Obstructive sleep disordered breathing (OSDB) is a common group of disorders with complex causes involving the central drive and regulation of breathing, the morphology of the upper airway, and the functional status of the upper airway opening musculature. Craniomandibular structural abnormalities, peri-airway soft tissue deformities, and peri-airway organ dysfunction can all lead to different regions of the upper airway with different degrees of narrowing or collapse to produce sleep apnea.
Patients’ age, health condition, knowledge and acceptance of various treatments and expectation of efficacy are all different, and the level of treatment varies from one medical unit to another.
1.OSDB surgery method and development
Abnormalities of craniomaxillofacial soft and hard tissues are the common causes of obstructive sleep disordered breathing, and surgery is one of the effective treatment means for OSDB. Surgery is mainly through the upper airway peri-airway soft tissue reduction to remove the occupancy removal, expand the bone structure and other methods to unblock the obstruction to achieve the purpose of treatment.
Currently, surgical treatment includes both upper airway reconstruction surgery and bariatric surgery. Upper airway reconstructive surgery has soft tissue reduction and craniomandibular surgery or a combination of both, and bariatric surgery is divided into three categories: restriction of intake, reduction of absorption and a combination of both.
The head and neck procedures are tracheotomy, palatoplasty, palatopharyngoplasty (Uvulopalatopharyngoplasty; UPPP/UP3), which appeared in the 1970s; genioglossus advancement-hyoid mytomy (GAHM), bimaxillary advancement ( Bimaxillary advancement (MMA); distraction osteogenesis (DO) in the mid to late 1990s and radiofrequency tissue ablation (RFTA) in the late 1990s; and The emergence of maxillomandibular advancement distraction osteogenesis (MMADO) at the beginning of the century, palatoplasty, palatopharyngoplasty and maxillary advancement simultaneous surgery (MMAUP3) for patients with convex facies, etc.
On the other hand, the concept of surgical treatment is not only limited to the head and neck, for patients with severe obesity, the remarkable effect of surgical weight loss not only makes sleep breathing disorder possible to cure, but also can effectively treat the systemic diseases secondary to obesity.
2.OSDB surgical treatment concept—whole view and development view
For the diagnosis of OSDB patients, we should focus on those aspects? When treating patients, what should be the priority of treatment?
In terms of diagnosis, in addition to routine clinical examination, routine nocturnal polysomnography (PSG) must be performed, supplemented by upper airway assessment and imaging of peri-upper airway tissues to clarify the location and nature of upper airway stenosis. In addition, corresponding examinations and evaluations should be performed for secondary or concurrent cardiac, cerebral, renal, endocrine and other systemic diseases.
In terms of treatment, it is important to focus not only on the sleep disordered breathing disease, but also on its secondary or concurrent cardiac, cerebral, renal, endocrine and other systemic diseases.
For pediatric and adolescent patients, adenoids/tonsils enlargement is a common cause of OSDB, and successful adenoids/tonsils surgery is not the end of treatment. It is well known that a common presentation in children with adenoids/tonsils enlargement is open-mouth breathing, which often does not correct with surgery. Prolonged open-mouth breathing in developing patients can cause craniomaxillofacial skeletal disorders, so these children must be followed closely to correct open-mouth breathing to prevent the recurrence of craniomaxillofacial developmental deformities and sleep apnea.
Similarly, in adolescent children with OSDB associated with craniomandibular deformity, corrective craniomandibular surgery is very effective in the treatment of craniomandibular deformity and OSDB, but the surgery may cause developmental disorders of the craniomandibular bone, and in the long term the child may still have recurrence of OSDB due to craniomandibular deformity.
For obese OSDB patients with mainly soft tissue deformity, weight and age change are closely related to the narrowing and obstruction of upper airway, and the treatment should also focus on the present and long term, and we should have a holistic and developmental concept.
3, OSDB surgical treatment strategy — comprehensive diagnosis, individualized, conservative, integrated and combined treatment
Clinical examination or PSG examination alone is not enough, there are many cases of positive pressure ventilation treatment for patients with floor of mouth or parapharyngeal masses, and cases of treating all patients with RF or low temperature plasma, UPPP surgery are not uncommon. A comprehensive diagnosis should include the nature and extent of OSDB disease, the site, nature and extent of upper airway obstruction, and the evaluation of secondary or concurrent disease.
