ORIGINAL ARTICLE Usefulness of Uvulopalatopharyngoplasty With Genioglossus and Hyoid Advancement in the Treatment of Obstructive

Isabel Vilaseca, MD; Antonio Morello´, MD; Josep Marı´a Montserrat, MD; Joan Santamarı´a, MD; Alex Iranzo, MD

Objective: To evaluate the usefulness of uvulopalato- (AHI) lower than 20 plus subjective resolution of day- pharyngoplasty plus mandibular osteotomy with genio- time symptoms. glossus and hyoid advancement in the treatment of ob- structive sleep apnea syndrome (OSAS). Main Outcome Measure: Surgical success rate.

Results: Mean±SD AHI decreased from 60.5±16.5 to Design: Prospective study of 20 consecutive patients 44.6±27(P=.007), and CT90 (percentage of time with oxy- with OSAS. hemoglobin saturation below 90%) decreased from 39.5%±26% to 25.1%±26.4% (P=.002). The overall sur- Setting: University medical center. gical success rate was 35% but increased to 57% in pa- tients with moderate OSAS (AHI, 41-60) and to 100% in Patients and Interventions: Twenty OSAS patients mild OSAS (AHI, 21-40). In the group of severe OSAS, the with multilevel upper airway obstruction who refused success rate was 9%. Predictors of surgical outcome suc- continuous positive airway pressure treatment. All cess were the AHI, CT90, stages 2 and 3-4 sleep percent- patients were evaluated before and 6 months after sur- ages, and the cephalometric ANB angle (angle formed from gery by clinical history, the Epworth Sleepiness Scale, the deepest point on the maxillary outer contour to the na- physical examination, fiberoptic nasopharyngoscopy sion to the deepest point on the outer mandibular contour). combined with the Mu¨ ller maneuver, cephalometric analysis, nocturnal polysomnography, and a second- Conclusion: Patients with mild and moderate OSAS and night polysomnography with upper airway pressure multilevel obstruction in the upper airway may benefit recording during sleep. Surgery procedures were uvulo- from uvulopalatopharyngoplasty plus genioglossus and palatopharyngoplasty plus mandibular osteotomy with hyoid advancement. genioglossus and hyoid advancement. Surgical success- ful outcome was defined as an apnea-hypopnea index Arch Otolaryngol Head Neck Surg. 2002;128:435-440

BSTRUCTIVE sleep apnea level reconstruction phase 1) was intro- syndrome (OSAS) is duced by Riley et al3 as a surgical alternative caused by repetitive oc- to isolated UPPP in patients with multi- clusion of the upper air- level obstruction. When this procedure fails, way during sleep and may maxillomandibular advancement (multi- beO treated with continuous positive airway level reconstruction phase 2) may follow pressure (CPAP) or with several surgical phase 1. This surgical strategy was adopted techniques. Surgery is used to correct any by several centers maintaining the gradual anatomic abnormality that potentially 2-phase surgical procedure proposed by narrows the upper airway, which may be Riley et al,3 who showed that the multi- disclosed clinically or by other means level reconstruction phase 2 success rate (eg, cephalometry and fiberoptic naso- was similar to CPAP efficacy. However, the pharyngoscopy).1 usefulness of multi-level phase 1 recon- From the Services of Uvulopalatopharyngoplasty (UPPP) is struction remains unclear because apart Otorhinolaryngology used to eliminate the upper airway obstruc- from those by the Stanford group,3 the stud- (Drs Vilaseca and Morello´), tion selectively at the level of the orophar- ies published are few, with small numbers Pneumology (Dr Montserrat), 4-10 and Neurology ynx by removing a portion of the soft pal- of patients and varying rates of success. (Drs Santamarı´a and Iranzo), ate and the uvula; it is effective in 33% to The aim of our study was to evaluate the 2 University of Barcelona, 77% of patients. The association of UPPP usefulness of a multilevel phase 1 surgical Hospital Clı´nic, Barcelona, plus mandibular osteotomy with genio- procedure in a group of OSAS patients with Spain. glossus and hyoid advancement (multi- multilevel obstruction.

