Hyoid Myotomy and Suspension

The genioglossus and geniohyoid muscles as well as the middle pharyngeal constrictors insert on the hyoid bone. Consequently, the position of the hyoid complex is important in maintaining the patency of the hypopharyngeal airway.

Van de Graaff et al. (67) reported that anterior hyoid advancement improved the posterior airway space in a canine model. In 1984, Kaya (68) was the first to demonstrate this concept in human subjects. Thus, the rationale for hyoid myotomy and suspension is to alleviate hypopharyngeal obstruction by advancing the hyoid complex in an anterior direction. This procedure is considered as part of phase I surgery and may be performed as an isolated procedure or in combination with other techniques.

Currently, we rarely perform hyoid suspension simultaneously with genio-glossus advancement. The added trauma to the hypopharyngeal region can be problematic for the patient to tolerate, and it may prolong recovery. Furthermore, UPPP and genioglossus advancement may have enlarged the posterior airway space, so as to eliminate the need for additional surgery. Hyoid myotomy and suspension has become an adjunctive procedure to treat tongue base obstruction for those who previously underwent genioglossus advancement.

Originally, this surgery involved suspending the hyoid to the mandible with fascia lata (63). However, this required additional incisions and dissection to harvest the fascia lata and expose the mandible. In order to reduce the extent of surgery, the technique has been modified to suspend the hyoid bone to the superior border of the thyroid cartilage (42). A single horizontal incision is made at the level of the hyoid. Both the hyoid bone and thyroid cartilage are exposed. The hyoid is advanced anteriorly and secured to the thyroid cartilage with three or four permanent sutures (Fig. 6). Either general or local anesthesia may be utilized (69).

As stated previously, the overall success rate for phase I surgery was 61%. However, the majority of patients underwent genioglossus advancement with hyoid suspension and UPPP (38). Riley and Powell (42) found that hyoid myotomy and suspension improved SDB and corrected EDS in 75% of consecutively treated patients (n = 15) with documented sleep apnea. Yet, these patients also had previous genioglossus advancement. Two studies have reviewed the outcomes of patients treated with hyoid suspension alone without concurrent or previous genioglossus advancement for hypopharyngeal obstruction. The success rate from these studies ranged from 17% to 78% (69,70). Our experience has indicated that hyoid suspension is not efficacious as primary treatment of hypopharyngeal obstruction, but rather may be reserved as an adjunctive therapy.

Major complications are exceedingly rare with this surgery. The potential for airway obstruction exists, but this has not been observed at our center. Seroma or hematoma formation may occur; however, the use of surgical drains has reduced this complication. Transient aspiration or dysphagia can be observed but usually

FIGURE 6 (See color Insert.) Hyoid myotomy and suspension. The hyoid bone and thyroid cartilage are exposed via a small neck incision. The hyoid bone is advanced anteriorly and secured to the thyroid cartilage with three or four permanent sutures. Source: From Ref. 121.

will resolve within 10 days. If these symptoms persist, removal of the suspension sutures should alleviate this problem (71). Meticulous dissection of the suprahyoid musculature protects vital structures. Specifically, dissection should not extend l ateral to the lesser cornu or superior to the upper border of the hyoid to avoid injury to the superior laryngeal nerve and hypoglossal nerve, respectively. Infection can be managed with wound care and antibiotics should it occur.

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