Transcript Epiglottis as a cause of Sleep Apnea

Epiglottis , A Little Cause of
Obstructive Sleep Apnea
BY
AHMAD YOUNES
PROFESSOR OF THORACIC MEDICINE
Mansoura Faculty of Medicine
Obstructive Sleep Apnea
• Obstructive Sleep Apnea
(OSA) is caused by
obstruction or narrowing of
the upper airway starting
from nose to laryngeal level.
Laryngeal Anatomy
• The LARYNX is an apparatus made up of
cartilage, ligaments, muscles, and mucous
membrane, which guards the entrance to the
lower respiratory passages (trachea, bronchi,
and lungs) and houses the vocal cords.
• Note that the hyoid bone is not usually
considered as part of the larynx.
Three major types of movement are possible:
1. MOVEMENT AFFECTING THE TENSION OF THE VOCAL
CORDS. Since the vocal cords are attached to the
arytenoid cartilages posteriorly and the thyroid
cartilage anteriorly, regulation of vocal cord tension
(and therefore pitch of the voice) is accomplished
primarily by pivoting the thyroid cartilage forward or
backward at the cricothyroid joint .
2. MOVEMENTS WHICH INCREASE OR DECREASE THE
SIZE OF THE OPENING BETWEEN THE VOCAL CORDS
(ABDUCTION OR ADDUCTION OF THE VOCAL
CORDS). This action is best appreciated by imagining
the larynx viewed from above.
Realize: I. That the vocal cords on each side are
covered with a mucous membrane, so that when
they are abducted, relatively little air can pass either
between them or around them.. The bases of the two
arytenoid cartilages are L-shaped. The medial process
of each is called the vocal process, and the vocal cords
attach to it. The lateral process of each is called the
muscular process, and most of the muscles which act
to abduct or adduct the vocal cords attach to it.
Abduction of the vocal cords may be accomplished either
by externally rotating the arytenoid cartilages on a
pivot located at the angle of the "L“ or by sliding the 2
arytenoid cartilages apart slightly.
Realize that there is only 1 muscle which has an abductor
action on the vocal cords, although there are several
which act to adduct the cords.
3. MOVEMENTS WHICH CLOSE OFF THE
ENTRANCE TO THE LARYNX, AS IN SWALLOWING.
• The movements of the
epiglottis and arytenoid
cartilages which take place
during swallowing to block
off the entrance to the
larynx, to prevent food from
entering the larynx.
Basically, the epiglottis is
pulled down, and the
arytenoid cartilages are
pulled forward, toward the
epiglottis.
Realize that two other mechanisms which are
independent of laryngeal movements per se also
help to keep food from entering the larynx during
swallowing.
• First, the larynx is raised, along with the
pharynx, by the contraction of the longitudinal
muscles of the pharynx.
• Second, the epiglottis also acts partly as a
passive barrier to the movement of food, so that
food tends to be funneled to either side of the
larynx, into the PIRIFORM RECESSES and from
there into the esophagus.
Pyriform sinus
• On either side of the laryngeal orifice is a recess, termed
the piriform sinus (also piriform recess, pyriform sinus, piriform
fossa, or smuggler's fossa), which is bounded medially by
the aryepiglottic fold, laterally by the thyroid
cartilage and thyrohyoid membrane. The fossae are involved in
speech.
• The term "piriform," which means "pear-shaped," is also
sometimes spelled "pyriform" .
• Deep to the mucous membrane of the piriform fossa lie
the recurrent laryngeal nerve as well as the internal laryngeal nerve,
a branch of the superior laryngeal nerve.
• The internal laryngeal nerve supplies sensation to the area, and it
may become damaged if the mucous membrane is inadvertently
punctured.
• It is a common place for food to become trapped; if foreign material
becomes lodged in the piriform fossa of an infant, it may be
retrieved nonsurgically. If the area is injured (e.g., by a fish bone), it
can give the sensation of food stuck in the throat.