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 PATIENTS AND METHODS mandibular deficiency (SNB Յ77°) and narrowing of the air- way space at the base of the tongue (PAS Յ10 mm).17 After surgery, mandibular advancement was calculated accord- STUDY DESIGN ing to the depth of the mandibular osteotomy.

We prospectively observed 20 consecutive OSAS patients SLEEP EVALUATION with UPPP failure and multilevel obstruction in the upper air- way. Inclusion criteria were (1) persistent symptoms sugges- All night PSG studies included 4 electroencephalogram leads tiveofOSASandpost-UPPPapnea-hypopneaindex(AHI)(total (C3-A1, C4-A2, O1-A1, O2-A2), electrooculogram, chin number of apneas and hypopneas per hour of sleep) greater and left and right anterior tibial surface electromyogram, than 20, as determined by polysomnography (PSG); (2) ob- electrocardiogram, nasal and oral airflow measure (therm- struction in both the oropharynx and the hypopharynx, istors), thoracic and abdominal movement determina- and (3) CPAP refusal or intolerance. Exclusion criteria were tion, and continuous oxyhemoglobin saturation evalua- (1) age older than 65 years, (2) chronic pulmonary disease tion by a pulse oximeter. Sleep stages were scored according and/or (3) poor health condition. Presurgical evaluation in- to criteria set out by Rechtschaffen and Kales.18 Obstruc- cluded clinical history, Epworth Sleepiness Scale (ESS) evalu- tive apneas were defined as the absence of airflow with ation,11 physical examination, fiberoptic pharyngolaryngos- respiratory effort for at least 10 seconds. Hypopneas were copy, cephalometry, nocturnal PSG, and second-night PSG defined by a greater than 50% reduction of airflow accom- with upper airway pressure measurement during sleep. panied by an oxygen desaturation of more than 4 points In all patients, the surgical procedure included UPPP and or occurrence of an arousal from sleep. The percentage of hyoid advancement. Inferior mandibular osteotomy with ge- time with oxyhemoglobin saturation below 90% (CT90) nioglossus advancement was also performed in 11 subjects and lowest saturation level were also calculated. according to cephalometric criteria of mandibular defi- Pressure recordings at the velopharynx, oropharynx, and ciency. To evaluate the effectiveness of the surgical proce- hypopharynx were evaluated during the PSG studies before dure, we repeated the presurgical evaluation 6 months after and after surgery using the esophagus pressure as reference. surgery. A procedure was considered successful (and the pa- We used a 3-lumen catheter adapted to an esophageal bal- tient, a responder) if the postoperative PSG demonstrated an loon that was connected to a pressure transducer. The right AHI lower than 20 and the patient reported significant clini- upper airway catheter placement was checked under visual cal improvement. This study was approved by the ethics com- inspection using catheter marks. The detection of changes mittee at our institution and written informed consent was and cessation of the signal during an obstructive apnea al- obtained from each patient. lowed us to detect the precise location of the collapse in the pharynx. When no obstruction was demonstrated, all regis- CLINICAL EVALUATION ters were parallel to the esophagus signal.

