Table Of ContentKarl Hörmann
Thomas Verse
Surgery
for Sleep-Disordered Breathing
Karl Hörmann
Thomas Verse
Surgery for
Sleep-Disordered
Breathing
With 92 Figures,Mostly in Colour,
and 32 Tables
123
Karl Hörmann,Prof.Dr.
Thomas Verse,Dr.
University Hospital Mannheim
Department ofOtorhinolaryngology,
Head and Neck Surgery
Theodor-Kutzer-Ufer 1-3
68167 Mannheim,Germany
ISBN-10 3-540-21951-X
Springer Berlin Heidelberg New York
ISBN-13 978-3-540-21951-4
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Preface
Sleep disordered breathing (SDB) is ofgrow- servative and apparative treatment modali-
ing interest. To address the importance to ties.
the public health,it has been shown in 1993 Referring to the present literature ofsleep
that 9% of middle-aged women and 24% of medicine especially concerning surgical pro-
middle-aged men suffer from SDB with con- cedures, we tried to summarize the recent
secutive cardiovascular disorders. It is sug- knowledge in this field.We want to give gen-
gested that the prevalence of undiagnosed eral advice as well as specific hints for the sur-
SDB is much higher. Among these patients gical treatment ofsleep disordered breathing.
the obstructive sleep apnea syndrome On the following pages we present standard
(OSAS) plays the most important subgroup surgical procedures as well as special con-
with cessations of breathing during sleep cepts concerning sleep surgery.In considera-
(apnea) and symptoms like snoring,daytime tion to our own clinical experience of more
sleepiness and hypersomnolence with loss than 15 years this book gives advices in indi-
in concentration. Nasal continuous positive cations and contraindications of each surgi-
airway pressure (nCPAP) ventilation is the cal procedure and explains the postoperative
gold standard in the treatment ofobstructive care.We hope,that this book will become a
sleep apnea (OSA). Unfortunately nCPAP helpful guidebook for all surgeons with spe-
ventilation does not exceed long-term com- cial interest in modern sleep medicine.
pliance rates of much more than 60 percent.
To address these patients several alternatives Mannheim,February 2005
exist.Beyond conservative therapies various
surgical concepts become more important.
For more than 15 years now,we give special
intent to the field of surgery in sleep medi- Acknowledgments
cine. Our sleep laboratory by now encom- We thank Mr.Gregor Bran for his help with the
passes 20 cardiorespiratory polysomnogra- figures in this book.
phies each night.Per year we perform almost
1000 surgical procedures for sleep disordered Karl Hörmann,Prof.Dr.
breathing apart from numerous other con- Thomas Verse,Dr.
Contents
Chapter 1 Chapter 6
Sleep-Disordered Breathing . . . . . . . . . . 1 Palatal Surgery. . . . . . . . . . . . . . . . . . . . . . 21
6.1 Tonsils . . . . . . . . . . . . . . . . . . . . . . . 21
Chapter 2 6.1.1 Tonsillectomy and Tonsillotomy 21
General Aspects ofTherapy . . . . . . . . . . . 3 6.1.1.1 Children . . . . . . . . . . . . . . . . . . . . . 21
6.1.1.2 Adults . . . . . . . . . . . . . . . . . . . . . . . 25
Chapter 3 6.1.2 Radiofrequency Surgery
Identifying the Site ofObstruction . . . . 9 ofthe Tonsils . . . . . . . . . . . . . . . . . 26
3.1 Pressure Measurements . . . . . . . . 9 6.1.2.1 Principle ofInterstitial
3.2 Flexible Endoscopy . . . . . . . . . . . . 10 Radiofrequency Surgery. . . . . . . . 26
3.3 Analysis ofthe Respiratory 6.1.2.2 Surgical Technique . . . . . . . . . . . . 28
Sounds During Sleep. . . . . . . . . . . 10 6.1.2.3 Effectiveness for SDB . . . . . . . . . . 29
3.4 Further Imaging Procedures . . . . 10 6.1.2.4 Postoperative Care
and Complications . . . . . . . . . . . . 29
Chapter 4 6.1.2.5 Indications
Nasal Surgery . . . . . . . . . . . . . . . . . . . . . . . 00 and Contraindications . . . . . . . . . 29
4.1 Effectiveness ofTreatment. . . . . . 13 6.2 Uvulopalatopharyngoplasty . . . . 30
4.1.1 Effectiveness 6.2.1 Surgical Technique . . . . . . . . . . . . 30