• Local anesthesia can be given here because of the presence of
internal laryngeal nerve underneath the mucous membrane.
OTHER STRUCTURAL FEATURES OF THE LARYNX
1. Above and parallel to the vocal cord on each side is a
second ligament called the VESTIBULAR or
VENTRICULAR LIGAMENT. This ligament is not actively
moved during vocalization, and is therefore referred to
as a "false vocal cord." Nonetheless, this ligament (or
the fold of mucous membrane which covers it) is a
prominent feature when the larynx is examined with a
laryngoscope.
2. The entire larynx is covered with a mucous membrane,
which is given different names in its different parts,
depending on the structures it covers over or runs
between .
3. The membrane running between the epiglottis and the
arytenoid cartilages, called the QUADRANGULAR
MEMBRANE, is reinforced by a small cartilage which is
embedded in it, the CUNEIFORM CARTILAGE.
4. On each side, another small cartilage, called the
CORNICULATE CARTHAGE, caps the arytenoid cartilage
superiorly.
PARTS OF THE LARYNGEAL
CAVITY
The boundaries formed by the
vestibular and vocal folds divide the
cavity of the larynx into three parts.
1. The VESTIBULE, which is the area
above the vestibular folds.
2. The VENTRICLE, which is a pocketlike recess between the vestibular and
vocal folds on both sides.
3. The INFRAGLOTTIC CAVITY, which is
the area below the vocal folds.
There are two other terms you must know:
1. The GLOTTIS is the aperture formed by the
vocal folds (analogous to the iris of the eye).
2. The RIMA GLOTTIDIS is the opening between
the vocal folds (analogous to the pupil of the
eye). Realize that the size of the rima glottidis is
a major factor in determining how much air can
enter the trachea and lungs.
MUSCLES OF THE LARYNX
1 . MUSCLES WHICH AFFECT THE TENSION OF THE
VOCAL CORDS. The CRICOTHYROID MUSCLES : The
muscles primarily responsible for regulating the tension
of the vocal cords. The small VOCALES muscles, which
lie parallel and inferior to the vocal cords (control fine
adjustment of vocal cord tension.
2. MUSCLES WHICH OPEN AND CLOSE THE RIMA
GLOTTIDIS (ABDUCT AND ADDUCT THE VOCAL
CORDS).
• Abductor: The posterior cricoarytenoid is the only
abductor of the vocal cords.
• Adductors: The major abductors of the vocal cords are
the LATERAL CRICOARYTENOID, THYROARYTENOID,
and ARYTENOIDEUS MUSCLES.
NERVE SUPPLY TO THE LARYNX AND
PHARYNX
1. MOTOR INNERVATION OF THE MUSCLES OF
THE PHARYNX AND LARYNX arises mainly
from the CRANIAL DIVISION of the ACCESSORY
NERVE (XI). Note, however, that these axons
TRAVEL with those of the VAGUS NERVE, and
are indistinguishable from it. Exception: The
STYLOPHARYNGEUS MUSCLE receives its
motor innervation from the
GLOSSOPHARYNGEAL NERVE (1X) . Note that
this is the ONLY muscle innervated by this
nerve.
Most of the muscles of the larynx receive their
innervation via the RECURRENT LARYNGEAL
BRANCH of the vagus nerve .
• Exception: The CRICOTHYROID MUSCLE, which
receives its innervation via the EXTERNAL LARYNGEAL
NERVE.
2. SENSORY INNERVATION OF THE LARYNX AND
PHARYNX.
• Pharynx: via the GLOSSOPHARYNGEAL NERVE
• Larynx: via branches of the VAGUS NERVE
• Above the vocal folds the sensory innervation of the
larynx is via the INTERNAL LARYNGEAL NERVE.
• Below the vocal folds it is by way of branches of the
RECURRENT LARYNGEAL NERVE.
3. PARASYMPATHETIC INNERVATION OF THE LARYNX
AND PHARYNX is mainly by way of branches of the
Epiglottis
• About 10% patients with OSA will not improve
unless one corrects the epiglottis factor.