Patients were evaluated by a comprehensive clinical history SURGICAL PROCEDURE that covered their sleep habits and the occurrence of sleep disturbances. Excessive daytime sleepiness was estimated by All 20 patients had experienced UPPP failures. A second the ESS: a score greater than 10 was considered indicative surgical phase included hyoid advancement in all 20 pa- of hypersomnia.11 Physical examination included measure- tients and mandibular osteotomy with genioglossus ad- ment of the body mass index (BMI) and neck circum- vancement in the 11 patients in whom the SNB angle was ference and evaluation of the anatomic characteristics and less than 78°, indicating a retroposition of the mandible. abnormalities of the upper airway. A combination of naso- The UPPP was performed as previously described by pharyngolaryngoscopy with the Mu¨ller maneuver12 was used Simmons et al.19 Hyoid advancement technique differed from to evaluate the upper airway compliance. the original description by Riley et al20 in that we advanced the to an anterior and downward direction over CEPHALOMETRIC ANALYSIS to the thyroid laminae where it was fixed with Gore-Tex (WL Gore & Associates, Flagstaff, Ariz) pushing the tongue ahead Lateral cephalometric radiographs were performed accord- and consequently increasing the PAS. The mandibular oste- ing to standard procedure.13 Before the exposure, patients otomy with procedure was per- swallowed contrast to outline the pharynx soft structures. formed as described by Riley et al3 advancing the tongue at We determined and evaluated the SNA angle (maxilla to cra- the genioid tubercle of the mandible to relieve the obstruc- nial base, position of the maxilla), SNB angle (mandible to tion at the hypopharyngeal level. Surgery was performed un- cranial base, postion of the mandible), PAS (posterior air- der general anesthesia, and during the 24 hours following sur- way space, distance between the base of the tongue and the gery patients were monitored in the intensive care unit. dorsal pharyngeal wall), PNS-P (distance from the poste- rior nasal spine to the tip of the soft palate, length of soft STATISTICAL ANALYSIS palate), point A (deepest point on the maxillary outer con- tour), point B (deepest point on the outer mandibular con- Data are presented as mean±SD. The Wilcoxon test was used tour), point G (palate thickness), point P (inferior tip of the to compare the preoperative and postoperative results. The palate), ANB angle (angle formed from point A to nasion to Mann-Whitney test was used to analyze the differences be- point B), and MP-H (distance from inferior mandible plane tween responders and nonresponders. Differences were also to hyoid bone; position of the hyoid bone).14,15 Palatal ob- tested with analysis of covariance, with disease severity as co- struction was defined when cephalometric analysis showed variable. Data were analyzed using SPSS, Windows version a PNS-P greater than 40 mm.16 Hypopharyngeal obstruc- 6.1.3 (SPSS Inc, Chicago, Ill), establishing P Ͻ.05 as statis- tion was defined when cephalometric analysis showed tically significant.