The treatment of OSDB should follow the principles of “individualization, conservatism, combination and synthesis”.
The authors believe that a proper assessment and understanding of the severity of the disease, the location and nature of the upper airway obstruction, the general physical condition and the patient’s intention for treatment should be made, and a comprehensive strategy of combining surgical sites and non-surgical treatments with different size gradients should be used for patients with different severity, different areas of obstruction, and different soft or hard tissue deformities. Treatment needs to be developed from the patient’s wishes and the medical unit’s reality. Although the professional orientation, level, and specialty of each medical unit may vary, the treatment plan given to the patient must be comprehensive and integrated, and interdisciplinary or inter-hospital cooperation is essential.
Treatment such as surgical treatment, non-surgical CPAP or oral appliances are not diametrically opposed, and surgical and non-surgical treatments can be organically combined. For patients with a non-surgical treatment line, appropriate surgical intervention can improve patient compliance or increase the efficiency of non-surgical treatment. The former, such as surgery for patients with deviated nasal septum and tonsillar hypertrophy, can greatly reduce the stress of CPAP treatment and improve the comfort of treatment; the latter, such as surgically assisted maxillary cortical or maxillary splitting for rapid arch expansion in children with adenoid facial features. For patients who use surgical treatment as the main line of treatment, interventions such as behavioral therapy/bariatric/CPAP/oral appliances undoubtedly have a positive effect on reducing surgical trauma and improving surgical efficiency.
In pediatric and adolescent patients, tonsillar/adenoids hypertrophy, craniomaxillofacial developmental malformations and obesity are common causes. Surgery is the first choice for children with peri-airway tissue and organ occupations or craniomandibular deformities, but if the child is too young to tolerate surgery for the time being (e.g., Pierre Robinson syndrome, Crouzon syndrome, first and second gill arch syndrome, Treacher-Collins syndrome, Pfeiffer syndrome, Apert syndrome, Down syndrome, small jaw deformity, etc.) can be treated with positive pressure ventilation before elective surgery. For children and adolescents with obesity and OSDB, non-surgical weight loss should be the focus of treatment.
For OSDB patients with mainly soft tissue hypertrophy, although craniofacial surgery is a fundamental treatment, but because of the trauma, risk and irreversibility of surgery, at the same time, the treatment is also difficult to reach the level of complete cure like craniomandibular deformity with OSDB patients, and at the same time, patients often do not have a deep understanding of the disease and surgery, it is appropriate to adopt conservative treatment measures for these patients first, and then consider surgery if it is not effective or cannot be tolerated. Then consider the option of surgery. This is not only safe, but also raises the patient’s awareness of the disease and current treatment methods, and has positive implications for improving patient compliance and avoiding doctor-patient disputes.
For OSAHS patients with BMI ≥ 32 who are severely obese combined with other systemic diseases, the root of treatment lies in weight loss and control of systemic metabolic diseases and complications caused by obesity, and the treatment of sleep breathing disorder is only one part of it, and generally the combination of surgical weight loss treatment with positive pressure ventilation is preferred.
4.Craniomaxillofacial surgery methods, indications and indications
Strict grasp of surgical indications and indications for surgery is one of the keys to successful surgical treatment, is the first of our surgical treatment. Craniomaxillofacial surgery is mainly used to restore the upper airway and craniofacial morphology of patients to achieve the therapeutic purpose, for non-morphological factors of SDB patients, surgical treatment is not appropriate.
The authors thought that the indications of surgery for OSDB: OSDB with predominantly morphological causes; no general contraindications to surgery; patients with active willingness to receive surgical treatment; patients with stable psycho-spiritual status, no depression, anxiety or other psychiatric disorders.
(1) Nasal reconstruction surgery
Although the upper airway obstruction of OSDB patients mostly occurs in the oropharyngeal cavity, the obstruction of nasal airway plays an important role in the occurrence of OSDB. Due to the narrowing or obstruction of nasal airway, the upper airway resistance of patients increases, which makes patients try to enhance breathing and increase the negative pressure of upper airway, and then causes the increase of upper airway collapse and induces the occurrence of obstructive sleep disordered breathing. Therefore, nasal reconstruction has an important role in the treatment of OSDB patients.
