- Email: [email protected]
Genioglossus advancement and hyoid myotomy under local anesthesia
Genioglossus advancement and hyoid myotomy under local anesthesia CHAIRAT NERUNTARAT,
MD,
Bangkok, Thailand
OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is a common chronic illness that results in significant morbidity in many patients. Upper airway obstruction of OSAS patients occurring during sleep can appear at multiple sites, including the hypopharynx. Successful results of genioglossus advancement and hyoid myotomy with suspension (GAHM) in the treatment of hypopharyngeal obstruction have been reported when performed under general anesthesia. However, many patients have difficulty at induction of anesthesia and intubation. Patients are predisposed to specific complications, owing to anatomical abnormalities of the airway and existence of underlying syndrome. The purpose of this study was to assess the safety and efficacy of GAHM for the treatment of OSAS with the patient under local anesthesia. METHODS: Thirty-one OSAS patients with hypopharyngeal obstruction underwent GAHM under local anesthesia. The inferior alveolar nerve was blocked. The osteotomized mandibular segment was advanced and turned to lock the inner surface of the mandible and geniotubercle at the outer surface. The hyoid bone was suspended to the superior aspect of the thyroid cartilage. Uvulopalatal flap was an adjunct surgical procedure for palatal obstruction. Patients had a mean age of 46.2 ⴞ 5.8 years and a body mass index of 28.8 ⴞ 3.2 kg/m2. Most of the patients were male. Data on patients were compared between preoperative and postoperative assessment points. Statistical analysis was performed using Student’s t test. RESULTS: All patients tolerated the procedure well. The mean follow-up was 8 months (range, 6 to 10
From the Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Vajira Hospital. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Chairat Neruntarat, MD, Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Vajira Hospital, 681 Samsaen Road, Bangkok 10300, Thailand; e-mail, [email protected]. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S1094-5998(03)00094-9
months). The mean Respiratory Disturbance Index (RDI) decreased from 48.2 ⴞ 10.8 to 14.5 ⴞ 5.8, and the lowest oxygen saturation increased from 81.8 ⴞ 3.8% to 88.8 ⴞ 2.9%. The Epworth Sleepiness Scale score improved from 14.9 ⴞ 2.3 to 8.2 ⴞ 1.7 (P < 0.001), and the snoring scale improved from 8.1 ⴞ 0.6 to 3.4 ⴞ 0.9 (P < 0.001). Postoperative complications included wound dehiscence in 3%, transient dysphagia in 3%, and transient paresthesia of the lower jaw in 6%. Bleeding, infection, and airway obstruction were not observed. Most patients had mild-to-moderate pain (visual analog scale, <7) for 5 to 7 days after procedures. Responders were defined as OSAS patients who had a reduction in the RDI of >50% and an RDI of <20 after surgery. By these criteria, 70% of the patients were regarded as having responded to GAHM. CONCLUSION: Significant reduction in RDI and clinical improvements in snoring and sleepiness were observed after GAHM. It appears to be a safe, inexpensive, and effective procedure that can be performed under local anesthesia with a low chance of complications in carefully selected OSAS patients. (Otolaryngol Head Neck Surg 2003; 129:85-91.)
O
bstructive sleep apnea syndrome (OSAS) is a common illness that affects 2% to 4% of middleaged adults.1 It is now seen as one end of a spectrum of sleep-related breathing disorders and is associated with hypertension, cardiovascular diseases, daytime sleepiness, impairment of quality of life, and risk for general anesthesia.2,3 Many patients respond to medical treatments with weight loss, body position training for sleep, avoidance of alcohol and sedative medication, oral appliances, and continuous positive airway pressure (CPAP). However, medical and behavioral managements require ongoing, prolonged followup, and adherence to therapy regimens; some patients are not able to comply with these recommended treatments. Several surgical procedures have been developed to treat OSAS. The surgical management continues to be a challenge, beginning with selec85
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tion of the surgical procedure to perform. Precise identification of each anatomic region of constriction is essential for accurate planning and sequencing of surgical intervention. Uvulopalatopharyngoplasty (UPPP), described by Fujita et al,4 was the operation especially designed to address the palatal abnormalities seen in many patients with OSAS. The surgical response of an isolated UPPP was quoted as 40.7%.5 In addition, the outcome of this procedure was difficult to predict. Although UPPP eliminated the obstruction at the palatal level, persistent obstruction remained at the hypopharynx. OSAS patients have a wide spectrum of disease severity. Upper airway obstruction of many patients, occurring during sleep, can appear at multiple sites. Results of genioglossus advancement and hyoid myotomy with suspension (GAHM) have been successfully reported, when performed under general anesthesia. Riley et al6 reported successful results that were based on severity and ranged from approximately 75% in patients with mild-to-moderate OSAS to 40% in patients with severe OSAS. The treatment outcomes of pharyngeal surgery addressing both oropharygeal and hypopharygeal areas of collapse have been validated at a number of centers.7-9 However, a significant proportion of OSAS patients have difficulty at induction of anesthesia and intubation. Patients are predisposed to specific complications, owing to the anatomic underlying syndrome.10,11 The purpose of this study was to assess the safety and efficacy of GAHM for the treatment of OSAS under local anesthesia. MATERIALS AND METHODS During a 12-month period, 210 consecutive patients were evaluated for the treatment of snoring and sleep apnea at Vajira Hospital. Patients were advised to bring their bed partners to the evaluation. The initial visit included a complete history, physical examination, and otolaryngologic examination. Fiberoptic pharyngoscopy with Muller’s maneuver was performed at the level of the nasopharynx and the base of tongue. Initial body weights and heights were obtained, and the body mass index (BMI) was calculated. A lateral cephalometric radiograph and panoramic radiograph of the mandible were also obtained.
