3.1 STEP ONE (BONE ANCHOR)

The procedure is performed under general or local anesthesia. Local anesthesia requires an external approach. Technically, the procedure may be combined with other pharyngeal procedures. Due to tethering and edema of the tongue, this procedure may augment the pain and dysphagia of other procedures. Benefits of combined procedures must be balanced with risks of increased perioperative morbidity and increased side effects. Using the procedure as an isolated intervention is recommended until clinical experience is adequate. Since a foreign body is placed, preoperative broad-spectrum antibiotics to cover and intraoral closed wound are given Decadron 10 mg reduces tongue pain and swelling and postoperative nausea. Intubation may be oral or nasal depending on the surgeon’s experience and preference. With oral intubation, care must be taken to protect the endotracheal tube from damage or displacement. The oral cavity is prepped with antibacterial solutions such as chlorhexidine oral solution. Exposure is facilitated by using a shoulder roll. Local anesthesia is infused into the anterior midline floor of mouth anterior to Wharton’s ducts.

When performing the intraoral approach, an intraoral incision is made posterior to the salivary papillae (Fig. 42.2). The incision should be generous. An excessively long linear incision is easily closed with excellent healing. An incision too small for the device may result in mucosal tearing that may damage the papillae and create an intraoral scar. If an external incision is used an incision is made 1cm posterior to the gnathion in a convenient skin crease or shadow.

Fig. 42.2 Placement of intraoral incision is shown. The midline incision should be generous in length to avoid trauma and possible tearing of mucosa. Alternatively, an extraoral approach may be performed (not shown).

3.2 STEP TWO

The suture is anchored to the bone. Two methods may be used. One method is an intraoral approach using the Repose (Influ-ENT Ltd, Concord, NH) bone screwanchoring device. Alternatively the suture may be anchored externally using the Repose device or other methods to anchor the suture to the inferior mandible. The Repose bone screw system consists of the U-shaped bone screw inserter that is used to place the bone screw onto the lingual surface of the mandible through an incision in the floor of mouth. It also includes the self-tapping titanium screw which is attached to two 1-0 Prolene sutures (Ethicon Endo-Surgery, Inc., Cincinnati, OH) at its base. Lastly, a suture passer is included to pass the suture through the tongue base.

A tunnel is created by dissecting between the genioglossus muscle bellies in the midline with a curved or right angle mixture hemostat. Intraorally, dissection is posterior and deep to Wharton’s ducts and is carried palpably to bone. Soft tissue may be gently scraped from the bone at this juncture. If using the Repose device intraorally, placement of the bone screw inserter into the mouth may be difficult in an OSA patient. The back blunt end of the distal device may first be placed into the mouth. The bone-anchoring screw may then be placed into the intraoral incision and then through the midline tunnel down to bone. Care must be taken to place the bone screw below the tooth roots. Using force and orienting the screw perpendicular to the mandibular cortex, the driver is placed against the mandible and inserted with the battery-operated inserter (Fig. 42.3). Alternatively, a Prolene suture may be directly anchored by drilling two parallel holes in the inferior mandible. The end (s) of the suture may then be looped through this attachment.

Fig. 42.3 Repose anchoring on the mandible is depicted. Care must be taken to stay below the level of the incisor teeth. Screw insertion must be perpendicular to the cortical bone to engage bone.

3.3 STEP THREE

The suture that is attached to the mandible is then advanced to the tongue base about 1–1.5cm lateral to the midline with an awl or a suture passer (Fig. 42.4). An empty suture loop is passed in a similar manner on the opposite side of the tongue taking care to avoid the neurovascular bundle that lies laterally. The suture attached to the screw is then threaded onto an empty Mayo needle, inserted into its own exit site on the tongue base and passed submucosally to the exit site of the second suture so that it is threaded into the loop of the second suture (Fig. 42.5). The second suture (the empty suture loop) is then pulled back to the anterior attachment. The Prolene suture attached to the mandible now is in a triangular configuration (Fig. 42.6). The suture is tied to itself and the knot is buried (Fig. 42.7). It is important that the tension on this suture be enough to feel a dimple on the posterior tongue base, but not so great as to cause strangulation. The correct angulation is undetermined and whether effectiveness is altered based on an intraoral or external approach is not known.

Fig. 42.4 Direction of the suture loop placement is depicted as view from above to an axial section of the tongue. Passing the suture loop on the patient’s right side is favorable for the right-handed surgeon to make passing the suspension suture across the tongue base easier in step 5. The internal anatomy of the tongue neurovascular pedicle is shown in shadowed grey. The first segment of the lingual artery and hypoglossal nerve run obliquely in the neck. The second segment courses more medially and vertically in the tongue and the third segment runs anteriorly. By keeping the sutures in the midline until well posterior, the neurovascular pedicle is avoided. The depth of passage should be superiorly towards the foramen cecum and not inferiorly into the valleculae.

Fig. 42.5 Placement of suspension suture on left side of patient’s tongue. This is then passed to right suture loop by a submucosal suture pass.

Fig. 42.6 Right suture loop pulls the suspension suture to complete the suture loop.

Fig. 42.7 The suture is tied anteriorly and the knot is buried submucosally.