Reconstructive nasal surgery includes traditional septal deviation correction surgery, nasal polyp removal, turbinate hypertrophy revision or radiofrequency/low temperature plasma ablation, etc. It also includes nasal dilation techniques such as trilinear nasal septum subtensionplasty, medial turbinate internal displacement fixation, bilateral sinus symmetry opening of the middle nasal tract, inferior turbinate external displacement fixation, etc.
For patients with adenoid facies, surgical or non-surgical maxillary dilation treatment not only improves the patient’s occlusion but also significantly relieves nasal airway obstruction.
(2) Tonsillectomy and adenoidectomy (T&A)
Tonsillectomy and adenoidectomy are common factors of upper airway obstruction in children and adolescents, and there is abundant lymphoid tissue in the oropharynx.
(3) Uvulopalatopharyngoplasty (UPPP/UP3)
UPPP/UP3 is a common procedure for patients with palatopharyngeal plane stenosis and obstruction, and is suitable for patients with moderate or mild OSAHS who are not severely obese, and patients with severe OSAHS with II-III tonsillar hypertrophy. there are numerous surgical approaches for UP3, and the overall surgical success rate ranges from 20% to 40%, with a success rate of 82% for highly selected UP3 procedures. Because of the poor long-term results and the potential for respiratory, articulatory, and swallowing dysfunction, there is currently opposition to performing this procedure.
The procedure is contraindicated in patients with scarring or COPD combined with OSAHS, in underage patients, and is cautioned in patients with high voice requirements, such as teachers, actors, and singers.
Some studies have summarized the results of OSDB soft tissue surgery in recent decades, and concluded that soft tissue reduction surgery (except for occupational disease) has poor long-term results and a large impact on function, and there is a current trend in Europe and the United States to reject this type of surgery.
The soft palate and tongue morphology are closely related to articulation and swallowing, and soft tissue surgery reduction not only damages these functions, but also found that the soft palate, palatal lobe and tongue mucosa contain mechanoreceptors involved in respiratory regulation, and surgical reduction makes these receptors lost, thus damaging respiratory regulation, and it is a popular international surgical concept to prefer craniomandibular surgery for patients with non-occupying diseases with OSDB.
(4) Craniomandibular surgery
Craniomandibular surgery is the treatment of choice for craniomandibular deformity with OSDB, and it is also an effective surgical method for non-very severe obese patients with severe OSAHS. The mechanism of craniomandibular reconstruction and expansion for OSDB is to compensate for the narrowing of the upper airway caused by soft tissue collapse during sleep with an expanded airway, so that the air-to-airway diameter is kept above the minimum requirement for not developing sleep breathing disorders.
The orthognathic surgery is designed for adult craniomandibular deformity with OSDB, obese patients with severe OSAHS, or patients who have failed other soft tissue surgery; it is suitable for cases with jaw movement range within 10-15mm, and patients who need significant bone movement should be solved by distraction osteogenesis.
Chin advancement hyoid suspension (GAHM)
In 1989, Riley et al. modified the hyoid suspension by fixing the hyoid bone to the thyroid cartilage to prevent the hyoid bone from moving backward. Since the chin-lingual and chin-glossus muscles are relatively weak, the suspension is limited. Clinically, we obtained enhanced suspension by removing all supraglossal muscles and shortening the supraglossal muscles with 10 mm sutures.
Overall, the effect of this surgery is limited, and the effect is to enhance the suspension, and there is no expansion effect, and it is only suitable for cases of chin recession and mild hypopharyngeal stenosis.
Anterior maxillary or mandibular osteotomy
For cases with underdeveloped or receding upper or lower jaw, single jaw advancement of the upper or lower jaw is used as a reference to restore facial morphology. In order to achieve the largest possible advancement and adjust the upper or lower jaw occlusal relationship, the upper or lower jaw can be extracted bilaterally with one bicuspid and osteotomy in blocks; postoperative orthodontic treatment is indispensable to obtain a perfect occlusal relationship.