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After a diagnosis of OSAS was made, patients were advised on various treatment options. When appropriate, patients were encouraged to lose weight, avoid sleeping supine if their problem was positional, lengthen the bedtime, and avoid alcohol and tobacco. CPAP, oral appliance, and surgical options were reviewed with each patient. The patients who had failed to respond to the conservative treatments were counseled about the benefits and risks of surgical procedures. Thirty-one patients (14.8%) who had a primary complaint of snoring and OSAS were found to be suitable for GAHM performed under local anesthesia. All patients had both oropharyngeal and hypopharyngeal obstruction. Patients with hypertrophic tonsil and nasal obstruction were excluded. Uvulopalatal flap (UPF) under local anesthesia was an adjunct surgical procedure for oropharyngeal obstruction. All patients were evaluated preoperatively and then at least 3 months postoperatively with polysomnography. OSAS was diagnosed in patients who experienced daytime sleepiness or disturbed sleep and had more than 5 respiratory disturbances per hour of sleep on their polysomnogram. Polysomnography was performed in the sleep laboratory with full monitoring that included EEG, electro-oculography, chin and leg electromyography, electrocardiography (modified V2 lead), airflow, thoracic and abdominal efforts, and pulse oximetry (Alice 3 System; Healthdyne; Atlanta, GA). The polysomnogram was analyzed according to the standards of the American Thoracic Society.12 Baseline information was collected. The patient’s bed partner or observer used a 10-cm visual analog scale (VAS) to grade the severity of snoring before the procedure and after treatment. “No snoring” occupied the far left portion of the scale, whereas “severe snoring” occupied the far right of the scale. The Epworth Sleepiness Scale (ESS) score that reflected the chance of dozing in specific situations as well as daytime sleepiness13 was completed at baseline. Patients with a Respiratory Disturbance Index (RDI) of ⬎40 and lowest oxygen saturation of ⬍80% were advised to use CPAP at least 2 weeks before surgery and to continue CPAP postoperatively until a polysomnogram was performed to document outcome. Prophylactic antibiotics were
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Fig 1. (A) Inferior alveolar nerve block is performed intraorally. (B) The needle tip is positioned near the inferior alveolar nerve in the pterygomandibular space. (C) Additional infiltration is performed at the labial and the lingual surface of the mandible. (D) The mixture of local anesthetic agents is injected over hyoid bone and upper part of thyroid cartilage.
administered intravenously to every patients. Diazepam (10 mg) was administered 1 hour preoperatively only for patients who had a significant gag reflex. Genioglossus Advancement and Hyoid Myotomy Under Local Anesthesia GAHM was performed essentially as decried by Riley et al,6,14 using the modification in which the procedure was performed under local anesthesia. A mixture of 15 mL of 1% lidocaine with 1:100,000 epinephrine and 15 mL of 0.5% bupivacaine with 1:200,000 epinephrine was prepared. Inferior alveolar nerve block was performed.15 The patient was in a supine position and opened the mouth wide. The mandibular foramen was located midway between the anterior and posterior borders of the mandibular ramus about 4 mm above the occlusal plan of the mandibular molars.
The angle of penetration was approached from the opposite premolar area. A 27-gauge needle was inserted at the center of the depth of the anterior border of the mandibular ramus, lateral to the pterygomandibular raphe and medial to the medial temporal crest. From 1 to 2 mL of the mixture was slowly injected. This sequence was repeated on the opposite side. Additional infiltration was performed at the anterior and posterior surfaces of the mandible over the operative field (Fig 1). An incision was made just to the labial side of gingivolabial sulcus. The mandibular bone was exposed down to the inferior margin. Mandibular osteotomy was performed using a 2-hole sagittal saw blade. The fragment was advanced and rotated 20 degrees. The outer table was removed, and the fragment was secured to the lower edge of the mandible using a lag-screw technique with an 11-mm ⫻ 2.0-mm screw in a 1.5-mm drill hole
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Fig 2. (A) Genioglossus advancement, frontal view. The osteomized mandibular segment is advance and fixed with a titanium screw. (B) Diagram of hyoid myotomy with suspension. The stylohyoid ligament is divided and the hyoid bone is advanced over the thyroid cartilage and fixed with 4 nonabsorbable sutures.
(Fig 2A). The wound was drained with a Penrose drain and sutured. The mixture was used to locally infiltrate over the hyoid bone and upper portion of the thyroid cartilage (Fig 1). A horizontal anterior cervical neck incision was made over the hyoid bone. The hyoid was released from its inferior attachments and advanced anteriorly and inferiorly over the thyroid cartilage. A 1-0 TICRON polyester suture (United States Surgical) was passed around the hyoid ⬃1 cm lateral to the midline and then passed through the thyroid ala, ⬃1 cm from the notch. A second suture was placed starting at the level of the lesser cornu and ending 2 cm from the thyroid notch. This sequence was repeated on the opposite side (Fig 2B). The wound was irrigated and drained with a Penrose drain. Uvulopalatal Flap Under Local Anesthesia UPF was performed as described originally by Powell et al16 using the modification in which the procedure was performed under local anesthesia instead of general anesthesia.17 It was performed with the patient sitting upright. The soft palate was anesthetized with lidocaine 10% topical dispersion, and the mixture was additionally injected at 3 points 1 cm from the lower rim of the palatal arch. The mucosa, submucosa with glands, and fat on the lingual surface of the uvula and soft palate were removed with a scalpel. The uvular tip was amputated, and bleeding was controlled with bipolar electrocoagulation. The uvula was reflected
back toward the soft palate and fixated into its new position with multiple sutures of 3-0 polyglyclic acid. Postoperative medications included antibiotic suspension for 7 days, acetaminophen with codeine elixir, Tramal, and/or anesthetic lozenges as needed for pain relief. Patients were carefully monitored with continuous pulse oximetry in a surgical ward environment until discharge. Sleep aids, anxiolytics, or other sedating medications were not administered in the immediate postoperative period. Several parameters, including intraoperative pain, postoperative pain, operating time, and complications, were recorded. Patients were seen in follow-up at intervals of 1, 2, and 4 weeks and after a repeat polysomnogram was completed. VASs for pain and speech problems were completed once daily for 10 days after the procedure. The patients were asked to rate pain on a continuous scale from 0 (none) to 10 (excruciating or intense pain) and speech problems from 0 (none) to 10 (extreme difficulty talking). Data on the patients were compared between the preoperative stage and the postoperative assessment and analyzed by Student’s t test. RESULTS The patients were examined between 6 and 10 months after the operation (mean ⫾ SD, 8.3 ⫾ 1.8 months). Age range was 30 to 54 years (mean ⫾ SD, 46.2 ⫾ 5.8 years). Twenty-nine patients (93.5%) were married, and 2 (6.5%) were single or
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Table 1. Polysomnographic results Variable
Preoperative
Postoperative
P
RDI LSAT (%) Stage 3 ⫹ 4 (%) REM sleep (%) Sleep efficiency (%)
48.2 ⫾ 10.8 81.8 ⫾ 3.8 7.3 ⫾ 4.3 8.6 ⫾ 3.4 80.2 ⫾ 10.3
14.5 ⫾ 5.8 88.8 ⫾ 2.9 9.4 ⫾ 2.8 19.2 ⫾ 8.4 85.2 ⫾ 4.1
⬍0.001 ⬍0.01 ⬍0.001 ⬍0.001 ⬍0.05
RDI, Respiratory Disturbance Index; REM, rapid eye movement; LSAT, lowest oxygen saturation.
