontics. Most bone healing issues self-resolve with completion of distraction.
Rarely, they may require a secondary bone graft. V2 paresthesia is usually temporary and resolves between 1 and 6months. Nasal sinus and odonotogenic infections
have not been reported with DOME.Maxillary central incisors occasionally show
signs of decreased perfusion. Loss of central incisors vitality requiring root canal
treatment is less than 5%. No loss of dentition is reported with DOME. Patients with
thin gingiva, which is common in OSA, likely benet from presurgical periodontal
and bone grafting to prevent the dental complications.
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S. Y.-C. Liu and A. A. Al-Sayed
Postoperative Care
Patients can be discharged home the same day. There are no true diet restrictions,
though we advise a soft diet for a few days as the bone graft and wounds heal.
Limited epistaxis and nasal congestion are expected and are self-resolving and is
best addressed by nasal irrigation. Blood and blood clots collect in the maxillary
sinus during the procedure.
Patients turn the expander daily at a rate of 0.25mm. For most patients, 7–12mm
of expansion at the nasal oor is achieved within 4–6weeks. Orthodontic treatment
is then applied to close the diastema, while the expander is left in place to prevent
relapse during the bone consolidation period. Typically, the consolidation period is
around 3-months for pediatric patients and 6–8 months in adults. The expander does
not interfere with dental movement, allowing the restoration of proper occlusion
without its removal. Average orthodontic treatment required is 12–18 months.
Following orthodontic treatment, the expansion can be maintained passively by a
removable retainer.
Outcomes
The early Stanford experience suggests the adult OSA patients with narrow and
high-arched palate improve the most with DOME if they also have an acute internal
nasal valve angle, narrow nasal oor, no signicant septal deviation or turbinate
hypertrophy, and TMH recalcitrant to palatopharyngoplasty. For adults with moderate to severe OSA, multilevel or multistage treatments remain the hallmarks of
effective surgical treatment. We have performed DOME in conjunction with genioglossus/genioplasty advancements. For patients with both transverse maxillary and
maxillary-mandibular hypoplasia, multistage treatment may be required. That is
usually in the form of DOME followed by UPPP (uvulopalato-preservation pharyngoplasty), upper airway stimulation, or maxillomandibular advancement (MMA).
Post-DOME patients have shown resolution of circumferential collapse of the
velum that would otherwise disqualify them from receiving upper airway stimulation.
Hypoglossal Nerve Stimulation (HGNS)
Loss of genioglossus muscle tone and upper airway collapse were rst reported by
Remmers etal. in the late 1970s [17]. Since then, attempts to stimulate the pharyngeal muscles with transcutaneous, intraoral, and intramuscular electrodes to treat
OSA were of limited success [18–20]. However, hypoglossal nerve stimulation has
emerged as a viable alternative option to CPAP in treating moderate to severe OSA
due to the technological advancement over the last decade [21, 22]. The indications,
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patient selection process, contraindications, surgical technique, postoperative care,
and complications are reviewed.
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Indications andPatient Selection Process
All patients being considered for HGNS surgery must undergo a comprehensive
sleep medicine history and upper airway evaluation including drug induced sleep
endoscopy (DISE). HGNS is still considered a second line procedure after CPAP
therapy intolerance or failure in patients with moderate to severe OSA.Additional
screening criteria include a body mass index (BMI) of less than or equal 32kg/m2,
and the absence of concentric velum collapse on DISE.The BMI cutoff has recently
been increased to 35kg/m2 [23]. It is important to note that these criteria oversimplify the complexity of OSA.The patient’s medical comorbidities and skeletal phenotype should factor in the selection process. A history of breast cancer or breast
augmentation may present a signicant challenge. Moreover, a patient with a narrow, high-arched palate might be at a higher risk of failing the procedure due to the
limited space for tongue displacement during stimulation, as well as persistent nasal
obstruction.
Contraindications
Contraindications to HGNS can be relative or absolute. Relative contraindications
include BMI more than 32kg/m2, electromagnetic incompatibility and interference
from other implantable medical devices, and incompatibility and interference from
diagnostic or therapeutic devices. Absolute contraindications include sleep study
showing greater than 25% central or mixed apneas, concentric palatal collapse seen
on DISE, inability to operate the therapy, pregnancy, severe anatomical challenges
to implantation, severe neurological conditions, and anticipated or ongoing need for
magnetic resonance imaging evaluation of the head, cervical spine, or thorax.
Surgical Technique
There are multiple upper airway neurostimulation devices in development. However,
there is only one currently approved by the Food and Drug Administration.
Therefore, the outlined surgical steps are for the Inspire II Upper Airway Stimulation
device (Inspire Medical Systems, Inc., Maple Grove, MN). The outlined steps are
meant to provide a high-level overview and do not address the nuances beyond the
scope of this chapter. In addition, the senior author has moved away from the original three-incision technique to a contemporary two-incision technique.