• Epiglottis prolapse during inspiration is an
unusual cause of airway obstruction and a rare
cause of OSA. The epiglottis can be seen large
and floppy closing like a door over the laryngeal
inlet during inspiration.
• In laryngomalacia the entire larynx collapses
including the epiglottis. These patients cannot
tolerate CPAP, their obstruction gets worse and
suffocated while wearing CPAP. In fact CPAP
therapy is contraindicated in laryngeal OSA.
Laryngomalacia
• Laryngomalacia, is a congenital abnormality of
the laryngeal cartilage.
• It is a dynamic lesion resulting in collapse of the
supraglottic structures during inspiration,
leading to airway obstruction.
• It is thought to represent a delay of maturation
of the supporting structures of the larynx.
• Laryngomalacia is the most common cause
of congenital stridor and is the most common
congenital lesion of the larynx.
Laryngomalacia
• The epiglottis is small and curled on itself (omegashaped). Approximation of the posterior edges of the
epiglottis contributes to the inspiratory obstruction.
• Laryngomalacia may affect the epiglottis, the arytenoid
cartilages, or both. When the epiglottis is involved, it is
often elongated, and the walls fold in on themselves.
The epiglottis in cross section resembles an omega, and
the lesion has been referred to as an omega-shaped
epiglottis.
• If the arytenoid cartilages are involved, they appear
enlarged.
Laryngomalacia
• In either case, the cartilage is floppy and is noted to
prolapse over the larynx during inspiration.
• This inspiratory obstruction causes an inspiratory noise,
which may be high-pitched sounds frequently heard in
other causes of stridor, coarse sounds resembling nasal
congestion, and low-pitched stertorous noises.
• More severe compromise may be associated with a lower
ratio of the aryepiglottic fold length to the glottic length.
• In type 1 laryngomalacia, the aryepiglottic folds are
tightened or foreshortened. Type 2 is marked by
redundant soft tissue in any area of the supraglottic
region. Type 3 is associated with other disorders, such as
neuromuscular disease and gastroesophageal reflux.
Types of Laryngomalacia
• Type 1 – Anterior prolapse of mucosa overlying
arytenoid cartilages (57%)
• Type 2 – Short aryepiglottic folds tethering of
supraglottic structures in close antero-posterior
approximation (15%)
• Type 3 - Posterior collapse of epiglottis over
glottis (13%)
• Combination of above types (15%)
Types of Laryngomalacia
1-Infantile Laryngomalacia:
• Symptoms occur early in life.
• Improve by the age of 2 years
2-Late onset Laryngomalacia:
• Children > 2 years.
• Present during feeding, exercise or sleep.
• Presented by snoring or OSA.
3-State Dependent Laryngomalacia:
• Older age group / Adults.
• Occurs only during sleep.
• Diagnosed by sleep endoscopy.
Anatomical Abnormalities
1. Omega shaped epiglottis.
2. Short Ary-Epiglottic fold:
Ary-Epiglottic /Glottic length
• 0.5 = N
• 0.3 = severe LM
3. Redundant mucosa over arytenoids.
Pathophysiology of Laryngomalacia
•
•
•
•
•
•
•
•
•
Neuromuscular hypotonia (Thompson and Turner, 1900)
Poor muscular tone causing laryngeal collapse
Association with neurologic disorders
Dysfunction in sensorimotor integration of afferent
reflexes, brainstem function and motor responses
Altered sensorimotor integrative function (Thompson,
2010)
Intrinsic muscles of larynx not triggered to stent larynx
open
Seen by lack of laryngeal adductor reflex
May be central/brainstem
Possibly related to damage from reflux
Associated Pathology
• Isolated finding in otherwise healthy infant.
• Association with neurologic disorders E.g.
cerebral palsy
• 15-20% have a synchronous lesion
• Mild subglottic stenosis
• Tracheomalacia
Laryngomalacia
• Laryngomalacia is the most common cause of chronic
inspiratory noise in infants, no matter which type of
noise is heard.