for Simple Snoring. . . . . . . . . . . . . 13 6.2.2 Effectiveness
4.1.2 Effectiveness for Simple Snoring . . . . . . . . . . . . 34
for Obstructive Sleep Apnea . . . . 14 6.2.2.1 Comparison ofDifferent Soft
4.2 Postoperative Care Palate Surgical Techniques. . . . . . 34
and Complications. . . . . . . . . . . . . 15 6.2.3 Effectiveness for OSA . . . . . . . . . . 35
4.3 Indications 6.2.4 Postoperative Care
and Contraindications . . . . . . . . . 16 and Complications . . . . . . . . . . . . 36
4.4 Impact ofNasal Surgery 6.2.5 Indications
on Nasal CPAP Treatment . . . . . . 16 and Contraindications . . . . . . . . . 40
4.5 Conclusion . . . . . . . . . . . . . . . . . . . 17 6.3 Uvulopalatal Flap. . . . . . . . . . . . . . 41
6.3.1 Surgical Technique . . . . . . . . . . . . 41
Chapter 5 6.3.2 Effectiveness for SDB . . . . . . . . . . 43
Nasopharyngeal Surgery . . . . . . . . . . . . . 00 6.3.3 Postoperative Care
5.1 Effectiveness ofTreatment. . . . . . 19 and Complications . . . . . . . . . . . . 44
5.1.1 Corticosteroids. . . . . . . . . . . . . . . . 19 6.3.4 Indications
5.1.2 Nasopharyngeal Tubes . . . . . . . . . 19 and Contraindications. . . . . . . . . . 45
5.1.3 Surgical Treatment . . . . . . . . . . . . 20 6.4 Laser-Assisted
5.2 Postoperative Care Uvulopalatoplasty . . . . . . . . . . . . . 46
and Complications. . . . . . . . . . . . . 20 6.4.1 Surgical Techniques. . . . . . . . . . . . 46
5.3 Indications 6.4.2 Effectiveness
and Contraindications . . . . . . . . . 20 for Simple Snoring. . . . . . . . . . . . . 50
6.4.2.1 Laser Uvulopalatoplasty. . . . . . . . 51
VIII Contents
6.4.2.2 Mucosal Strip Technique . . . . . . . 51 7.2.3 Ongoing Modification
6.4.2.3 Laser-Assisted by Hörmann. . . . . . . . . . . . . . . . . . 78
Uvulopalatoplasty . . . . . . . . . . . . . 52 7.2.4 Effectiveness
6.4.3 Effectiveness for OSA . . . . . . . . . . 52 for Sleep-Disordered Breathing. . 81
6.4.4 Postoperative Care 7.2.5 Postoperative Care
and Complications . . . . . . . . . . . . 54 and Complications . . . . . . . . . . . . 81
6.4.4.1 Pain . . . . . . . . . . . . . . . . . . . . . . . . . 56 7.2.6 Indications
6.4.5 Indications and Contraindications . . . . . . . . . 82
and Contraindications . . . . . . . . . 56 7.3 Tongue Base Reduction . . . . . . . . 82
6.5 Radiofrequency Surgery 7.3.1 Surgical Technique . . . . . . . . . . . . 83
ofthe Soft Palate . . . . . . . . . . . . . . 57 7.3.2 Effectiveness for OSA . . . . . . . . . . 85
6.5.1 Surgical Technique . . . . . . . . . . . . 58 7.3.3 Postoperative Care
6.5.2 Effectiveness and Complications . . . . . . . . . . . . 86
for Simple Snoring . . . . . . . . . . . . 59 7.3.4 Indications
6.5.3 Effectiveness for OSA . . . . . . . . . . 61 and Contraindications . . . . . . . . . 86
6.5.4 Postoperative Care 7.4 Tongue Suspension . . . . . . . . . . . . 87
and Complications . . . . . . . . . . . . 62 7.4.1 Surgical Technique . . . . . . . . . . . . 87
6.5.5 Indications 7.4.2 Effectiveness
and Contraindications . . . . . . . . . 62 for Simple Snoring . . . . . . . . . . . . 88
6.6 Palatal Implants. . . . . . . . . . . . . . . 63 7.4.3 Effectiveness for OSA . . . . . . . . . . 88
6.6.1 Surgical Technique . . . . . . . . . . . . 63 7.4.4 Postoperative Care
6.6.2 Effectiveness and Complications . . . . . . . . . . . . 89
for Simple Snoring . . . . . . . . . . . . 65 7.4.5 Indications
6.6.3 Postoperative Care and Contraindications . . . . . . . . . 89
and Complications . . . . . . . . . . . . 65
6.6.4 Indications Chapter 8
and Contraindications . . . . . . . . . 65 Maxillofacial Surgeries . . . . . . . . . . . . . . . 00
6.7 Other Soft Palate Procedures. . . . 66 8.1 Genioglossus Advancement. . . . . 91
6.7.1 Uvulectomy . . . . . . . . . . . . . . . . . . 66 8.1.1 Surgical Technique . . . . . . . . . . . . 91
6.7.2 Palatal Stiffening Operation. . . . . 66 8.1.2 Effectiveness for OSA . . . . . . . . . . 92
6.7.3 Injection Snoreplasty . . . . . . . . . . 68 8.1.3 Postoperative Care
6.7.4 Transpalatal and Complications . . . . . . . . . . . . 93