Bimaxillary advancement and chin-forming lingual suspension
As the primary or final treatment for severe OSAHS, the results of bimaxillary advancement surgery are related to the magnitude of jaw advancement and are influenced by postoperative weight changes and changes in neuromuscular function due to ageing. One study reported that bimaxillary advancement surgery is suitable for patients with BMI ≤ 32 kg/m2 and AHI ≤ 70, and the success rate is > 90%; for patients with BMI ≥ 32 kg/m2 and AHI ≥ 70, the success rate is about 60%. It can be seen that bimaxillary advancement surgery does not play the role of “last resort”, and for patients with severe obesity, the direction of treatment is still weight loss.
For oriental people with a slightly convex face, the range of forward movement of both jaws is limited, especially the range of forward movement of the upper jaw limits the overall movement, and if the forward movement of the upper jaw is aggravated, it may cause convex facial deformity. According to our clinical research and experience, there are two ways to solve the problem: to control the maxillary advancement using the simultaneous UP3 method, and to fix the maxillary block by appropriate counterclockwise rotation to increase the advancement of the lower jaw. For those who cannot solve the convex facial deformity by simulating the first plan, adopt tooth extraction, maxillary and mandibular subapical block osteotomy surgery, extraction of tooth area 1-44 to control the amplitude of anterior displacement of the maxillary anterior bone block, and anterior displacement of the maxillary posterior bone block and mandible as much as possible.
②distraction osteogenesis (DO)
OSDB treatment is mainly used for adolescent patients with craniomandibular deformity and adult patients with severe craniomandibular deformity or severe OSAHS who need significant anterior displacement of the craniomandibular bone, and it is also one of the effective methods to treat adenoid facial/maxillary lateral hypoplasia.
Retraction osteotomy is a good treatment for all ages, all areas or directions of bone underdevelopment and defects, and can also be used to expand the bone structure in patients with “normal” facial features. The maxillary osteotomy can be Le Fort I-III, and the mandibular osteotomy is a bilateral sagittal split of the ascending branch.
Is this the result of surgical trauma to the developing jaw or is it the result of a developmental disorder of the jaw itself or both? The effect of distraction osteogenesis on the developing jaw has yet to be studied, and the design of the distraction direction and magnitude of distraction for the developing jaw has yet to be determined.
Osteotomy correction or completion is the reconstruction of the skeletal framework, the perfection of the occlusal relationship, in adolescents and young patients still need to cooperate with orthodontic treatment, for middle-aged and elderly OSAHS patients need to combine with orthognathic surgical techniques.
5. Principles of craniomaxillofacial surgery for OSDB patients
OSDB patients with craniomaxillofacial all have morphological or structural abnormalities, some mainly in soft tissues, some mainly in craniomaxillary developmental disorders; or there may be morphological abnormalities in both soft and hard tissues, which is the basis for craniomaxillofacial surgery.
Strict surgical indications, grasp the indications for surgery, prevent abusive surgery; control the postoperative craniomaxillofacial and upper airway morphology and occlusal relationship; protect the function of tissues and organs in the surgical area are the treatment principles we should follow in surgery.
(1) Surgery for craniomandibular deformity with OSDB – restoration of craniomandibular surface morphology/structure
The craniomandibular bone is the scaffold of the craniofacial surface and the support structure of the upper airway. The size and position of the skull base, maxilla, mandible and hyoid bone are one of the determinants of human appearance and upper airway morphology; changing the morphology or position of the craniomandibular bone can change the appearance and upper airway morphology.
Underdevelopment or recession of craniomandibular bone can cause craniofacial deformity and OSDB, such as micromaxillary (mandibular, maxillary) deformity, first and second gill arch syndrome, Pierre-Robin syndrome, Downs syndrome, Treacher-Collins syndrome, Crouzon syndrome, Marie-Sainton syndrome, Apert syndrome, The narrowing or obstruction of the upper airway in these patients is caused by morphological factors, which is the result of insufficient development of bone support structures.
Therefore, for patients with craniomandibular deformity with OSDB, unquestionably craniomandibular reconstruction surgery is the first choice. For these patients our reference goal is to restore the craniomaxillofacial morphology of the patient.