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 RESULTS Table 1. Change in Key Patient Parameters After Surgery* PREOPERATIVE AND POSTOPERATIVE EVALUATION P Value Measured Parameter Presurgery Postsurgery (Wilcoxon Test) The main clinical, polysomnographic, and cephalomet- BMI, kg/m2 27.8 ± 3.3 28 ± 3.3 .45 (NS) ric characteristics before and after surgery are summa- Neck circumference, cm 40.9 ± 2.1 40.7 ± 2.2 .95 (NS) rized in Table 1. All 20 patients were men with a ESS 12.0 ± 5.8 7.9 ± 5 .06 (NS) mean±SD age of 44.7±5.7 years (range, 34-58 years). The Total sleep time, min 306.9 ± 66.6 334.7 ± 70.4 .04 (NS) BMI was 27.8±3.3 kg/m2, and neck circumference, SE, % 87.6 ± 5.3 85.6 ± 6.3 .18 (NS) 40.9±2.1 cm. After 6 months of follow-up, the BMI and Stage 1, % 6.6 ± 4.7 11.8 ± 14.8 .05 (NS) neck circumference showed no significant differences. Stage 2, % 72.9 ± 7.8 64.5 ± 12 .01 All 20 patients were habitual and heavy snorers and Stage 3-4, % 5.8 ± 5.5 7.9 ± 6.9 .06 (NS) Stage REM, % 15.56 ± 5.2 15.7 ± 8.5 .75 (NS) reported daytime fatigue and somnolence; 16 (80%) felt AHI 60.4 ± 16.5 44.6 ± 27 .007 not refreshed on awakening. Postoperatively, was CT90, % 39.5 ± 26.0 25.1 ± 26.4 .002 eliminated in 15 patients (75%), decreased in 5 (25%), LOS, % 68.3 ± 10.1 74.8 ± 12.16 .001 and early morning fatigue persisted in 6 (30%). PNS-P, mm 50.7 ± 4.9 35.3 ± 4.9 Ͻ.001 Before surgery, the ESS score was greater than 10 G, mm 11.8 ± 2.0 15.1 ± 1.8 Ͻ.001 in 11 subjects, and following treatment the score im- PAS, mm 10.9 ± 4.1 12.8 ± 3.8 .07 (NS) SNA, degrees 78.1 ± 4.2 78.1 ± 4.2 Ͼ.99 (NS) proved in all but 1 (Table 2). The ESS score improved SNB, degrees 76.6 ± 3.3 77.7 ± 3.2 .002 from 12±5.8 (range, 0-24) to 7.9±5 (range, 0-18) but ANB, degrees 1.5 ± 2.8 0.4 ± 3.0 .002 this difference was not statistically significant (P=.64). MP-H, mm 35.3 ± 9.7 42.5 ± 8.7 .005 Mean baseline PSG parameters were characteristic of severe OSAS, showing a high AHI (60.5±16.5), severe oxy- *Unless otherwise indicated, data are mean ± SD. BMI indicates body mass gen desaturation (mean CT90, 39.6%±26.0%; lowest mean index; ESS, Epworth Sleepiness Scale; SE, sleep efficiency; REM, rapid eye movement; AHI, apnea-hypopnea index; CT90, percentage of time with saturation, 68.3%±10.1%), and sleep fragmentation in- oxyhemoglobin saturation below 90%; LOS, lowest oxygen saturation; PNS-P, duced by a high number of arousals and brief awaken- distance from the posterior nasal spine to the tip of the soft palate (length of ings. Total sleep time and sleep efficiency did not differ be- soft palate); G, palate thickness; PAS, posterior airway space (distance between the base of the tongue and the dorsal pharyngeal wall); SNA, angle of maxilla to tween preoperative and postoperative studies. There was cranial base (position of the maxilla); SNB, angle of mandible to cranial base a statistically significant reduction in the AHI (PϽ.001), (position of the mandible); ANB, angle formed from the deepest point on the with a trend toward a decrease in the apnea index and an maxillary outer contour to the nasion to the deepest point on the outer mandibular contour; MP-H, distance from inferior mandible plane to hyoid bone increase in the hypopnea index. Postoperative studies (position of the hyoid bone); and NS, not significant. showed a reduction in the AHI in 16 patients (80%), with an AHI lower than 20 in 7, and 50% or more AHI reduc- tion in 8 (Table 2). In 4 patients, the postoperative AHI was and only 1 of them had a preoperative PAS smaller than slightly higher than before surgery. Oximetric analysis 11 mm (Table 3). showed a significant decrease in CT90 (P=.002) and in- Preoperative pressures of the upper airway during crease in lowest oxyhemoglobin saturation (P=.001) be- sleep showed multilevel obstruction in all patients, al- tween preoperative and postoperative studies. After sur- though a reduced sleep efficiency related to discomfort gery, sleep architecture improved, showing a significant was disclosed in 2. Postoperative pressure could not be decrease in stage 2 sleep (P=.01) and a tendency toward assessed in 8 patients because they refused the proce- an increase in slow-wave sleep (P=.06) and REM (rapid dure. Complete preoperative and postoperative studies eye movement) sleep (P=.07). to measure pressures were done and well tolerated in 10 Before surgery, cephalometric analysis showed long nonresponders. In these 10 patients, multilevel obstruc- and thick soft palates, narrowing in the PAS behind the tion was still demonstrated after surgery. tongue, mild mandibular and maxillar deficiency, and There was no correlation between postoperative AHI lowered position of the hyoid bone. Eleven patients (55%) changes and postoperative variations in BMI, neck cir- had mandibular deficiency (SNB Ͻ78°). cumference, ESS score, sleep stage percentages, and the There were significant differences between preop- cephalographic parameters PNS-P, point G, PAS, and erative and postoperative findings in the palate param- MP-H. Changes in AHI were correlated with postopera- eters PNS-P and point G, the hyoid bone position MP-H, tive changes in ANB (P=.01) and SNB (P=.01). and the SNB angle. Seventeen patients (85%) experi- enced significant increase in MP-H from 35.3±9.7 mm SURGICAL OUTCOME to 42.5±8.7 mm (P=.005). In those with mandibular os- teotomy with genioglossus advancement, the mean depth Seven patients (35%) met our polysomnographic and of osteotomy was 11.5±2.4 mm, resulting in a signifi- clinical criteria for surgical success. Statistical analysis cant SNB angle increase of 9.4°±2.1°. Preoperative PAS identified AHI, CT90, stages 2 and 3-4 percentages (sleep was less than 11 mm in 7 subjects (35%), and after sur- quality), and the ANB angle as predictors of surgical out- gery increased from 10.9±4.1 mm to 12.8±3.8 mm come. Before surgery, the successful group had signifi- (P=.07) and enlarged in 14 patients (70%). The 6 sub- cantly fewer apneas and oxyhemoglobin desaturations, jects who had no increase in their PAS had undergone lower stage 2 sleep percentage, higher slow-wave sleep mandibular osteotomy with genioglossus advancement, percentages, and lower maxillary/mandible discrep-