Advancement Pharyngoplasty. . . 69 8.1.4 Indications
and Contraindications . . . . . . . . . 93
Chapter 7 8.2 Maxillomandibular
Lower Pharyngeal Airway Procedures . . 00 Advancement . . . . . . . . . . . . . . . . . 94
7.1 Radiofrequency Surgery 8.2.1 Surgical Technique . . . . . . . . . . . . 94
ofthe Base ofTongue . . . . . . . . . . 71 8.2.1.1 Surgery on the Upper Jaw. . . . . . . 94
7.1.1 Surgical Technique . . . . . . . . . . . . 71 8.2.1.2 Surgery on the Lower Jaw. . . . . . . 95
7.1.2 Effectiveness 8.2.2 Effectiveness
for Simple Snoring . . . . . . . . . . . . 73 ofMaxillomandibular
7.1.3 Effectiveness for OSA . . . . . . . . . . 73 Advancement for OSA . . . . . . . . . 96
7.1.4 Postoperative Care 8.2.3 Postoperative Care
and Complications . . . . . . . . . . . . 75 and Complications . . . . . . . . . . . . 97
7.1.5 Indications 8.2.4 Indications
and Contraindications . . . . . . . . . 76 and Contraindications . . . . . . . . . 98
7.2 Hyoid Suspension . . . . . . . . . . . . . 77 8.3 Distraction Osteogenesis . . . . . . . 99
7.2.1 Original Surgical Technique 8.3.1 Mandibular
(1986). . . . . . . . . . . . . . . . . . . . . . . . 77 Distraction Osteogenesis . . . . . . . 99
7.2.2 First Modification (1994) . . . . . . . 78 8.3.1.1 Surgical Technique . . . . . . . . . . . . 100
Contents IX
8.3.2 Maxillary-Midfacial 10.3 Indications
Distraction Osteogenesis . . . . . . . 100 and Contraindications . . . . . . . . . 120
8.3.2.1 Surgical Technique . . . . . . . . . . . . 101 10.4 Multi-Level Surgery
8.3.3 Efficiency ofDistraction in Children . . . . . . . . . . . . . . . . . . . 121
Osteogenesis for OSA . . . . . . . . . . 102
8.3.4 Complications Chapter 11
and Postoperative Care. . . . . . . . . 105 Tracheotomy. . . . . . . . . . . . . . . . . . . . . . . . 00
8.3.5 Indications 11.1 Surgical Technique . . . . . . . . . . . . 123
and Contraindications . . . . . . . . . 105 11.2 Effectiveness for OSA . . . . . . . . . . 123
11.3 Postoperative Care
Chapter 9 and Complications . . . . . . . . . . . . 124
Laryngeal Obstructive Sleep Apnea . . . . 00 11.4 Indications
9.1 Pediatric Laryngeal OSA . . . . . . . 107 and Contraindications . . . . . . . . . 125
9.1.1 Surgical Techniques. . . . . . . . . . . . 108
9.1.2 Effectiveness Chapter 12
for Sleep-Disordered Breathing. . 110 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . 00
9.1.3 Postoperative Care 12.1 Effectiveness for OSA . . . . . . . . . . 127
and Complications . . . . . . . . . . . . 110 12.2 Postoperative Care
9.1.4 Indications and Complications . . . . . . . . . . . . 128
and Contraindications . . . . . . . . . 111 12.3 Indications
9.2 Adult Laryngeal OSA . . . . . . . . . . 111 and Contraindications . . . . . . . . . 129
9.2.1 Surgical Techniques . . . . . . . . . . . 112
9.2.2 Effectiveness Chapter 13
for Sleep-Disordered Breathing. . 113 Anesthesiologic Airway Management . . 00
9.2.3 Postoperative Care 13.1 Implications in Patients
and Complications . . . . . . . . . . . . 113 with OSA. . . . . . . . . . . . . . . . . . . . . 131
9.2.4 Indications 13.2 Strategies for Intubation
and Contraindications . . . . . . . . . 113 in Patients with a Known
or Suspected Difficult Airway . . . 132
Chapter 10 13.3 Life-Threatening Situations . . . . . 134
Multi-Level-Surgery . . . . . . . . . . . . . . . . . 00 13.4 Extubating
10.1 Surgical Concepts . . . . . . . . . . . . . 115 the Difficult Airway. . . . . . . . . . . . 134
10.1.1 Effectiveness ofMinimally 13.5 Postoperative Care. . . . . . . . . . . . . 135
Invasive Multi-Level Surgery 13.6 Documentation . . . . . . . . . . . . . . . 135
for Mild to Moderate OSA . . . . . . 115
10.1.2 Effectiveness References . . . . . . . . . . . . . . . . . . . . . . . . . . 137
ofMulti-Level Surgery
for Moderate to Severe OSA. . . . . 116 Subject Index . . . . . . . . . . . . . . . . . . . . . . . 159
10.2 Postoperative Care
and Complications . . . . . . . . . . . . 119
Contributors
Karl Hörmann,M.D. Joachim T.Maurer,M.D.
