There are two types of hyoid suspensions: hyoid thyroid cartilage suspension and hyoid mandibular median suspension.
Indications
(1) Those with posterior fall of tongue root, hypertrophy of tongue root or lymphatic tissue hyperplasia.
(2) Those with collapsed hypopharyngeal tissue.
(3) Those with epiglottis deformity.
(4)Moderate to severe patients who have not remitted after UPPP or refused to apply CPAP.
[Contraindications
(1)Those with oropharyngeal single plane obstruction.
(2)Those who still have soft palate plane obstruction after UPPP.
(3)Those with poor general condition who are not suitable for general anesthesia are relative contraindications.
Preoperative preparation
(1) Comprehensive examination to exclude any abnormalities in heart, liver, lung function and hematological system.
(2) Preoperative polysomnography (PSG), including apnea index (AHI), oxygen saturation (SaO2), oral and nasal airflow and other indicators.
(3) Electronic laryngoscopy, CT and other examinations to determine the site and degree of obstruction to facilitate preoperative development of a feasible plan.
(4) Introduce the surgical method, postoperative functional changes and complications to the patient and the patient’s family, and sign the surgical protocol.
(5) Preoperative neck skin preparation.
(6) Fasting for 6 hours before surgery and intramuscular injection of atropine and luminal a half hour before surgery.
【Anesthesia】.
General anesthesia, insertion of anesthetic cannula with balloon through the nose or mouth to keep the airway unobstructed.
Body position
The patient lies supine on the operating table with a pillow under the shoulder and the head tilted back.
I. Hyoid thyroid cartilage fixation surgery
The hyoid thyroid cartilage fixation surgery is to fix the hyoid bone and the upper edge of the thyroid cartilage, so that the hyoid bone is displaced forward and downward to enlarge the hypopharyngeal cavity.
Surgery steps
(1) UPPP or PPP procedure in supine head-down position, or nasal surgery, or staged surgery. If single plane lingual root obstruction, lingual turbinate cartilage fixation can also be performed alone.
(2) If simultaneous surgery is performed, the above procedures are completed, re-sterilized and toweled, and cervical surgery is performed. Make a transverse incision between the upper edge of the hyoid bone and the thyroid cartilage, 5-6 cm long, separate the subcutaneous tissue to expose the upper edge of the thyroid cartilage, then separate the lower edge of the hyoid bone upward, cut off the muscles of the sternocleidomastoid muscle, scaphoid hyoid muscle and thyroid hyoid muscle on the lower edge of the hyoid bone to expose the hyoid bone.
(3) Separate the supraglottis muscle group but do not cut it off, pull the hyoid bone downward to ride at the thyroid cartilage laryngeal node, pass a 10-gauge silk or metal wire through the thyroid cartilage plate around the hyoid bone, exit the hyoid bone with 2 stitches on each side, and fix the hyoid bone to the upper edge of the thyroid cartilage plate. A drainage strip is placed, and the anterior cervical strap muscle fascia is sutured to the supraglottis muscle fascia to enhance fixation, and the incision is made with intracutaneous sutures.
(4) Intraoperatively, the hypopharynx can be observed under fiberoptic endoscope to see if it is widened, usually by about 1 cm, if the movement is not enough to separate to both sides of the hyoid bone, but not to cross the small corner of the hyoid bone to avoid injury to the supraglottic artery and nerve.
Second, hyoid bone mandibular suspension
Hyoid mandibular suspension surgery is to fix the hyoid bone and mandibular suspension, so that the hyoid bone can be shifted forward and upward to enlarge the hypopharyngeal cavity.
【Surgery steps】.
(1) UPPP or PPP procedure in supine head-down position, or nasal surgery, or staged surgery. If single-plane lingual root obstruction is present, lingual mandibular median suspension fixation can also be performed alone.
(2) If simultaneous surgery is performed, the above procedures are completed, re-sterilized and toweled, and cervical surgery is performed. A transverse skin incision is made on the surface of the hyoid bone as the first incision, 4-5 cm long, to separate the subcutaneous tissues and isolate the hyoid bone, and cut off the muscles of the lower edge of the hyoid bone such as the sternocleidomastoid muscle, the scapulocleidomastoid muscle, the thyroglossus muscle and other muscles to expose the hyoid bone.
(3) Excise the subcutaneous fat above the hyoid bone, separate the supraglottis muscle group but do not cut it off, and use two No. 10 silk or nylon threads to pass through the hyoid bone, exit the stitches from the hyoid bone, and suture 2 sutures on each side for backup.
(4) A transverse skin incision was made at the lower edge of the mandible right in the middle as a second incision, 2-3 cm long, separating the subcutaneous tissue, separating the lower edge of the mandible right in the middle, and separating each side medially and laterally to expose the mandible for about 1 cm.
(5) A bone drill is used to drill a hole 1 cm above the lower median edge of the mandible.
(6) The 2 sutures reserved for the first incision are passed under the skin to the second incision, and 1 of them is threaded through the needle with both strands, passing it through the bone hole from the outside to the inside, and fixed with the other suture drawn and ligated under the mandible to properly stop bleeding, place a drainage strip, and suture the subcutaneous tissue and skin in turn.
(7) Intraoperatively, the hypopharynx can be observed under the fiberoptic endoscope to see if it is widened, and it can generally be widened by about 1 cm.
【Postoperative treatment】.
(1)The tracheal intubation is removed after awakening, and cardiac monitoring is performed for 12~24h.
(2) This procedure generally does not work as tracheotomy, and if incision is needed, it is treated as post-tracheotomy.
(3)The drainage strip can be removed 48~72h after the operation if the drainage flow is less than 10ml in 24h.
(4) Routine use of antibiotics and hemostatic drugs after surgery.
(5) Postoperative diet should be changed from liquid or semi-liquid to normal diet.
(6) The stitches are removed after 1 week and the PSG is rechecked after 3 months.
【Complications】.
(1)Postoperative infection.
(2) Bleeding, both intraoperative and postoperative.
(3) Postoperative neck scar changes, especially in scarred patients.
(4) Articulation and swallowing disorders (rarely occurring).
(5) There may also be chondromalacia and osteochondritis.