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 2. Change in Apnea-Hypopnea Index (AHI) and Epworth Sleepiness Scale (ESS) Scores After Survey*

AHI ESS Patient No. Type of Surgery Presurgery Postsurgery % Change Presurgery Postsurgery Difference 1 UPPP+HA+GA 71 56 −21 9 1 −8 2 UPPP+HA+GA 83.4 75.47 −9.5 11 5 −6 3 UPPP+HA+GA 52 15.8 −70 23 18 −5 4 UPPP+HA 39 19.4 −50.3 13 10 −3 5 UPPP+HA+GA 64 58.8 −8.1 13 6 −7 6 UPPP+HA+GA 64.3 53.7 −16.5 7 10 3 7 UPPP+HA+GA 94 68.9 −26.7 6 7 1 8 UPPP+HA+GA 60.7 81.2 33.8 21 16 −5 9 UPPP+HA+GA 66 18 −72.7 9 9 0 10 UPPP+HA+GA 69.6 78.9 13.4 18 14 −4 11 UPPP+HA+GA 61 74 21.3 12 10 −2 12 UPPP+HA+GA 89.1 51 −42.8 8 6 −2 13 UPPP+HA 66.49 60 −10 8 10 2 14 UPPP+HA 29 1 −97 14 9 −5 15 UPPP+HA 57 14 −75.4 10 6 −4 16 UPPP+HA 40 19 −52.5 12 13 1 17 UPPP+HA 49 76 55.1 13 5 −8 18 UPPP+HA 42 11 −73.8 24 0 −24 19 UPPP+HA 55 23 −58 10 3 −7 20 UPPP+HA 57.2 38 −33.6 0 0 0

*UPPP indicates uvulopalatopharyngoplasty; HA, hyoid advancement; and GA, mandibular osteotomy with genioglossus advancement.