divorced; 28 (90.3%) were male. BMI at the time of surgery ranged from 27.4 to 30.2 kg/m2 (28.8 ⫾ 3.2 kg/m2), and at postoperative period, 27.5 to 31.2 kg/m2 (28.9 ⫾ 2.5 kg/m2). There was no significant difference between preoperative and postoperative BMI. In the first period, HM was performed 1 month after GA and UPF in 7 patients. In the remaining 24 patients, GAHM and UPF were performed concurrently. All patients tolerated the procedure well. Operating time for GA ranged from 45 to 75 minutes, with a mean of 55.9 ⫾ 18.4 minutes, for HM, 40 to 70 minutes, with a mean of 50.9 ⫾ 16.8 minutes. From 7 to 10 mL (9.2 ⫾ 1.4 mL) of the mixture was used for GA, and 10 to 15 mL (12.5 ⫾ 3.2 mL) was used for HM. There was a mean hospital stay of 2.7 ⫾ 0.8 days (range, 2 to 5 days). Patients had an intraoperative pain scale (VAS) of 2.5 ⫾ 1.2 (range, 2 to 4). All patients completed preoperative and postoperative polysomnograms. The mean preoperative RDI was 48.2 ⫾ 10.8. The mean postoperative RDI was 14.5 ⫾ 5.8. This was a statistically significant change (P ⬍ 0.001). The maximal desaturation was significantly changed, with a preoperative mean of 81.8 ⫾ 3.8% and a postoperative mean of 88.8 ⫾ 2.9% (P ⬍ 0.01). There were significant improvements in sleep quality after the operation (Table 1). Response to the GAHM procedure were defined as a 50% improvement in RDI and a final RDI of ⱕ20. By these criteria, 22 of 31 (70.1%) patients responded. Significant improvement from the baseline (8.1 ⫾ 0.6) was observed in VAS at postoperative period (3.4 ⫾ 0.9, P ⬍ 0.001). The average preoperative VAS was 8.1, indicating moderate to severe snoring in this group of patients. Snoring was considered to be cured by the bed partner or observer if the VAS was less than half the base-
line. Based on this criterion for a cure of snoring, the problem was eliminated in 87.1% (27 of 31) of the patients. The subjective data measured with the ESS (0 to 24) showed significant improvement. The mean preoperative ESS score was 14.9 ⫾ 2.3, and the mean postoperative ESS score was 8.2 ⫾ 1.7 (P ⬍ 0.001). There was a significant reduction in the distance between the posterior nasal spine and soft palate from 45.2 ⫾ 2.5 mm to 43.9 ⫾ 2.8 mm (P ⬍ 0.01). A significant increase in the distance between mandibular plane and hyoid bone from 20.1 ⫾ 2.4 mm to 22.2 ⫾ 1.3 mm (P ⬍ 0.05) was observed. There was an increase in posterior airway space from 6.1 ⫾ 2.4 mm to 8.2 ⫾ 2.1 mm (P ⬍ 0.001). There were no changes in skeletal measurements because these areas were not treated or affected by the treatment (Table 2). One (3%) patient had wound dehiscence, which was resolved without sequel after intraoral wound dressing and appropriate antibiotic therapy for 4 weeks. Other complications included dysphagia in 3% (1 of 31) and paresthesia of lower jaw in 6% (2 of 31). These were self-limited and resolved. Vasovagal episode, bleeding, aspiration, seroma, mandibular fracture, and extrusion of the screw were not observed. There were no emergent airway complications in this study. GAHM postoperative pain was rated as mild to moderate (VAS ⫽ 5.2 ⫾ 1.1; range, 4 to 7). Data collected from VAS showed the discomfort to be worst at postoperative day 3 and nearly resolved by postoperative day 7. Operating time for UPF ranged from 15 to 25 minutes with a mean of 20.5 ⫾ 4.9 minutes. From 3 to 5 mL (range, 4.2 ⫾ 1.2 mL) of the mixture was used. UPF complications included transient nasal regurgitation in 9.7% (3 of 31) and foreign body sensation in 12.9% (4 of 34). Bleeding, in-
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Table 2. Cephalometric analysis Variable
Preoperative
Postoperative
SNA (degrees) SNB (degrees) PNS-P (mm) MP-H (mm) PAS (mm)
84.2 ⫾ 3.9 80.6 ⫾ 3.2 45.2 ⫾ 2.5 20.1 ⫾ 2.4 6.1 ⫾ 2.4
84.3 ⫾ 4.1 80.7 ⫾ 3.5 43.9 ⫾ 2.8 22.2 ⫾ 1.3 8.2 ⫾ 2.1
P
NS NS ⬍0.01 ⬍0.05 ⬍0.001
SNA, sella–nasion–point A angle; SNB, sella–nasion–point B angle; PNS-P, length from posterior nasal spine to uvula; MP-H, length between mandibular plane and hyoid bone; PAS, posterior airway space.