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Fig. 6.4 The stimulation
cuff electrode is placed
around the distal protrusor
branches of the
hypoglossal nerve
S. Y.-C. Liu and A. A. Al-Sayed
The steps are as follows: after general orotracheal anesthesia, sensing electrodes
are placed in the genioglossus muscle and the hyoglossus/styloglossus muscles for
intraoperative nerve monitoring. After standard sterile prep and drape, a 4cm incision is made in the right upper neck parallel to a natural skin crease and carried
down to the oor of the submandibular triangle, where the main trunk of the hypoglossal nerve is identied. Nerve monitoring is used to selectively capture the distal
tongue protrusor branches and to exclude branches innervating the tongue retractor
muscles. The stimulation cuff electrode is placed around the distal protrusor
branches and C1 and secured to the digastric tendon (Fig.6.4). A second incision is
made in the right upper chest with the development of a subcutaneous pocket overlying the pectoralis fascia for the pulse generator. The pocket is carefully sized to t
the implantable pulse generator with minimal dead space to minimize seroma formation. The sensing lead is then inserted between the external and the internal
oblique intercoastal muscles and secured to a cuff of the external intercoastal muscle. The sensing lead and stimulation lead are each then tunneled into the right
upper chest pocket and connected to the implantable pulse generator (IPG), which
is secured to the pectoralis fascia. The telemetry unit is then activated, and the
implant conrmed with both a good sensing lead waveform and uninhibited tongue
protrusion.
Postoperative Care
Postoperative radiographs of the neck and chest are obtained before the patient is
discharged to document the baseline position of the device and rule out pneumothorax. Patients can be discharged home the same day, but as they tend to be older, an
overnight stay is advisable. They are instructed to avoid strenuous or repetitive
activity of the ipsilateral arm for the rst 3–4weeks, although this is more permissive without the former third incision at right lower chest. Device activation is done
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at approximately the 1-month mark. After patients adjust to the therapy, optimization of stimulation voltage is performed during an attended PSG.
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Complications
Serious complications are uncommon in the published literature. Bleeding, infection, and injury to the hypoglossal nerve or marginal mandibular nerve and pneumothorax formation are the main complications. Hardware failure can also be an issue,
particularly with detachment of sensing or stimulation leads. Sleep disturbance and
aggravation of insomnia are potential side effects of device activation.
Uvulopalato-“Preservation” Pharyngoplasty (UPPP)
Often referred as the workhorse of sleep apnea surgery, uvulopalatopharyngoplasty
(UPPP) is performed alone or in conjunction with other surgeries. The procedure
traces its origin to the 1950s [24]. Many technique variations have been described with
varying degree of tissue sacrice. Moreover, most of these techniques do not account
for the interaction between the vectors of tissue suspension and physiologic muscle
function [25, 26]. The indications, patient selection process, contraindications, postoperative care, complication, and outcomes are thoroughly described in the literature.
Therefore, the focus in this section is on the senior author’s surgical technique that
emphasizes tissue preservation and augmentation of airway dilator muscle function.
Surgical Technique
When present, tonsillectomy is performed in the standard fashion. After removal of
the tonsils, the following vectors of horizontal mattress sutures are performed. First,
the palatopharyngeus muscle is anchored to a brous pad at the retromolar trigone
and secured to the palatoglossus muscle. Next, the medial palatopharyngeus muscle
is sutured toward the levator veli palatini muscle. Finally, the newly approximated
medial palatopharyngeus and levator muscles are anchored toward the tensor veli
palatini muscle. The rst two vectors dilate the soft palate, whereas the last vector
advances it. Overall, the vector of suspension augments the function of pharyngeal
dilators and allows for maximal tissue preservation reducing postoperative pain and
scarring in the long term (Fig.6.5). The uvula muscle is always preserved. However,
there is often long-term negative pressure that results in elongated mucosa. The
mucosa can be trimmed slightly, although this is often not necessary and needs to be
judiciously performed to prevent velopharyngeal insufciency or globus sensation.
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Fig. 6.5 Using 3–0 Vicryl the palatopharyngeus muscle is anchored to a brous pad at the retromolar trigone and secured to the palatoglossus muscle. Next, the medial palatopharyngeus muscle
is sutured toward the levator veli palatini muscle. Finally, the newly approximated medial palatopharyngeus and levator muscles are anchored toward the tensor veli palatini muscle. (a) Depicts
presuspension and (b) Depicts postsuspension. Note that the uvula and muscles of the pillars are
preserved
S. Y.-C. Liu and A. A. Al-Sayed
Postoperative Care
Unlike tonsil surgery for children, the senior author focuses on adequate pain control for the adult patients so that they can eat as regular of a diet as possible. Active
swallowing is important to prevent bleeding resulting from tearing of scab tissue as
the wounds heal. Antibiotics have been shown to reduce the incidence of bleeding
in OSA patients following UPPP [27].
Complications
The most serious complication is bleeding, and this is 5% [28]. Patients can help
reduce incidence of bleeding by the postoperative care regimen as described.
Surgically, the use of low heat on monopolar cautery and meticulous hemostasis
with bipolar cautery are helpful. The less scabs created with accurate dissection in
the avascular plane, the less likely for delayed bleeding. Hemostasis should also be
checked with anesthesia directed Valsalva maneuver.
Genioglossus Advancement (GGA)
GGA was initially described by Riley and Powell in 1984 as an intervention for base
of tongue collapse in a patient who had failed palate surgery [29]. Many variations
of the original GGA have since been described, but they all share the common goal
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