ancy. Patients with severe OSAS (AHI, Ͼ60) had a low Our success rate is similar to that in 2 previous incidence of success. Surgical outcome rate was higher publications, which showed a success rate between 27% in patients with moderate (AHI, 41-60) and mild (AHI, and 42%,8,9 but is lower than that of the Stanford group3 21-40) OSAS: and other researchers who reported a 50% to 78% rate 4-7,10 OSAS Severity No. of Responders/Total No. of success. There are several possible explanations of Patients (% Response) for these differences in results. First, our patients might Mild (AHI, 21-40) 2/2 (100) have changed weight during the 6 months after surgery Moderate (AHI, 41-60) 4/7 (57) and subsequently increased their AHIs and CT90s. Severe (AHI, Ͼ60) 1/11 (9) However, this speculation was not confirmed; statistical Ͼ Total (AHI, 20) 7/20 (35) analysis showed that there were no differences between Patients who were not successfully treated tended to BMI and neck circumference before and 6 months after have bigger neck circumferences (P=.09) and higher surgery. ESS scores (P=.08) than responders. There were no sta- Second, our patients had moderately severe OSAS tistical differences between the 2 groups in BMI, age, with a mean AHI of 60, while other studies selected pa- and all the cephalometric parameters except ANB angle tients with lower AHIs (range, 45-58).4,5,7,8 Because suc- (Table 4). cess rate is predicted by the AHI, it can be speculated that None of the patients in this series had postoperative our surgical success would have been higher if we had bleeding, infection, difficulty swallowing, persistent rhi- selected patients with lower severity. nolalia and nasal regurgitation, or significant pain. Two Third, our definition of surgical success included days after surgery, 1 patient with a preoperative history not only an AHI lower than 20, but also daytime clini- of coronary heart disease had an angina pectoris, which cal resolution. Because some studies considered an AHI resolved with adequate medical treatment. lower than 20 as the sole indicative parameter of sur- gical success, some of our patients with AHIs lower COMMENT than 20 but without complete disappearance of daytime symptoms would have been classified as responders. This study showed that UPPP plus mandibular oste- However, all patients with remaining postsurgery otomy with genioglossus and hyoid advancement was symptoms in our study also showed AHIs higher than effective in 35% of OSAS patients with multilevel ob- 20 and hypersomnia, and consequently were classified struction. Patients in the successful group reported elimi- in the failure group. Furthermore, if our definition of nation of snoring and were free of daytime symptoms. success had included a 50% reduction in the AHI,4 Treatment success predictors were AHI, oxyhemo- then the success rate of our study would have increased globin saturation, sleep architecture, and the ANB angle. to 40%. The highest treatment effect was obtained in patients with Fourth, we found a postoperative reduction in the mild to moderate AHI, no significant desaturations, no number of apneas at the expense of an increase in the sleep disruption, and slight mandibular deficiency. number of hypopneas. This finding was also observed by

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Table 3. Change in Posterior Airway Space (PAS) After Surgery*

PAS Patient No. Type of Surgery Presurgery Postsurgery % Change Result 1 UPPP+HA+GA 16 17 6.25 Improved 2 UPPP+HA+GA 6 11 83.3 Improved 3 UPPP+HA+GA 7 16 128.6 Improved 4 UPPP+HA 11 20 81.8 Improved 5 UPPP+HA+GA 16 10 −37.5 Not improved 6 UPPP+HA+GA 15 12 −20 Not improved 7 UPPP+HA+GA 9 16 77.7 Improved 8 UPPP+HA+GA 8 10 25 Improved 9 UPPP+HA+GA 13 7 −46.2 Not improved 10 UPPP+HA+GA 15 13 −13.3 Not improved 11 UPPP+HA+GA 8 8 0 Not improved 12 UPPP+HA+GA 13 11 −15.4 Not improved 13 UPPP+HA 10 13 30 Improved 14 UPPP+HA 10 13 30 Improved 15 UPPP+HA 20 21 5 Improved 16 UPPP+HA 10 12 20 Improved 17 UPPP+HA 10 14 40 Improved 18 UPPP+HA 12 14 16.7 Improved 19 UPPP+HA 5 7 40 Improved 20 UPPP+HA 4 10 150 Improved

*UPPP indicates uvulopalatopharyngoplasty; HA, hyoid advancement; and GA, mandibular osteotomy with genioglossus advancement.