fection, and nasopharyngeal stenosis were not encountered. Patients had mild-to-moderate pain (VAS ⫽ 6.2 ⫾ 1.2) and mild speech problems (VAS ⫽ 3.5 ⫾ 0.8) for 5 to 7 days after the procedure. DISCUSSION Many treatment options are available for patients with OSAS. Surgical treatments become particularly important when initial medical treatments have failed. However, UPPP failure may occur from persistent hypopharyngeal collapse.18 The anatomic obstruction associated with OSAS may occur at multiple sites. Many different approaches have been developed with the intent to better treat hypopharyngeal obstruction. GAHM was undertaken to enlarge the hypopharyngeal area. The genial tubercle, which is the anterior attachment of genioglossus muscle, is mobilized by osteotomies, and the hyoid with its attached musculature is drawn anteriorly over the thyroid ala, to expand the hypopharyngeal lumen and decrease the airway resistance.6,14 In this study, there was a significant widening of posterior airway space and the mandibular plane–to– hyoid bone distance lengthened after surgery. The surgical results from GAHM in conjunction with the UPPP for the relief of OSAS are encouraging. Riley et al6 reported that the treatment was successful for 57% (133 of 233) of patients. Patients with mild to moderately severe OSAS had an approximately 75% success rate. Utley et al7 showed a 57% (8 of 14) success rate, defined as a reduction in RDI by 50% and a postoperative RDI of ⬍20 or RDI equivalent to that obtained with CPAP. Troell et al19 revealed that 63.6% (7 of 11) of patients were cured, defined as an RDI of ⬍10. Ramirez and Loube8 reported a 42% success rate
in morbidity obese patients. However, these multilevel pharyngeal procedures were performed under general anesthesia. OSAS patients are predisposed to specific complications, owing to anatomic abnormalities of the airway and existence of underlying syndrome. Eighteen percent of OSAS patients have difficulty at induction of anesthesia and intubation.20 The combination of the anesthetic agents, analgesic effects, and upper airway edema can worsen apnea and lead to complications. Intraoperative narcotics were also found to increase the risk of airway obstruction at extubation. Sedatives and narcotic medications pose a specific anesthetic risk because they increase the collapsibility of the pharynx and oral soft tissue, leading to additional airway obstruction.21,22 In this study, GAHM was performed under local anesthesia and it did not put the airway at risk. The inferior alveolar nerve block is frequently performed for intraoral surgery of the lower jaw. It is reproducible, easily administered, and routinely effective if properly performed.15 Intraoperative discomfort was low (VAS ⱕ4), and patients tolerated the GAHM procedure well. The GAHM results in this study were comparable to those of previous studies. It has a 70% success rate of decreasing RDI by ⱖ50%, and postoperative RDI was ⬍20 events per hour. GAHM literature showed that short-term improvement in OSA occurred in 42% to 75%.6-8 The ESS score improved in this study from a preoperative mean of 14.9 ⫾ 2.3 to a postoperative mean of 8.2 ⫾ 1.7 (P ⬍ 0.001). These scales were compared with reported mean ESS scores from John13 for normal control subjects, primary snoring, and OSAS of 5.9 ⫾ 2.2, 6.5 ⫾ 3.0, and 11.7 ⫾ 4.6, respectively. The
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preoperative mean ESS scores were consistent with a moderate level of sleepiness, and they declined after treatment to a near-normal level. There were no serious complications after GAHM in this study; complications included wound dehiscence, transient dysphagia, and transient paresthesia of the lower jaw. UPF reported by Powell et al,16 which was performed under general anesthesia, achieved the same results as the UPPP but with fewer postoperative complications. It had been performed as a 1-stage procedure under local anesthesia in an outpatient procedure and appeared to be a safe and effective procedure for the treatment of snoring.17 In this study, there was a significant reduction in the distance between the posterior nasal spine and the soft palate after the operation. The reposition and stabilization of the uvula on the soft palate were responsible for the wide opening of the retropalatal airway space. There was minimal morbidity associated with the treatment. It was a safe and effective adjunct procedure under local anesthesia for the treatment of palatal obstruction in OSAS patients. CONCLUSIONS Results of GAHM in the treatment of OSAS have been previously reported when performed under general anesthesia. This study demonstrates that it is safely and effectively performed under local anesthesia with low chance of significant complications, in carefully selected patients. It may actually be preferable to general anesthesia in some cases because it is less expensive and does not put the airway at risk with intubation, extubation, and sedation. We thank Rachadaporn Adchariyapet, DDS, and Ronayuth Boonchu, MD, for assistance during surgery; Anusorn Taneepan, MD, for polysomnographic data; and Somchart Maneenoy, MS, for statistical analysis. REFERENCES
1. Young T, Palta M, Dempsey J, et al. The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993;328:1230-5. 2. Coleman J. Complications of snoring, upper airway resistance syndrome, and obstructive sleep apnea syndrome in adults. Otolaryngol Clinic North Am 1999;32:223-34. 3. Shepard JW. Hypertension, cardiac arrhythmias, myocardial infarction, and stroke in relation to obstructive sleep apnea. Clin Chest Med 1992;13:437-58.