• Infants with laryngomalacia have a higher incidence of
gastroesophageal reflux, presumably a result of the
more negative intrathoracic pressures necessary to
overcome the inspiratory obstruction.
• Conversely, children with significant reflux may have
pathologic changes similar to laryngomalacia,
especially enlargement and swelling of the arytenoid
cartilages.
• Some of the swelling of the arytenoid cartilages and of
the epiglottis may be secondary to reflux.
Laryngomalacia
• Occasional inflammatory changes are observed in the
larynx, which is referred to as reflux laryngitis.
• When the epiglottis is involved, gravity makes the noise
more prominent when the baby is supine.
• The exaggerated inspiratory effort increases blood
return to the pulmonary vascular bed. This could
account for the increased likelihood of pulmonary artery
hypertension in infants with hypoxemia.
• Rarely, the lesion may cause enough hypoxemia or
hypoventilation to interfere with normal growth and
development.
• In severe cases, when laryngomalacia may be
associated with gastroesophageal reflux, feeding
problems such as choking or gagging may occur .
Laryngomalacia
• Although this is a congenital lesion, airway sounds
typically begin at age 4-6 weeks. Until that age,
inspiratory flow rates may not be high enough to
generate the sounds. Symptoms typically peak at age 68 months and remit by age 2 years.
• Late-onset laryngomalacia may be a distinct entity,
which can present after age 2 years.
• Noises are inspiratory and may sound like nasal
congestion, with which they are initially confused.
• Usually, no feeding intolerance is noted, although
occasional choking or coughing with feedings may be
noted if the baby has reflux.
• Oxygen saturation is usually normal and the noise may
be increased if the baby is placed supine.
• laryngomalacia may present primarily with snoring and/or
sleep-disordered breathing and swallowing dysfunction in
a significant proportion of children, the diagnosis must be
considered in children, older than 3 months, presenting
with these upper airway complaints.
• Differential Diagnoses Congenital Stridor ,Croup
,Hypocalcemia, Airway Foreign Body, Gastroesophageal
Reflux ,Subglottic Stenosis Surgery ,Respiratory
Papillomatosis.
• Fluoroscopy of the airway may be performed by a pediatric
radiologist .The cartilages may be observed collapsing on
inspiration on a lateral view of the airway.
• Laryngoscopy :Direct visualization of the airway reveals an
omega-shaped epiglottis and Enlarged arytenoid cartilages
that prolapse over the larynx during inspiration may also
be present.
Laryngomalacia
• In more than 90% of cases, the only treatment necessary
for laryngomalacia is time. The lesion gradually
improves, and noises disappear by age 2 years in
virtually all infants.
• The noise steadily increases over the first 6 months, as
inspiratory airflow increases with age. Following this
increase, a plateau often occurs with a subsequent
gradual disappearance of the noise.
• In some cases, the signs and symptoms dissipate, but
the pathology may persist into childhood and adulthood.
In those cases, symptoms or signs may recur with
exercise or sometimes with viral infections.
• Children with severe retractions, cyanotic spells, and
apneas during sleep may have obstructive sleep apnea
associated with laryngomalacia. These children should
Laryngomalacia
• Children with severe retractions, cyanotic spells, and
apneas during sleep may have obstructive sleep apnea
associated with laryngomalacia.
• These children should be evaluated with a sleep study.
Supraglottoplasty may be of benefit in children with
severe symptoms of laryngomalacia . Thus, a detailed
sleep history should be taken in all infants with
symptoms of laryngomalacia.