(2) Principles of craniomaxillofacial surgery for obese OSDB patients
(1) Bone surgery and soft tissue reduction option – bone surgery is preferred
For the surgical treatment of obese OSDB patients, should we use soft tissue reduction method or apply bone anterior displacement surgery? For patients with OSDB caused by non-soft tissue occupancy around the upper airway, we think it is appropriate to prefer bone surgery if available.
There are two reasons: there are various receptors under the mucosa of soft tissues around the upper airway, and surgical removal of soft tissues may affect the corresponding function, while the change of morphology may also cause dysfunction in breathing, swallowing and speech; compared with soft tissues, bone mainly plays the role of movement and scaffolding, and the current orthognathic surgery technology can make the surgery not to destroy its movement function, and the preoperative changes can also be predicted and grasped after the surgery, and the treatment effect is Stable and reliable.
②Soft tissue reduction and functional protection
The soft tissues around the tongue, soft palate and upper airway are responsible for various functions. For patients who must choose to undergo soft tissue reduction surgery, close attention should be paid to the soft tissue reduction and protection of their corresponding functions.
In the case of UP3 surgery, it is important to protect the palatopharyngeal closure and to ensure adequate length of the soft palate, which is essential for normal speech and swallowing function. In the case of tongue or lingual root reduction surgery, the protection of the hypoglossal nerve and lingual nerve and the length of the tongue are very important to protect the functions of mastication, swallowing and speech.
③ Grasp the upper airway – facial shape – occlusion relationship
The movement of the maxilla and mandible is bound to change the facial shape and cause changes in the occlusal relationship of the teeth. For patients undergoing maxillary/mandibular or bimaxillary advancement surgery, it is necessary to grasp the upper airway-facial shape and occlusal relationship, so that the treatment of OSDB will not cause secondary deformity or disorder of the occlusal relationship of the jaw.
For normal people, there can be a certain range of variation in jaw position, and within this scale, the appearance will not be visually deformed. Whether the occlusal relationship is normal affects the normal exercise of masticatory function, pronunciation and TMJ function, and also affects the appearance. Patients with jaw surgery must undergo computerized surgical simulation and model surgery before surgery, and the bone must be osteotomized and moved strictly according to the design during surgery.
④ Stop the abuse of surgery
Each surgery has its own indications, but the current clinical practice of the absolute abuse of surgery is not uncommon. Such as UP3 surgery to treat all OSDB patients, such as unlimited application of radiofrequency or low-temperature plasma surgery …… for surgical treatment, preoperative patients need to pass the diagnosis and screening of PSG, upper airway and systemic condition assessment before performing surgery.
6, obese OSDB patients bariatric surgery methods and indications
Obesity is one of the social and medical problems facing mankind at present, with a very high prevalence rate, obesity is not only a sleep breathing disorder problem, but also the following health risks such as high cholesterol, hypertension, atherosclerosis, heart disease, fatty liver and liver function damage, type II diabetes, gallstones, gastroesophageal reflux disease, infertility, depression, etc., which seriously affects the physical and mental health of patients and should cause comprehensive It should be given comprehensive and high attention.
The surgical indications established in the 2007 Chinese guidelines for the surgical treatment of obesity: simple obesity with related metabolic disorder syndrome, such as II diabetes, fatty liver, lipid metabolism disorder, OSAHS, etc.; stable or steadily increasing weight for more than 5 consecutive years, BMI ≥ 32; age 16-65 years old, poorly treated by non-surgical treatment or intolerant; no alcohol or drug dependence, no serious Patients who are aware of the bariatric surgery modality and understand and accept the risk of potential complications of the surgery; who understand the postoperative lifestyle and dietary changes and can actively cooperate with postoperative follow-up; otherwise, surgical treatment is not recommended.
Buchwald et al. reported that the risk of untreated simple obesity is much higher than the risk of surgery, with a mortality rate of 0.68% for patients treated with surgery and 6.17% for those not treated for 5 years; bariatric surgery can completely cure or partially improve obesity-related diseases: 77% for diabetes, 62% for hypertension, 86% for SDB, and 71% for high cholesterol. This shows the importance of surgical bariatric surgery for severely obese patients.
