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How should the diagnosis be established and the treatment?
¿Cuál sería su planteamiento diagnóstico y su tratamiento?

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Thirty-three year-old male patient, smoker of 20 cigarettes a day with mild alcohol use, was referred to our Unit from the Neurophysiology Unit of our center in order to evaluate a surgical option for an obstructive sleep apnea syndrome. The disorder was classified as severe following a polysomnography, with an Apnea-Hypopnea index of 62.4 and a total of 420 episodes of apnea or hypopnea during sleep.

The patient's [medical] history was remarkable for tonsillectomy at the age of 8. He presented a mild Class II skeletal [pattern] and severe periodontal disease (Fig. 1) with considerable lack oral hygiene.

The patient was under CPAP and he requested an appointment in order to evaluate a surgical option as a result his a low tolerance, and his partner's, of the CPAP [machine].

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Genioglossus advancement in the treatment of Obstructive Sleep Apnea Syndrome
Avance geniogloso en el tratamiento del síndrome de apnea obstructiva del sueño

 

J. Mareque Bueno¹, X. Martínez Fuster¹, J. González Lagunas², C. Bassas³,G. Raspall Martín⁴

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1 Médico residente.
2 Médico adjunto.
3 Jefe clínico.
4 Jefe de servicio.
Hospital Vall d´Hebrón. Barcelona, España

Correspondencia:
Dr. Javier Mareque Bueno
Hospital Vall d'Hebrón,
Pg. Vall d´Hebrón 119
08035 Barcelona, España
E-mail 36984jmb@comb.es

 

The Obstructive Sleep Apnea Syndrome (OSAS) is due to pharyngeal narrowing and to the repeated collapse of the airway during sleep.¹ It is associated with other symptoms and signs such as snoring, episodes of apnea/hypopnea, sleep fragmentation, daytime drowsiness, cognitive impairment and arterial hypertension. An estimated 2-4% of the general adult population is affected in the industrialized world and it is particularly frequent in middle-aged males, with more than 60% being obese.

The are a series of predisposition factors such as obstruction of the airways (nasal cavity, oro/nasal/hypopharynx, larynx), maxillofacial malformations (micro or retrognathia, Pierre-Robin Syndrome, Klippel-Feil syndrome, Prader-Willi syndrome), general medical disorders (obesity, hypothyroidism, amyloidosis) or the nocturnal intake of alcohol.

Some of the muscles involved in the control of airway diameters are attached to the maxillary bones. As a result, certain facial deformities can be associated with airway compromise. These can be corrected surgically by means of conventional orthognathic surgery techniques that can lead to considerable clinical improvement.

The genioglossus muscle acts as a dilator of the pharynx, and this means that it plays an important role in OSAS.² In 1984, Riley³ was the first to propose the horizontal sliding of the genioglossus muscle, suggesting that on tensing it the extent to which the tongue collapsed on the airway would be reduced during sleep hypotonia.

The diagnostic protocol in our unit included, apart from a general clinical examination and a polysomnography (PSG), the following parameters:

Facial analysis: (Fig. 2) [all] thirds in proportion with no asymmetries, mandibular retrusion, accentuated mentolabial groove, obtuse neck-chin angle.

Dental analysis: many missing [teeth] (18,15,28,38, 37,36,47), severe periodontal disease, periapical image of the mesial root of nº 46.

Cephalometric analysis: (Fig. 1) (Table 1) Mild class II skeletal [pattern].

Treatment protocol

The treatment options currently available for (OSAS) are multiple. The decision as to how to treat a patient with OSAS, once confirmed and evaluated by means of a PSG, depends on 4 fundamental points: clinical severity, PSG, complications and etiology of the obstruction. The following therapeutic measurements are available:

Medical: CPAP, weight loss, dental orthopedics, posture treatment, pharmacology therapy, hygiene measures.

Surgical: Tracheostomy, septoplasty, uvulopalatopharyngoplasty (UPPP), facial osteotomies.

CPAP is the treatment of choice but its low acceptance among younger patients can lead to compliance complications, and this can lead to other treatments being requested.

Tracheostomies have good results in most of the polysomnography indexes, but they are unacceptable due to the high complication rate. A UPPP is indicated for nasopharyngeal problems⁴ but the results are poor if used as a universal technique. ⁵

Facial osteotomies are indicated for patients with a clear abnormality that can be corrected. But they can also be indicated in patients if conservative treatment has failed, or in patients requiring a rapid solution, with osteotomies being an alternative.

With OSAS, the surgical objective is to reduce the resistance of the upper airway increasing its diameter and eliminating the anatomical defects that block the flow of air. The election of the candidates and surgical procedure has to be based on the topographic diagnosis of the upper airway obstruction. Fujita⁶ described the different levels of airway obstruction:

• Type I or upper: soft palate.
• Type II upper or lower: soft palate and base of tongue.
• Type III lower: base of tongue.