Bettega et al.8 Because the definition criteria for a hypop- nea and the methods used to register the oral and nasal Table 4. Preoperative Comparison of Key Patient Parameters Between Success and Failure Groups airflow may differ depending on the sleep laboratory,21 a meticulous measurement of respiratory events is nec- P Value essary to avoid underestimation of residual hypopneas Success Failure (Mann-Whitney after surgery. Measured Parameter (n=7) (n = 13) Test) Finally, our surgical protocol differed slightly from BMI, kg/m2 26.5 ± 2.2 28.5 ± 3.7 .23 (NS) 3 that of previous studies, and the procedures were not the Neck circumference, cm 40.4 ± 0.9 41.1 ± 2.5 .09 (NS) same for all the patients in our series. For example, we per- ESS 15.0 ± 6.0 10.4 ± 5.3 .08 (NS) formed hyothyropexia instead of hyoid suspension, and Total sleep time, min 304.1 ± 46.4 308.3 ± 77.1 .55 (NS) genioglossus advancement was only performed in 11 pa- SE, % 86.1 ± 6.9 88.4 ± 4.3 NS tients (55%). However, our cephalometric analysis showed Stage 1, % 9.7 ± 7.8 5.6 ± 3.1 .35 (NS) Stage 2, % 63.7 ± 6.4 75.9 ± 5.6 .01 significant differences (as have previous publica- Stage 3-4, % 9.5 ± 4.3 4.6 ± 5.6 .04 4,9,10 tions ) in most of the parameters between preopera- Stage REM, % 17.5 ± 3.4 15.0 ± 5.6 .27 (NS) tive and postoperative studies, suggesting a significant effect AHI 46.4 ± 12.5 68.0 ± 13.3 .006 of our surgical protocol in the anatomic structures respon- CT90, % 23.7 ± 9.3 48.1 ± 28.3 .03 sible for the obstruction during sleep. Six of the 7 pa- LOS, % 70.8 ± 5.4 66.9 ± 11.9 .52 (NS) tients in the successful group showed an increase in PAS. PNS-P, mm 52.0 ± 2.1 50.0 ± 5.8 .31 (NS) Furthermore, postoperative changes in AHI were signifi- G, mm 12.1 ± 1.7 11.6 ± 2.2 .59 (NS) PAS, mm 12.0 ± 4.0 10.3 ± 4.3 .48 (NS) cantly correlated with postoperative changes in ANB and SNB, degrees 77.8 ± 2.5 76.0 ± 4.3 .31 (NS) SNB angles. However, while all patients with isolated hy- ANB, degrees −0.4 ± 2.9 2.6 ± 2.2 .01 oid advancement experienced increased PAS, 6 (55%) of MP-H, mm 37.8 ± 10.3 33.9 ± 9.5 .60 (NS) 11 patients with genioglossus plus hyoid advancement did not, suggesting that the combination of genioglossus and *Unless otherwise indicated, data are mean ± SD. BMI indicates body mass index; ESS, Epworth Sleepiness Scale; SE, sleep efficiency; REM, rapid eye hyoid advancement may not always reduce the hypopha- movement; AHI, apnea-hypopnea index; CT90, percentage of time with ryngeal obstruction (Table 3). oxyhemoglobin saturation below 90%; LOS, lowest oxygen saturation; PNS-P, In all of our patients, clinical examination, fiberop- distance from the posterior nasal spine to the tip of the soft palate (length of tic nasopharyngoscopy, cephalometry, and upper air- soft palate); G, palate thickness; PAS, posterior airway space (distance between the base of the tongue and the dorsal pharyngeal wall); SNB, angle of mandible way manometry during sleep disclosed preoperative to cranial base (position of the mandible); ANB, angle formed from the deepest obstruction in both the soft palate and the base of the point on the maxillary outer contour to the nasion to the deepest point on the tongue. Since all patients were symptomatic and re- outer mandibular contour; MP-H, distance from inferior mandible plane to hyoid jected CPAP, the multilevel surgery approach was pro- bone (position of the hyoid bone); and NS, not significant. posed and accepted. The procedure was designed to re- move the obstruction in the oropharynx by UPPP and hyoid advancement. After 6 months of follow-up, 66% increase the size of the airway at the hypopharnyx by man- of patients with preoperative mild to moderate sleep ap- dibular osteotomy with genioglossus advancement and nea (mean AHI, 46) had successful outcome, while most