Contraindications to bariatric surgery: active substance abusers, patients with psychiatric disorders, critical personality disorder, schizophrenia, active major depression, bulimic eating disorder, complete refusal to change lifestyle and refusal to follow up treatment, patients with cancer, tuberculosis and HIV, patients with gastric ulcer, people at high risk for surgery, pregnant women, etc.
(1) Intake restriction surgery
Commonly, adjustable gastric banding, vertical banding gastric reduction, and sleeve gastrectomy are performed to restrict intake while maintaining normal digestive and absorption functions without reducing absorption side effects. The average weight loss at 2, 4 and 5 years after surgery is 49%, 55% and 57%, respectively. Adjustable gastric banding is a widely used and preferred surgical method for weight loss, i.e., a silicone band is looped around the upper part of the stomach body through laparoscopic technique to form a small gastric sac with a volume of less than 15 ml, and the tightness of the band can be adjusted by a one-way injection pump buried under the skin. To achieve the effect of weight loss.
(2) Intake restriction + absorption reduction surgery
Gastrointestinal short-circuiting, or jejuno-ileal short-circuiting/gastric bypass, is performed by forming a gastric bursa of 12-25 ml in volume at the proximal end of the stomach using a direct cutting anastomosis, opening all of the duodenum and about 40 cm of the proximal jejunum, and anastomosing the bursa to the jejunum, with a Roux arm length of 75-150 cm depending on the patient’s obesity. This significantly shortens the digestive tract for the purpose of reducing digestion and absorption, while reducing gastric volume to limit feeding and digestion, and reducing excess weight by 56% within 4 years after surgery. This procedure is used for patients who have failed gastric banding surgery or for patients with severe obesity.
(3) Absorption reduction surgery
Biliopancreatic open and duodenal transposition are two procedures with the main purpose of reducing absorption. 74% of excess body weight is lost within 1 year, 78% within 2 years, 81% within 3 years, 84% within 4 years, and 91% within 5 years after surgery. These two types of surgery, although the weight loss effect is good, but the operation is complicated, the complication rate and mortality rate are higher than other surgery, plus the side effects of malabsorption of nutrients are more serious, need to take related supplemental mineral drugs for life, mainly for other surgery weight loss failure patients or very heavy obese patients, not recommended for the promotion of the national people.
7. Assessment and treatment of patients’ psychological and mental status
OSDB patients’ physical and cosmetic changes and sleep breathing disorders may cause their serious psychological disorders or even mental illnesses, and it is not uncommon for patients with sleep breathing disorders to suffer from anxiety and depression. Psychological or psychiatric disorders often cause patients to have serious biases in their judgment of things, and for these patients, simple surgery will certainly have serious adverse consequences. Preoperative evaluation, screening and treatment are indispensable. For patients who cannot effectively relieve their psychological or psychiatric disorders, surgical treatment is not recommended for the time being.
8. Perioperative upper airway management
The upper airway management during the perioperative period is related to the life of the patient. The patient’s long-term hypoxic sleep causes impaired central respiratory drive regulation, insensitivity to hypoxic state, the effect of anesthetic drugs on respiratory regulation and upper airway opening muscle function, swelling caused by surgery, increased secretion or bleeding from the incision may cause asphyxia. .
Tracheotomy is an effective temporary, emergency measure to relieve patients from upper airway obstruction during the perioperative period or in emergency situations. For primary care hospitals and patients with severe OSAHS, tracheotomy not only facilitates the correction of preoperative hypoxia and improves the regulation and stability of the respiratory center, but also provides safety for the performance of surgical anesthesia and postoperative airway management, which can greatly reduce the risk of surgery.
There are many patients who are clinically difficult to undergo tracheotomy, and our current routine methods are.
(1) routine preoperative application of CPAP/Bi-PAP/Auto-PAP therapy to correct patient hypoxia and improve patient tolerance to surgery.
(2) Preoperative sedation is disabled and conscious transsphenoidal anesthesia is administered, and the tube is left in place for 0 to 3 d after surgery, depending on the situation.
(3) Postoperative assisted positive pressure ventilation; in this way, tracheotomy can be avoided in the majority of patients.