The current protocols regarding surgical procedures for patients with associated facial deformities follow sequential guidelines⁷ according to the location of the defect and the response to the initial treatment.⁸ We have adapted these guidelines and suggest the following protocol:

• Type I patients with bimaxillary hypoplasia: bimaxillary advancement.
• Type II patients with mandibular hypoplasia:

- If orthodontic treatment is accepted: Mandibular advancement
- If orthodontic treatment is not acceptable.
- No aesthetic commitment. Geniohyoid advancement by means of anterior mandibular osteotomy.
- Aesthetic compromise. Mentoplasty.

Treatment applied

The patient presented was a CPAP user and he requested an appointment in order to evaluate surgery as an option given his low tolerance of the CPAP [machine] and his partner's. Following an evaluation of the case, a mandibular advancement by means of a sagittal ramus osteotomy was proposed to him as a first option. In view of the need for periodontal treatment beforehand and of the essential orthodontic preparation, the patient rejected this option, and an anterior mandibular osteotomy was then suggested as an alternative.

Given the patient's profile of the lower third, and his rejection of a modification of his facial profile, a mentoplasty as an alternative technique was ruled out.

An anterior mandibular osteotomy was carried out, and the genioglossus muscles were advanced.

Surgical technique

Under general anesthesia an buccal sulcus incision was made from canine to canine with two vertical releasing incisions. An osteotomy was made of the vestibular cortex at least 5 mm away from the apices of the incisors and leaving 10 mm to the base of the mandible.⁹ The limit at the sides should not extend beyond the center of the canine in order to avoid its long root (Fig. 3). Before completing the osteotomy as far as the lingual cortex, a titanium screw is placed in the external cortex in order to be able to control and manipulate the tubercle fragment. The osteotomy is then completed, and the fragment that is [now] free is rotated 90º (Fig. 4) so that it remains anchored in front of the external cortex of the mandibular symphysis. This technique does not require rigid fixation, and the titanium screw is removed (Fig. 5). The more prominent areas of the external cortex are eliminated in order to avoid decubitus [lesions], and the wound is then sutured so that no blood is lost.

Results

During the immediate postoperative period, the patient and his partner noted a considerable improvement in quality of sleep, and reduced snoring.

Six months after the surgery a PSG was performed, that showed an improvement in the principal values of the parameters studied, as can be seen in Table 2. This had gone from a severe OSAS to a moderate OSAS, and the risk of an associated medical pathology, as carries a severe OSAS, had as a result been reduced.

Conclusions

The anterior mandibular osteotomy is a simple technique. The approach is intraoral and there are no external scars. The operating time is short (less than 60 minutes), the average [hospital] stay is short and technical morbidity is low.

Given its characteristics, this technique should be included in the management protocol for patients presenting obstructive sleep apnea syndrome that have to be treated with facial osteotomies.

References

1. Remmers JE, Degroot WJ, Sauerland EK, et al. Pathogensis of upper airway occlusion during sleep. J Appl Physiol 1978;44:931-5.        [ Links ]

2. Okabe S, Hida W, Kikuchi Y, y cols. Upper airway muscle activity during REM and non- Rem sleep of patients with obstructive sleep apnea. Chest 1994;106:767-1.        [ Links ]

3. Riley R, Guilleminault C, Powell N, y cols. Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: A case report. Sleep 1984;7:79-84.        [ Links ]

4. Johnson NT, Chin J. Uvulopalatopharyngoplasty and inferior sagittal mandibular osteotomy with genioglossus advancement for the treatment obstructive sleep apnea. Chest 1994;105:278-83.        [ Links ]

5. Miller FR, Watson D, Boseley M. The role of the Genial Bone Advancement Trephine system in conjunction with uvulopalatopharyngoplasty in the multilevel management of obstructive sleep apnea. Otolaryngol- Head Neck Surg 2004;130-3.        [ Links ]

6. Fujita W, Conway W, Zorick F, y cols. Surgical correction of anatomic abnormalities of obstructive sleep apnea syndrome: Uvulopalatoparingoplasty. Otolaryngol-Head Neck Surg 1981;89:923-6.        [ Links ]

7. Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: A review of 306 consecutively treated surgical patients. Otolaryngol Head Neck Surg 1993;108:117-21.        [ Links ]

8. Tiner BD. Surgical management of obstructive sleep apnea. J Oral Maxillofac Surg 1996;54:1109-14.        [ Links ]

9. Kasey K, Li, Riley RW. Obstructive sleep apnea surgery: Genioglossus advancement revisited. J Oral Maxillofac Surg 2001;59:1181-4.        [ Links ]