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4. Fujita S, Conway, Zorick F, et al. Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 1981;89:923-7. 5. Sher AE, Shechtman KB, Piccirillo JF. The efficacy of surgical modifications for the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19:156-77. 6. Riley R, Powell N, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993;108: 117-25. 7. Utley DS, Shin EJ, Terris DJ. A cost-effective and rational surgical approach to patients with snoring, upper airway resistence syndrome or obstructive sleep apnea syndrome. Laryngoscope 1997;107:726-34. 8. Ramirez SG, Loube DI. Inferior sagittal osteotomy with hyoid bone suspension for obese patients with sleep apnea. Arch Otolaryngol Head Neck Surg 1996;122:953-7. 9. Johnson NT, Chinn J. Uvulopalatopharyngoplasty and inferior sagittal mandibular osteotomy with genioglossus advancement for treatment of obstructive sleep apnea. Chest 1994;105:278-82. 10. Esclamando R, Glenn M, McCulloch T, et al. Perioperative complications and risk factors in the surgical treatment of obstructive sleep apnea syndrome. Laryngoscope 1989;99:1125-9. 11. Norton ML, Brown ACD. Evaluating the patient with a difficult airway for anesthesia. Otolaryngol Clin North Am 1990;23:771-85. 12. Phillipson EA, Remmers JA. American Thoracic Society consensus conference on indications and standards for cardiopulmonary sleep studies. Am Rev Respir Dis 1989; 139:559-68. 13. John MW. A new method for measuring daytime sleepiness: the Epworth Sleepiness Scale. Sleep 1991;14: 540-5. 14. Riley R, Powell N, Guilleminault C. Obstructive sleep apnea and the hyoid: a revised surgical procedure. Otolaryngol Head Neck Surg 1994;111:717-21. 15. Gans BJ. Local anesthesia. In: Gans BJ, editor. Atlas of oral surgery. St Louis: CV Mosby; 1972. p. 27-37. 16. Powell N, Riley R, Guilleminault C, et al. A reversible uvulopalatal flap for snoring and sleep syndrome. Sleep 1996;19:593-9. 17. Neruntarat C. Uvulopalatal flap for snoring on an outpatient basis (abstract). Otolaryngol Head Neck Surg 2000; 123:211-2. 18. Riley R, Guilleminault C, Powell N, et al. Palatopharyngoplasty failure, cephalometric roentgenograms, and obstructive sleep apnea. Otolaryngol Head Neck Surg 1985; 93:240-3. 19. Troell R, Riley R, Powell N, et al. Surgical management of the hypopharyngeal airway in sleep disordered breathing. Otolaryngol Clinic North Am 1998;31:979-1012. 20. Riley R, Powell N, Guilleminault C, et al. Obstructive sleep apnea surgery: risk management and complications. Otolaryngol Head Neck Surg 1997;117:648-52. 21. Fairbanks DNF. Uvulopalatopharyngoplasty complications and avoidance strategies. Otolaryngol Head Neck Surg 1990;102:239-45. 22. Macalusa RA, Reams C, Gibson WS, et al. Uvulopalatopharyngoplasty: postoperative management and evaluation of results. Ann Otol Rhinol Laryngol 1989;89: 502-7.
MD,
Bangkok, Thailand
OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) is a common chronic illness that results in significant morbidity in many patients. Upper airway obstruction of OSAS patients occurring during sleep can appear at multiple sites, including the hypopharynx. Successful results of genioglossus advancement and hyoid myotomy with suspension (GAHM) in the treatment of hypopharyngeal obstruction have been reported when performed under general anesthesia. However, many patients have difficulty at induction of anesthesia and intubation. Patients are predisposed to specific complications, owing to anatomical abnormalities of the airway and existence of underlying syndrome. The purpose of this study was to assess the safety and efficacy of GAHM for the treatment of OSAS with the patient under local anesthesia. METHODS: Thirty-one OSAS patients with hypopharyngeal obstruction underwent GAHM under local anesthesia. The inferior alveolar nerve was blocked. The osteotomized mandibular segment was advanced and turned to lock the inner surface of the mandible and geniotubercle at the outer surface. The hyoid bone was suspended to the superior aspect of the thyroid cartilage. Uvulopalatal flap was an adjunct surgical procedure for palatal obstruction. Patients had a mean age of 46.2 ⴞ 5.8 years and a body mass index of 28.8 ⴞ 3.2 kg/m2. Most of the patients were male. Data on patients were compared between preoperative and postoperative assessment points. Statistical analysis was performed using Student’s t test. RESULTS: All patients tolerated the procedure well. The mean follow-up was 8 months (range, 6 to 10
From the Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Vajira Hospital. Presented at the Annual Meeting of the American Academy of Otolaryngology–Head and Neck Surgery, Denver, CO, September 9-12, 2001. Reprint requests: Chairat Neruntarat, MD, Department of Otolaryngology, Faculty of Medicine, Srinakharinwirot University, Vajira Hospital, 681 Samsaen Road, Bangkok 10300, Thailand; e-mail, [email protected]. Copyright © 2003 by the American Academy of Otolaryngology–Head and Neck Surgery Foundation, Inc. 0194-5998/2003/$30.00 ⫹ 0 doi:10.1016/S1094-5998(03)00094-9
months). The mean Respiratory Disturbance Index (RDI) decreased from 48.2 ⴞ 10.8 to 14.5 ⴞ 5.8, and the lowest oxygen saturation increased from 81.8 ⴞ 3.8% to 88.8 ⴞ 2.9%. The Epworth Sleepiness Scale score improved from 14.9 ⴞ 2.3 to 8.2 ⴞ 1.7 (P < 0.001), and the snoring scale improved from 8.1 ⴞ 0.6 to 3.4 ⴞ 0.9 (P < 0.001). Postoperative complications included wound dehiscence in 3%, transient dysphagia in 3%, and transient paresthesia of the lower jaw in 6%. Bleeding, infection, and airway obstruction were not observed. Most patients had mild-to-moderate pain (visual analog scale, <7) for 5 to 7 days after procedures. Responders were defined as OSAS patients who had a reduction in the RDI of >50% and an RDI of <20 after surgery. By these criteria, 70% of the patients were regarded as having responded to GAHM. CONCLUSION: Significant reduction in RDI and clinical improvements in snoring and sleepiness were observed after GAHM. It appears to be a safe, inexpensive, and effective procedure that can be performed under local anesthesia with a low chance of complications in carefully selected OSAS patients. (Otolaryngol Head Neck Surg 2003; 129:85-91.)