• Recent data suggest infants with laryngomalacia and
hypoxemia may more readily develop pulmonary
hypertension.[7] Therefore, children with hypoxemia
should periodically undergo evaluation for pulmonary
hyperte
Indications for Surgery
• 10-31% of infants need surgery for
laryngomalacia
• Not following expected course/ responding to
medical therapy
• Severe laryngomalacia
1-Respiratory compromise
2-Feeding difficulty – reflux/aspiration
3-Weight loss/failure to thrive
4- Obstructive sleep apnea
Supraglottoplasty
• Procedure tailored to site/mechanism of
obstruction
• Type 1 :Excise redundant arytenoid tissue
• Type 2: Divide shortened aryepiglottic folds
• Type 3 : Pexy posteriorly displaced epiglottis to
base of tongue
Sleep endoscopy
• Sleep endoscopy is
examining the upper
airway using a flexible
laryngoscope.
• The patient is sedated by
giving propofol
intravenously.
• Awake endoscopy will not
give much information in
these two areas.
• Dynamic MRI can be done
first.
There are two areas need special attention-one is the
tongue base and other the epiglottis.
• Tongue base snorers are common and correcting the
palatal area and nose will give only partial improvement.
• Debulking the tongue base may have to be repeated.
Some surgeons perform resection of tongue base.
• Before considering radical surgery, the simple RF
Coblation of tongue base and lateral borders can be
done under local anesthesia or along with multilevel
surgery.
• The treatment of epiglottic collapse is Partial
Epiglottidectomy using Co2 laser but one might have to
be prepared for a temporary Percutaneous tracheotomy
and get consent before surgery.
• Injecting sclerosants in the epiglottis will not work.
EPIGLOTTIS SURGERY
• The epiglottis can contribute to obstructive sleep
apnea in some patients, with improvement after
partial removal of the epiglottis (epiglottidectomy).
• This procedure is performed in the operating
room under general anesthesia and is performed
entirely by working through the open mouth,
without any skin incisions.
• A laser or other method of cutting is used to
remove a portion of the epiglottis and control any
bleeding.
RISKS
• Bleeding :As with any procedure, there is a risk of
bleeding. Bleeding in this area can be serious if it is
substantial, as it would be close to the opening into the
windpipe (trachea).
• Typically, however, there is only minor oozing from the
cut edge of the epiglottis that resolves completely within
the first 24 hours after surgery.
• A major factor in preventing serious bleeding is to avoid
the use of aspirin, NSAIDs (such as ibuprofen, Advil®,
Motrin®, naproxen, or Aleve®), vitamin supplements, or
herbal medications for at least two weeks before and
after surgery.
• Infection :Infection is uncommon, but patients typically
receive antibiotics at the time of surgery to reduce the
chance of infection.
RISKS
• Tooth injury :Operating in the back of the throat is
impossible unless an instrument is placed to keep the
mouth open. This is the same instrument used when
tonsillectomies are done. Rarely, a tooth may be injured
by this instrument, and the risk is much higher if a tooth
is loose or decayed prior to surgery.
• Difficulty swallowing :The epiglottis is important in
swallowing because it closes off the opening into the
lungs through the trachea . After epiglottis surgery, it is
possible to have foods, especially liquids, entering the
trachea, only to be cleared with a gentle cough. It is
unusual for this complication to be permanent and
significant.
RISKS
• Changes in speech : Any operation on the throat can cause
changes in speech. The epiglottis is next to the larynx (voice
box), but no surgery is performed on the larynx itself. Therefore,
any changes in voice are usually temporary and are not
noticeable.
• Continued snoring :Many patients undergoing epiglottis
surgery will also have loud snoring. The goal of epiglottis
surgery is to eliminate obstructive sleep apnea. Usually snoring
will improve dramatically if this goal is accomplished. However,
many patients will continue to snore to some extent, even after
surgery that resolves obstructive sleep apnea completely.
• Need for additional procedures :Epiglottis surgery may not be
effective in accomplishing the goals of surgery. Another
procedure—either performed on the tongue region or on another
area—may be necessary.
POSTOPERATIVE INSTRUCTIONS
• Hospital stay and discharge :Most patients stay in the
hospital 1-2 days. The major concerns while you are in
the hospital are making sure you are breathing freely,
having no bleeding, controlling your pain with oral
medications, and drinking enough fluids to have no risk
of dehydration.
