Success defined as a postoperative reduction in apnea/hypopnea index (AHI) of at least 50% and AHI value below 20.
Triological Society Best Practice
Are hyoid procedures a reasonable choice in the surgical treatment of obstructive sleep apnea?
Article first published online: 20 JAN 2010
Copyright © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.
Volume 120, Issue 2, pages 221–222, February 2010
How to Cite
Chau, J. K. M. and Goode, R. L. (2010), Are hyoid procedures a reasonable choice in the surgical treatment of obstructive sleep apnea?. The Laryngoscope, 120: 221–222. doi: 10.1002/lary.20784
- Issue published online: 20 JAN 2010
- Article first published online: 20 JAN 2010
- Manuscript Accepted: 27 OCT 2009
- Manuscript Revised: 11 SEP 2009
- Manuscript Received: 12 AUG 2009
Over the last 28 years the surgical management of sleep disordered breathing (SDB) has undergone considerable evolution from isolated uvulopalatopharyngoplasty to multilevel soft tissue and facial skeletal airway reconstruction. Although controversy exists over the timing and grouping of procedures (single-stage multilevel surgery vs. a staged approach), it is generally agreed that multiple sites of the upper airway need to be addressed in attempts at surgical cure.
Traditional uvulopalatopharyngoplasty and its numerous variations have been widely reported with good efficacy at addressing soft palate obstruction. Surgical procedures to correct oropharyngeal and hypopharyngeal obstruction, however, comprise a more heterogeneous group and include volumetric tissue reduction, suspension techniques, both soft tissue and bony, and facial skeletal procedures. The role of hyoid procedures in the surgical management of SDB remains uncertain as several reports have emerged questioning their potential benefit.
The existing literature on hyoid surgical procedures for SDB report its efficacy in the context of a multilevel surgical approach either as the sole method to treat oro/hypopharyngeal obstruction or in combination with another procedure, such as radiofrequency ablation, mortised genioplasty, or genioglossus advancement. Hyoid myotomy and suspension from the mandible was the original technique described in phase one of the Stanford surgical protocol, but has since been revised to myotomy and suspension from the thyroid cartilage. As no published study has yet examined the efficacy of hyoid surgery alone in treating SDB, and because the diagnostic accuracy in identifying the exact site(s) of obstruction remains a challenge, its utility must be carefully interpreted in context of the possible confounding effects of concurrent procedures.
In early 2006, Kezirian and Goldberg1 performed an evidence-based review of hypopharyngeal surgical procedures for obstructive sleep apnea. They identified four studies on hyoid surgery alone to treat retrolingual obstruction and found surgical cure rates varied from 17% to 78%. All four series included patients who had palate surgery performed previously or in the same setting. Bowden et al.2 reported the poorest success rate having studied 29 patients with a mean body mass index (BMI) of 34.1 and preoperative apnea/hypopnea index (AHI) of 36.5. Surgical success with no change in daytime somnolence symptoms was achieved in 17%. Conversely, Neruntarat et al.3 reported a success rate of 78% with improvement of daytime somnolence having studied 32 patients with a mean BMI of 29.3 and preoperative AHI of 44.5. Both of these series defined surgical success as a 50% or more reduction in AHI and an AHI <20.
Kezirian and Goldberg also identified seven articles that evaluated hyoid surgery in combination with other hypopharyngeal procedures, such as genioglossus advancement and mortised genioplasty, and reported variable cure rates of 18% to 77%. All articles included patients who had undergone palate surgery and hyoid suspension to either the mandible or the thyroid cartilage.
Since that review, two publications have reported on the efficacy of hyoid surgery to address retrolingual obstruction. Baisch et al.4 reported on a multilevel surgical concept that involved treating (perceived) tongue base obstruction with hyoid suspension (to the thyroid cartilage) and radiofrequency tongue tissue reduction. With surgical success being defined as a reduction of AHI by at least 50% and below a value of 15, a success rate of 59.7% was achieved. Benazzo et al.5 more recently published results of hyoidthyroidpexia as the sole method of addressing the retrolingual airspace in a multilevel surgical model. Defining success as a decrease in AHI to <20 yielded a success rate of 61.5%. A summary of the cited studies are provided in Table I.
|First Author (yr)||Evidence Level||Sample Size||Hyoid Method||Other Retrolingual Procedure||Other Level Procedure||Success Rate, %|
|Bowden (2005)||4||29||Thyroid cartilage||None||UPPP, tonsillectomy, Turbinoplasty, submentoplasty||17*|
|Neruntarat (2003)||4||32||Thyroid cartilage||None||UPPP||78*|
|Baisch (2006)||4||83||Thyroid cartilage||Radiofrequency of tongue base||UPPP, tonsillectomy/reduction, septoplasty, turbinoplasty||59.7†|
|Benazzo (2008)||4||109||Thyroid cartilage||None||UPPP||61.5*|
Based upon the available evidence, hyoid surgery achieves reasonable, if not widely variable, success (17%–78%) when utilized as part of a multilevel surgical approach and when combined with other oro/hypopharyngeal procedures. There is no evidence to support the use of hyoid surgery alone in treating SDB. Despite there being a greater number of reports on hyoid suspension to the thyroid cartilage, there is insufficient evidence at this time to recommend one suspension technique over another.
LEVEL OF EVIDENCE
The current body of published literature on hyoid surgery is level 4 according to the Oxford classification of levels of evidence.