Surgery to Correct Obstruction of the Lower Throat
Many individuals with OSA and snoring have narrowing of the airway in the lower throat that contributes to blockage during sleep. The cause of this blockage often varies, so multiple procedures have been developed to correct or reduce the blockage. Selecting the best procedure for any patient is based on many factors. No single procedure is best for all. The following procedures modify tissues of the lower pharynx when the involved tissues are obstructive or abnormal.
Mandibular (Lower Jaw) Advancement
This procedure moves the bone, soft tissue and muscles of the jaw forward to enlarge the airway. The amount of advancement may be limited by the natural position of the teeth. People with a backward positioning of the teeth and jaw may benefit from lower jaw advancement alone.
Bimaxillary (Upper and Lower Jaw) Advancement
This procedure is done for people with significant jaw deficiency, morbid obesity, and those with obstructive sleep apnea who have failed more conservative treatments. The procedure involves cutting the bones of the upper and lower jaws and lengthening them a small amount. The tongue and the palate are pulled forward, enlarging the airway. The surgery also enlarges the mouth to provide more room for the tongue. Both jaws are advanced together, retaining the person’s bite. The surgery is performed through incisions inside the mouth.
Limited Mandibular Osteotomy (Cutting the Jaw Bone) and Genioglossus Advancement
Genioglossus advancement detaches the tongue muscle from the back of the mandible (jaw bone) and moves it to the front. Moving this attachment pulls the tongue forward and enlarges the airway. To do this, the primary tongue muscle that controls the size of the lower airway (genioglossus muscle) and a small piece of attached bone are moved. The procedure has the advantage over other mandible surgeries in that it does not surgically move the teeth and does not require braces or orthodontic procedures.
An alternative to mandibular advancement procedures, that does not require osteotomies or skeletal adjustments, is to perform tongue suspension. These procedures use an implantable device to help support the tongue and prevent collapse during sleep. Several different devices are used to perform the procedure. For most patients, a successful result requires that tongue suspension be performed in conjunction with other procedures.
The hyoid bone is a small C-shaped bone in the upper neck above the Adam’s apple cartilage. Many muscles of the tongue and throat attach to the hyoid. Hyoid myotomy and suspension is a procedure to move this bone to increase the size of the lower airway. In the procedure, a small portion of the middle of the hyoid bone is exposed in the neck. To do this, two small bone anchored screws are placed in the back of the chin and several “tethers” are passed around the hyoid bone which is then pulled forward toward the lower jaw. This procedure may be done under local anesthesia as day surgery or may be combined with other surgeries.
Enlargement of the lingual tonsils (at the base of the tongue) is a common contributor to airway obstruction in OSA. Removing lingual tonsils was markedly improved with the application of plasma surgical technology and endoscopic minimally invasive techniques. Many of these procedures were pioneered at the Froedtert & the Medical College of Wisconsin's Sleep Disorders Program.
Midline glossectomy (MLG)
For many individuals, the back of the tongue is too large for the airway. For some this may be due to large lingual tonsils, and excessively small lower jaw, increased fat, or other causes. For some patients reducing the size of the tongue increases the size of the lower throat (pharyngeal) airway.
In the 1990s, these procedures were done with traditional surgical tools or lasers. These resulted in excessive pain and recovery for many patients. Newer plasma and radiofrequency surgical tools provide less damaging methods to reduce the size of the tongue and to increase the airway size with lower side effects, improved healing and faster recovery. For some patients, these procedures can be done as outpatient or office-based procedures.
Historically, tracheotomy was the only treatment for severe, life-threatening sleep apnea and breathing failure at night. Now, because of modern medical and surgical alternatives, it is rarely required.
A tracheotomy is a surgical “hole” from the skin of the neck to the windpipe below the voice box. A tracheotomy is done for people with severe obstructive sleep apnea and those who are not candidates for other therapies. Because the hole bypasses the throat, blockage does not occur during sleep. Tracheotomy is very successful in the treatment of apnea and its complications. Since the upper airway is open during wakefulness, after healing, the tracheotomy hole may be closed except during sleep.
Despite the benefits of tracheotomy, the psychosocial implications, risks of infection and other potential complications may make it unacceptable for many patients. In patients who accept a tracheotomy, there is a reduction in the incidents and mortality associated with sleep apnea.
In rare or unusual situations, other tissues cause airway blockage in sleep apnea and snoring. For these, the surgeon may need to modify tissues surrounding the voicebox to successfully treat obstructive sleep apnea.