• You do need someone to stay with you the first night
home after discharge, for safety. Beyond that, it is
helpful to have someone available and checking on you
to provide assistance when needed, although they do
not have to stay with you 24 hours a day, every day.
• Planning before surgery (for example, buying milk or
nutritional supplements) will decrease the amount of
help you need at home after surgery.
POSTOPERATIVE INSTRUCTIONS
• Pain control :Like most surgeries, there is pain in the
recovery period. Controlling your pain is important for
breathing, healing, and being able to swallow enough to
maintain your nutrition.
• While in the hospital, we will control your pain with oral
medications, starting on the day of surgery. You can
also hold ice chips inside your mouth to decrease
swelling and reduce pain.
• Although we will use intravenous pain medications if
necessary, the goal will be to use oral medications alone
because this is what you will use when you go home
after surgery.
POSTOPERATIVE INSTRUCTIONS
• When you are at home, take your pain medication as
you need it. You can also continue to hold ice chips
inside your mouth to decrease pain and swelling. Try
not to let the pain increase until it becomes intolerable
before you take the medication.
• If you prefer to avoid narcotics, you should feel free to
use acetaminophen (Tylenol®). Avoid aspirin, NSAIDs
(such as ibuprofen, Advil®, Motrin®, naproxen, or
Aleve®), vitamin supplements, or herbal medications for
at least two weeks because they can increase your risk
of bleeding after surgery.
• Your pain will be significant for at least the first 7-10
days following surgery, but it should improve markedly
by 14 days following surgery.
POSTOPERATIVE INSTRUCTIONS
• Nutrition and fluids : It is very important to have good
nutrition and avoid dehydration after surgery.
• Due to the pain and swelling that is expected after
surgery, you will most likely only be able to tolerate a
liquid diet for the first 4-5 days after surgery. Push
yourself to drink fluids, even if it is painful.
• The first sign of dehydration is a decrease in urination,
so keep track of this. In addition to water, it is It is
helpful to drink other liquids, such as juices .
• It is also essential that your body receive protein and fat
in your diet to help with healing and maintaining your
energy level. Every day, you should have 3 glasses of
something with fat and protein like milk or chocolate
milk,
POSTOPERATIVE INSTRUCTIONS
• As your recovery continues, you will transition
to soft solid foods such as eggs, yogurt, or
mashed potatoes.
• You should be able to tolerate a fairly normal
diet by 2 weeks after surgery.
• During the recovery period, you should avoid
foods with sharp edges such as chips because
these can cause bleeding.
• Antibiotics :Most patients receive an antibiotic while in
the hospital. You may be prescribed an antibiotic to take
when you go home. This can be useful for preventing
infection and decreasing swelling.
POSTOPERATIVE INSTRUCTIONS
• Do not use mouthwashes, lozenges, or throat sprays
:Patients should not use mouthwashes, lozenges, or throat
sprays following surgery because many of these contain
alcohol that can irritate the lining of the mouth or numbing
medication that can expose you to a serious complication
when used for more than a couple of times.
• Activity :Walking after surgery is important. Patients should
walk at least 3 times a day starting the day after surgery.
Walking helps prevent blood clots from forming in your
legs. Spending more time out of bed (walking or in a chair)
than in bed is helpful because your lungs fill up with air,
lowering the risk of fevers and pneumonia.
• Patients should avoid strenuous activity for 4 weeks
following surgery because that typically raises heart rate
and blood pressure. For this reason, it can increase swelling
or cause bleeding to start.
POSTOPERATIVE INSTRUCTIONS
• Ear problems or jaw discomfort :The swelling in your
throat that occurs after surgery can cause jaw pain or
ear symptoms such as pain, pressure, or fullness. This
is common and should improve within 1-2 weeks
following surgery.
• It occurs because the soft palate and tonsils are next to
the jaw and the small Eustachian tube that connects the
space behind the eardrum to the top of the throat.