O
bstructive sleep apnea syndrome (OSAS) is a common illness that affects 2% to 4% of middleaged adults.1 It is now seen as one end of a spectrum of sleep-related breathing disorders and is associated with hypertension, cardiovascular diseases, daytime sleepiness, impairment of quality of life, and risk for general anesthesia.2,3 Many patients respond to medical treatments with weight loss, body position training for sleep, avoidance of alcohol and sedative medication, oral appliances, and continuous positive airway pressure (CPAP). However, medical and behavioral managements require ongoing, prolonged followup, and adherence to therapy regimens; some patients are not able to comply with these recommended treatments. Several surgical procedures have been developed to treat OSAS. The surgical management continues to be a challenge, beginning with selec85
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tion of the surgical procedure to perform. Precise identification of each anatomic region of constriction is essential for accurate planning and sequencing of surgical intervention. Uvulopalatopharyngoplasty (UPPP), described by Fujita et al,4 was the operation especially designed to address the palatal abnormalities seen in many patients with OSAS. The surgical response of an isolated UPPP was quoted as 40.7%.5 In addition, the outcome of this procedure was difficult to predict. Although UPPP eliminated the obstruction at the palatal level, persistent obstruction remained at the hypopharynx. OSAS patients have a wide spectrum of disease severity. Upper airway obstruction of many patients, occurring during sleep, can appear at multiple sites. Results of genioglossus advancement and hyoid myotomy with suspension (GAHM) have been successfully reported, when performed under general anesthesia. Riley et al6 reported successful results that were based on severity and ranged from approximately 75% in patients with mild-to-moderate OSAS to 40% in patients with severe OSAS. The treatment outcomes of pharyngeal surgery addressing both oropharygeal and hypopharygeal areas of collapse have been validated at a number of centers.7-9 However, a significant proportion of OSAS patients have difficulty at induction of anesthesia and intubation. Patients are predisposed to specific complications, owing to the anatomic underlying syndrome.10,11 The purpose of this study was to assess the safety and efficacy of GAHM for the treatment of OSAS under local anesthesia. MATERIALS AND METHODS During a 12-month period, 210 consecutive patients were evaluated for the treatment of snoring and sleep apnea at Vajira Hospital. Patients were advised to bring their bed partners to the evaluation. The initial visit included a complete history, physical examination, and otolaryngologic examination. Fiberoptic pharyngoscopy with Muller’s maneuver was performed at the level of the nasopharynx and the base of tongue. Initial body weights and heights were obtained, and the body mass index (BMI) was calculated. A lateral cephalometric radiograph and panoramic radiograph of the mandible were also obtained.
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After a diagnosis of OSAS was made, patients were advised on various treatment options. When appropriate, patients were encouraged to lose weight, avoid sleeping supine if their problem was positional, lengthen the bedtime, and avoid alcohol and tobacco. CPAP, oral appliance, and surgical options were reviewed with each patient. The patients who had failed to respond to the conservative treatments were counseled about the benefits and risks of surgical procedures. Thirty-one patients (14.8%) who had a primary complaint of snoring and OSAS were found to be suitable for GAHM performed under local anesthesia. All patients had both oropharyngeal and hypopharyngeal obstruction. Patients with hypertrophic tonsil and nasal obstruction were excluded. Uvulopalatal flap (UPF) under local anesthesia was an adjunct surgical procedure for oropharyngeal obstruction. All patients were evaluated preoperatively and then at least 3 months postoperatively with polysomnography. OSAS was diagnosed in patients who experienced daytime sleepiness or disturbed sleep and had more than 5 respiratory disturbances per hour of sleep on their polysomnogram. Polysomnography was performed in the sleep laboratory with full monitoring that included EEG, electro-oculography, chin and leg electromyography, electrocardiography (modified V2 lead), airflow, thoracic and abdominal efforts, and pulse oximetry (Alice 3 System; Healthdyne; Atlanta, GA). The polysomnogram was analyzed according to the standards of the American Thoracic Society.12 Baseline information was collected. The patient’s bed partner or observer used a 10-cm visual analog scale (VAS) to grade the severity of snoring before the procedure and after treatment. “No snoring” occupied the far left portion of the scale, whereas “severe snoring” occupied the far right of the scale. The Epworth Sleepiness Scale (ESS) score that reflected the chance of dozing in specific situations as well as daytime sleepiness13 was completed at baseline. Patients with a Respiratory Disturbance Index (RDI) of ⬎40 and lowest oxygen saturation of ⬍80% were advised to use CPAP at least 2 weeks before surgery and to continue CPAP postoperatively until a polysomnogram was performed to document outcome. Prophylactic antibiotics were
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Fig 1. (A) Inferior alveolar nerve block is performed intraorally. (B) The needle tip is positioned near the inferior alveolar nerve in the pterygomandibular space. (C) Additional infiltration is performed at the labial and the lingual surface of the mandible. (D) The mixture of local anesthetic agents is injected over hyoid bone and upper part of thyroid cartilage.
administered intravenously to every patients. Diazepam (10 mg) was administered 1 hour preoperatively only for patients who had a significant gag reflex. Genioglossus Advancement and Hyoid Myotomy Under Local Anesthesia GAHM was performed essentially as decried by Riley et al,6,14 using the modification in which the procedure was performed under local anesthesia. A mixture of 15 mL of 1% lidocaine with 1:100,000 epinephrine and 15 mL of 0.5% bupivacaine with 1:200,000 epinephrine was prepared. Inferior alveolar nerve block was performed.15 The patient was in a supine position and opened the mouth wide. The mandibular foramen was located midway between the anterior and posterior borders of the mandibular ramus about 4 mm above the occlusal plan of the mandibular molars.
The angle of penetration was approached from the opposite premolar area. A 27-gauge needle was inserted at the center of the depth of the anterior border of the mandibular ramus, lateral to the pterygomandibular raphe and medial to the medial temporal crest. From 1 to 2 mL of the mixture was slowly injected. This sequence was repeated on the opposite side. Additional infiltration was performed at the anterior and posterior surfaces of the mandible over the operative field (Fig 1). An incision was made just to the labial side of gingivolabial sulcus. The mandibular bone was exposed down to the inferior margin. Mandibular osteotomy was performed using a 2-hole sagittal saw blade. The fragment was advanced and rotated 20 degrees. The outer table was removed, and the fragment was secured to the lower edge of the mandible using a lag-screw technique with an 11-mm ⫻ 2.0-mm screw in a 1.5-mm drill hole
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Fig 2. (A) Genioglossus advancement, frontal view. The osteomized mandibular segment is advance and fixed with a titanium screw. (B) Diagram of hyoid myotomy with suspension. The stylohyoid ligament is divided and the hyoid bone is advanced over the thyroid cartilage and fixed with 4 nonabsorbable sutures.