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©2002 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 subjects with severe sleep apnea (mean AHI, 68) were 5. Johnson NT, Chinn J. Uvulopalatopharyngoplasty and inferior sagittal mandibu- still symptomatic and had an AHI higher than 20, con- lar osteotomy with genioglossus advancement for treatment of . Chest. 1994;105:278-283. tinued desaturations, altered sleep architecture, and rem- 6. Le´vy J, Laxenaire A, Blanchard P, Lerondeau JC, Tesiner F, Scheffer P. The sur- nant oropharyngeal and hypopharyngeal obstruction dem- gical management of obstructive sleep apnea syndromes: preliminary phase I onstrated by endoscopy and upper airway manometry results (the Stanford technique) in a series of 26 patients. Rev Stomatol Chir Max- recording during sleep. illofac. 1997;98:19-25. 7. Lee NR, Givens CD Jr, Wilson J, Robins RB. Staged surgical treatment of ob- Our study shows the importance of routine postop- structive sleep apnea syndrome: a review of 35 patients. J Oral Maxillofac Surg. erative PSG studies and clinical follow-up. The finding that 1999;57:382-385. only OSAS severity predicted the surgical outcome in our 8. Bettega G, Pe´pin JL, Veale D, Deschaux C, Raphae¨lB,Le´vy P. Obstructive sleep study suggests that genioglossal and hyoid advancement apnea syndrome: fifty-one consecutive patients treated by maxillofacial sur- cannot be recomended on the basis of cephalometrics alone. gery. Am J Respir Crit Care Med. 2000;162:641-649. 9. Ramirez S, Loube DI. Inferior sagittal osteotomy with hyoid bone suspension Patients for whom phase 1 failed were still symptomatic, for obese patients with sleep apnea. Arch Otolaryngol Head Neck Surg. 1996; had a significant number of apneas, retained multilevel 122:953-957. obstruction, and consequently required additional treat- 10. Yao M, Utley DS, Terris DJ. Cephalometric parameters after multilevel pharyn- ment. Therapeutic alternatives in these patients may be bi- geal surgery for patients with obstructive sleep apnea. Laryngoscope. 1998;108: maxillary advancement22,23 and another nasal CPAP at- 789-795. 11. Johns MW. A new method for measuring daytime sleepiness: the Epworth Sleepi- tempt. In conclusion, although limited by the small number ness Scale. Sleep. 1991;14:540-545. of patients, our study suggests that after UPPP, only pa- 12. Petri N, Suadicani P, Wildschiodt G, Bjorn-Jorgensen J. Predictive value of Mu¨ller tients with mild to moderate OSAS with oropharyngeal and maneuver, cephalometry and clinical features for the outcome of uvulopalato- hypopharyngeal obstruction may benefit from a multi- pharyngoplasty. Acta Otolaryngol. 1994;114:565-571. 13. Jamieson A, Guilleminault C, Partinen M, Quera-Salva MA. Obstructive sleep level reconstruction phase 1 surgical approach. apnea patients have craniomandibular abnormalities. Sleep. 1986;9:469-477. Accepted for publication September 14, 2001. 14. Riley RW, Guilleminault C, Herran J, et al. Cephalometric analyses and flow- volume loops in obstructive sleep apnea patients. Sleep. 1983;6:303-311. This work was supported by grant FISS 94/0434 15. de Barry-Borowiecki B, Kukwa A, Blanks R. Cephalometric analysis for diagnosis from the Fondo de Investigaciones Sanitarias, Madrid, Spain and treatment of obstructive sleep apnea. Laryngoscope. 1998;98:226-234. (Dr Morello´). 16. Riley RW, Guilleminault C, Powell NB, Simmons SB. Palatopharyngoplasty fail- Corresponding author and reprints: Isabel Vilaseca, ure, cephalometric roentgenograms, and obstructive sleep apnea. Otolaryngol Head Neck Surg. 1985;93:240-244. MD, Otorhinolaryngology Service, Hospital Clı´nic de Bar- 17. Hochban W, Conradt R, Brandenburg U, Heitmann J, Peter JH. Surgical maxillofa- celona, C/ Villarroel 170, Barcelona 08036, Spain (e-mail: cial treatment of obstructive sleep apnea. 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