Swelling in the throat can interfere with your ability to
clear or pop your ears, and it can also be sensed by
your body as pain coming from your ears even though
the ears are not affected (a phenomenon called referred
pain).
POSTOPERATIVE INSTRUCTIONS
• Sleep with head elevated (at 45 degrees) and
avoiding supine position for at least three days
:Elevating your head during sleep decreases
blood flow to the head and neck regions.
Therefore, it decreases swelling and the
associated pain. Elevating the head during
sleep may also improve breathing patterns by
better movement of diaphrgm .
POSTOPERATIVE INSTRUCTIONS
• Nausea and constipation :Nausea and constipation are
very common after any surgery. The anesthetic
medications that you receive during surgery and the
narcotic pain medication you receive after surgery can
cause these.
• You will receive medications after surgery to decrease
nausea and constipation, but please notify your doctor .
if you feel constipated or have not had a bowel
movement in any 3 days after surgery.
• Postoperative appointment :Yout doctor likes to see his
patients 1-2 weeks after surgery.
POSTOPERATIVE INSTRUCTIONS
• There is hardly any chance of aspiration after removal of
part of the epiglottis as the patient fears.
• The vestibular fold acts as good protective valve during
swallowing.
• Effective and relatively safe treatment can be achieved
by partial resection of the epiglottis with a
microlaryngoscopic CO2 laser.
• Hyoid Suspension – If collapse occurs at the tongue
base, a hyoid suspension may be indicated. The
procedure secures the hyoid bone to the thyroid
cartilage and helps to stabilize this region of the airway.
Hyoid Suspension
Other upper airway surgery
• Genioglossus Advancement – The procedure tightens
the front tongue tendon; thereby, reducing the degree of
tongue displacement into the throat. This operation is
often performed in tandem with at least one other
procedure such as the UPPP or hyoid suspension.
• Maxillomandibular Advancement is a procedure that
surgically moves the upper and lower jaws forward. As
the bones are surgically advanced, the soft tissues of
the tongue and palate are also moved forward, again
opening the upper airway.
• For some individuals, the MMA is the only technique
that can create the necessary air passageway to resolve
their OSA condition.
Genioglossus Advancement
Maxillomandibular Advancement
AIRvance System for Obstructive Sleep Apnea
• The AIRvance Bone Screw
System enables surgical
treatment of tongue- and hyoidbased obstructive sleep apnea.
• For treating obstructive sleep
apnea, there are two surgical
procedures that may be performed
with the AIRvance System . The
tongue suspension procedure can
be done with or without the adjunct
hyoid suspension procedure.
Advantages of the AIRvance procedures
•
•
•
•
Quick (about 30 minutes for each procedure)
Low technical complexity
Effective
Reversible
AIRvance Tongue Suspension
• The AIRvance Tongue Suspension Procedure is
indicated for the treatment of obstructive sleep
apnea and/or snoring.
• The tongue suspension procedure can be
performed with or without the adjunct hyoid
suspension procedure.
• The objective of this procedure is to advance
and stabilize the genioglossus muscle to help
prevent it from falling back and occluding the
airway when the patient is supine and asleep.
A small titanium
screw with attached
sutures is implanted
in the lower
mandible, then the
sutures are looped
through the tongue
to form a hammock
that suspends it.
AIRvance Hyoid Suspension
• The AIRvance Hyoid Suspension procedure is
indicated for the treatment of OSA and/or
snoring.
• It serves as an adjunct to the AIRvance Tongue
Suspension procedure.
• The goal of this procedure is to help improve
airway patency by providing anterior/posterior
and lateral support of the lower airway, as well as
lateral support of the base of the tongue. This is
accomplished by advancing and suspending the
hyoid bone and associated musculature.
AIRvance Hyoid Suspension
• Two small titanium
screws with attached
sutures are implanted in
the lower mandible, and
the sutures are looped
around the hyoid bone
to suspend it.