(Fig 2A). The wound was drained with a Penrose drain and sutured. The mixture was used to locally infiltrate over the hyoid bone and upper portion of the thyroid cartilage (Fig 1). A horizontal anterior cervical neck incision was made over the hyoid bone. The hyoid was released from its inferior attachments and advanced anteriorly and inferiorly over the thyroid cartilage. A 1-0 TICRON polyester suture (United States Surgical) was passed around the hyoid ⬃1 cm lateral to the midline and then passed through the thyroid ala, ⬃1 cm from the notch. A second suture was placed starting at the level of the lesser cornu and ending 2 cm from the thyroid notch. This sequence was repeated on the opposite side (Fig 2B). The wound was irrigated and drained with a Penrose drain. Uvulopalatal Flap Under Local Anesthesia UPF was performed as described originally by Powell et al16 using the modification in which the procedure was performed under local anesthesia instead of general anesthesia.17 It was performed with the patient sitting upright. The soft palate was anesthetized with lidocaine 10% topical dispersion, and the mixture was additionally injected at 3 points 1 cm from the lower rim of the palatal arch. The mucosa, submucosa with glands, and fat on the lingual surface of the uvula and soft palate were removed with a scalpel. The uvular tip was amputated, and bleeding was controlled with bipolar electrocoagulation. The uvula was reflected
back toward the soft palate and fixated into its new position with multiple sutures of 3-0 polyglyclic acid. Postoperative medications included antibiotic suspension for 7 days, acetaminophen with codeine elixir, Tramal, and/or anesthetic lozenges as needed for pain relief. Patients were carefully monitored with continuous pulse oximetry in a surgical ward environment until discharge. Sleep aids, anxiolytics, or other sedating medications were not administered in the immediate postoperative period. Several parameters, including intraoperative pain, postoperative pain, operating time, and complications, were recorded. Patients were seen in follow-up at intervals of 1, 2, and 4 weeks and after a repeat polysomnogram was completed. VASs for pain and speech problems were completed once daily for 10 days after the procedure. The patients were asked to rate pain on a continuous scale from 0 (none) to 10 (excruciating or intense pain) and speech problems from 0 (none) to 10 (extreme difficulty talking). Data on the patients were compared between the preoperative stage and the postoperative assessment and analyzed by Student’s t test. RESULTS The patients were examined between 6 and 10 months after the operation (mean ⫾ SD, 8.3 ⫾ 1.8 months). Age range was 30 to 54 years (mean ⫾ SD, 46.2 ⫾ 5.8 years). Twenty-nine patients (93.5%) were married, and 2 (6.5%) were single or
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Table 1. Polysomnographic results Variable
Preoperative
Postoperative
P
RDI LSAT (%) Stage 3 ⫹ 4 (%) REM sleep (%) Sleep efficiency (%)
48.2 ⫾ 10.8 81.8 ⫾ 3.8 7.3 ⫾ 4.3 8.6 ⫾ 3.4 80.2 ⫾ 10.3
14.5 ⫾ 5.8 88.8 ⫾ 2.9 9.4 ⫾ 2.8 19.2 ⫾ 8.4 85.2 ⫾ 4.1
⬍0.001 ⬍0.01 ⬍0.001 ⬍0.001 ⬍0.05
RDI, Respiratory Disturbance Index; REM, rapid eye movement; LSAT, lowest oxygen saturation.
divorced; 28 (90.3%) were male. BMI at the time of surgery ranged from 27.4 to 30.2 kg/m2 (28.8 ⫾ 3.2 kg/m2), and at postoperative period, 27.5 to 31.2 kg/m2 (28.9 ⫾ 2.5 kg/m2). There was no significant difference between preoperative and postoperative BMI. In the first period, HM was performed 1 month after GA and UPF in 7 patients. In the remaining 24 patients, GAHM and UPF were performed concurrently. All patients tolerated the procedure well. Operating time for GA ranged from 45 to 75 minutes, with a mean of 55.9 ⫾ 18.4 minutes, for HM, 40 to 70 minutes, with a mean of 50.9 ⫾ 16.8 minutes. From 7 to 10 mL (9.2 ⫾ 1.4 mL) of the mixture was used for GA, and 10 to 15 mL (12.5 ⫾ 3.2 mL) was used for HM. There was a mean hospital stay of 2.7 ⫾ 0.8 days (range, 2 to 5 days). Patients had an intraoperative pain scale (VAS) of 2.5 ⫾ 1.2 (range, 2 to 4). All patients completed preoperative and postoperative polysomnograms. The mean preoperative RDI was 48.2 ⫾ 10.8. The mean postoperative RDI was 14.5 ⫾ 5.8. This was a statistically significant change (P ⬍ 0.001). The maximal desaturation was significantly changed, with a preoperative mean of 81.8 ⫾ 3.8% and a postoperative mean of 88.8 ⫾ 2.9% (P ⬍ 0.01). There were significant improvements in sleep quality after the operation (Table 1). Response to the GAHM procedure were defined as a 50% improvement in RDI and a final RDI of ⱕ20. By these criteria, 22 of 31 (70.1%) patients responded. Significant improvement from the baseline (8.1 ⫾ 0.6) was observed in VAS at postoperative period (3.4 ⫾ 0.9, P ⬍ 0.001). The average preoperative VAS was 8.1, indicating moderate to severe snoring in this group of patients. Snoring was considered to be cured by the bed partner or observer if the VAS was less than half the base-
line. Based on this criterion for a cure of snoring, the problem was eliminated in 87.1% (27 of 31) of the patients. The subjective data measured with the ESS (0 to 24) showed significant improvement. The mean preoperative ESS score was 14.9 ⫾ 2.3, and the mean postoperative ESS score was 8.2 ⫾ 1.7 (P ⬍ 0.001). There was a significant reduction in the distance between the posterior nasal spine and soft palate from 45.2 ⫾ 2.5 mm to 43.9 ⫾ 2.8 mm (P ⬍ 0.01). A significant increase in the distance between mandibular plane and hyoid bone from 20.1 ⫾ 2.4 mm to 22.2 ⫾ 1.3 mm (P ⬍ 0.05) was observed. There was an increase in posterior airway space from 6.1 ⫾ 2.4 mm to 8.2 ⫾ 2.1 mm (P ⬍ 0.001). There were no changes in skeletal measurements because these areas were not treated or affected by the treatment (Table 2). One (3%) patient had wound dehiscence, which was resolved without sequel after intraoral wound dressing and appropriate antibiotic therapy for 4 weeks. Other complications included dysphagia in 3% (1 of 31) and paresthesia of lower jaw in 6% (2 of 31). These were self-limited and resolved. Vasovagal episode, bleeding, aspiration, seroma, mandibular fracture, and extrusion of the screw were not observed. There were no emergent airway complications in this study. GAHM postoperative pain was rated as mild to moderate (VAS ⫽ 5.2 ⫾ 1.1; range, 4 to 7). Data collected from VAS showed the discomfort to be worst at postoperative day 3 and nearly resolved by postoperative day 7. Operating time for UPF ranged from 15 to 25 minutes with a mean of 20.5 ⫾ 4.9 minutes. From 3 to 5 mL (range, 4.2 ⫾ 1.2 mL) of the mixture was used. UPF complications included transient nasal regurgitation in 9.7% (3 of 31) and foreign body sensation in 12.9% (4 of 34). Bleeding, in-
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Table 2. Cephalometric analysis Variable
Preoperative
Postoperative
SNA (degrees) SNB (degrees) PNS-P (mm) MP-H (mm) PAS (mm)
84.2 ⫾ 3.9 80.6 ⫾ 3.2 45.2 ⫾ 2.5 20.1 ⫾ 2.4 6.1 ⫾ 2.4
84.3 ⫾ 4.1 80.7 ⫾ 3.5 43.9 ⫾ 2.8 22.2 ⫾ 1.3 8.2 ⫾ 2.1
P
NS NS ⬍0.01 ⬍0.05 ⬍0.001
SNA, sella–nasion–point A angle; SNB, sella–nasion–point B angle; PNS-P, length from posterior nasal spine to uvula; MP-H, length between mandibular plane and hyoid bone; PAS, posterior airway space.