Professor,Head ofthe Department Head ofSleep Disorders Center
ofOtorhinolaryngology, Department ofOtorhinolaryngology,
Head and Neck Surgery Head and Neck Surgery
University Hospital Mannheim,Germany University Hospital Mannheim,Germany
Thomas Verse,M.D. Wolfgang Pirsig,M.D.
Associate Professor Professor,Department
Department ofOtorhinolaryngology, ofOtorhinolaryngology,
Head and Neck Surgery Head and Neck Surgery
University Hospital Mannheim,Germany University ofUlm,Germany
Joachim Schmeck,M.D.
With Contributions from Associate Professor
Department ofAnesthesiology
Harald V.Genzwuerker,M.D. and Operative Intensive Care Medicine
Department ofAnesthesiology University Hospital Mannheim,Germany
and Operative Intensive Care Medicine
University Hospital Mannheim,Germany Boris A.Stuck,M.D.
Associate Professor
Thomas Hierl,M.D.,D.D.S. Department ofOtorhinolaryngology,
Associate Professor,Department Head and Neck Surgery
ofOral and Maxillofacial Plastic Surgery University Hospital Mannheim,Germany
University ofLeipzig,Germany
Abbreviations
ACP Antral choanal polyp MLP Midline partial glossectomy
AHI Apnea hypopnea index.Number MLS Multi-level surgery
ofapneas and hypopneas that MMA Maxillomandibular advancement
occur per hour ofsleep MO Mandibular osteotomy with
AI Apnea index.The number of genioglossus advancement
apneas that occur per hour ofsleep MRI Magnet resonance imaging
ATE Adenotonsillectomy MST Mucosal strip technique;a surgical
BMI Body mass index.A measure procedure for simple snoring
ofweight compared to height, nCPAP Nasally applied continuous positive
calculated as weight in kilograms airway pressure
divided by height in meters squared NSAID Non-steroidal anti-inflammatory
(healthy:18.5–24.9kg/m2; drugs
overweight 25–29.9kg/m2; ODI Oxygen desaturation index.
obesity >30kg/m2; Number ofoxygen desaturations
morbid obesity >40kg/m2) >4% that occur per hour ofsleep
BSSO Bilateral sagittal split osteotomy OSA Obstructive sleep apnea
CAPSO Cautery-assisted palatal stiffening PAS Posterior airway space
operation PSG Polysomnography.A graphic
CPAP Continuous positive airway pres- measurement ofsleep and
sure.Gold standard treatment cardiorespiratory parameters
ofobstructive sleep apnea and the RDI Respiratory disturbance index.
upper airway resistance syndrome The number ofrespiratory events
CT Computer tomography that occur per hour ofsleep
DOG Distraction osteogenesis (equivalent to AHI)
EBM Evidence-based medicine RFQ Radiofrequency.An interstitial
ECG Electrocardiogram thermal ablative technique to
ESS Epworth Sleepiness Scale.A subjec- reduce hypertrophy ofsoft tissues
tive measurement ofsleepiness. and produce scarification
FFT Fast Fourrier transformation SDB Sleep-disordered breathing.
HS Hyoid suspension.A surgical An inclusive term that denotes
procedure for OSA all respiratory abnormalities
LAUP Laser-assisted uvulopalatoplasty. during sleep
A surgical procedure for simple SI Snoring index
snoring STS Sodium tetradecyl sulfate
LUPP Laser uvulopalatoplasty.A surgical TAP Transpalatal advancement
procedure for simple snoring pharyngoplasty;a surgical
MAD Mandibular advancement device. procedure for OSA
An oral appliance that moves TE Tonsillectomy
the lower jaw forward against TT Tonsillotomy
the upper jaw UARS Upper airway resistance syndrome