fection, and nasopharyngeal stenosis were not encountered. Patients had mild-to-moderate pain (VAS ⫽ 6.2 ⫾ 1.2) and mild speech problems (VAS ⫽ 3.5 ⫾ 0.8) for 5 to 7 days after the procedure. DISCUSSION Many treatment options are available for patients with OSAS. Surgical treatments become particularly important when initial medical treatments have failed. However, UPPP failure may occur from persistent hypopharyngeal collapse.18 The anatomic obstruction associated with OSAS may occur at multiple sites. Many different approaches have been developed with the intent to better treat hypopharyngeal obstruction. GAHM was undertaken to enlarge the hypopharyngeal area. The genial tubercle, which is the anterior attachment of genioglossus muscle, is mobilized by osteotomies, and the hyoid with its attached musculature is drawn anteriorly over the thyroid ala, to expand the hypopharyngeal lumen and decrease the airway resistance.6,14 In this study, there was a significant widening of posterior airway space and the mandibular plane–to– hyoid bone distance lengthened after surgery. The surgical results from GAHM in conjunction with the UPPP for the relief of OSAS are encouraging. Riley et al6 reported that the treatment was successful for 57% (133 of 233) of patients. Patients with mild to moderately severe OSAS had an approximately 75% success rate. Utley et al7 showed a 57% (8 of 14) success rate, defined as a reduction in RDI by 50% and a postoperative RDI of ⬍20 or RDI equivalent to that obtained with CPAP. Troell et al19 revealed that 63.6% (7 of 11) of patients were cured, defined as an RDI of ⬍10. Ramirez and Loube8 reported a 42% success rate
in morbidity obese patients. However, these multilevel pharyngeal procedures were performed under general anesthesia. OSAS patients are predisposed to specific complications, owing to anatomic abnormalities of the airway and existence of underlying syndrome. Eighteen percent of OSAS patients have difficulty at induction of anesthesia and intubation.20 The combination of the anesthetic agents, analgesic effects, and upper airway edema can worsen apnea and lead to complications. Intraoperative narcotics were also found to increase the risk of airway obstruction at extubation. Sedatives and narcotic medications pose a specific anesthetic risk because they increase the collapsibility of the pharynx and oral soft tissue, leading to additional airway obstruction.21,22 In this study, GAHM was performed under local anesthesia and it did not put the airway at risk. The inferior alveolar nerve block is frequently performed for intraoral surgery of the lower jaw. It is reproducible, easily administered, and routinely effective if properly performed.15 Intraoperative discomfort was low (VAS ⱕ4), and patients tolerated the GAHM procedure well. The GAHM results in this study were comparable to those of previous studies. It has a 70% success rate of decreasing RDI by ⱖ50%, and postoperative RDI was ⬍20 events per hour. GAHM literature showed that short-term improvement in OSA occurred in 42% to 75%.6-8 The ESS score improved in this study from a preoperative mean of 14.9 ⫾ 2.3 to a postoperative mean of 8.2 ⫾ 1.7 (P ⬍ 0.001). These scales were compared with reported mean ESS scores from John13 for normal control subjects, primary snoring, and OSAS of 5.9 ⫾ 2.2, 6.5 ⫾ 3.0, and 11.7 ⫾ 4.6, respectively. The
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preoperative mean ESS scores were consistent with a moderate level of sleepiness, and they declined after treatment to a near-normal level. There were no serious complications after GAHM in this study; complications included wound dehiscence, transient dysphagia, and transient paresthesia of the lower jaw. UPF reported by Powell et al,16 which was performed under general anesthesia, achieved the same results as the UPPP but with fewer postoperative complications. It had been performed as a 1-stage procedure under local anesthesia in an outpatient procedure and appeared to be a safe and effective procedure for the treatment of snoring.17 In this study, there was a significant reduction in the distance between the posterior nasal spine and the soft palate after the operation. The reposition and stabilization of the uvula on the soft palate were responsible for the wide opening of the retropalatal airway space. There was minimal morbidity associated with the treatment. It was a safe and effective adjunct procedure under local anesthesia for the treatment of palatal obstruction in OSAS patients. CONCLUSIONS Results of GAHM in the treatment of OSAS have been previously reported when performed under general anesthesia. This study demonstrates that it is safely and effectively performed under local anesthesia with low chance of significant complications, in carefully selected patients. It may actually be preferable to general anesthesia in some cases because it is less expensive and does not put the airway at risk with intubation, extubation, and sedation. We thank Rachadaporn Adchariyapet, DDS, and Ronayuth Boonchu, MD, for assistance during surgery; Anusorn Taneepan, MD, for polysomnographic data; and Somchart Maneenoy, MS, for statistical analysis. REFERENCES
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