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Geniotubercle Advancement With a Uvulopalatal Flap and Its Effect on Swallow Function in Obstructive Sleep Apnea Joseph W. Rohrer, MD, Captain, USAF, MC; Robert Eller, MD, Lt Col, USAF, MC; Phyllis G. Santillan, MS, CCC-SLP; Jose E. Barrera, MD, FACS, Lt Col, USAF, MC Objectives/Hypothesis: Evaluate swallowing characteristics before and after geniotubercle advancement (GTA) with a uvulopalatal flap (UPF). Study Design: Prospective case control series in an academic military practice. Methods: Fourteen patients with apnea-hypopnea index (AHI) >10 scheduled for GTA were enrolled consecutively, eight of whom completed all aspects of the study for evaluation. Video fluoroscopic swallow study was performed preoperatively and 4 months postoperatively. National Institute of Health freeware ImageJ64 software was used to measure hyolaryngeal elevation and displacement. Video recordings assessed vallecular pooling, aspiration, and bolus movement. Studies were reviewed by a speech pathologist and an otolaryngologist. Results: Preoperatively, the mean AHI was 48.3 6 48.45 events per hour, with a median of 48.5 (range, 12.4–76). Postoperatively the mean AHI was 11.6 6 10.7 events per hour, with a median of 10.75 (range, 3.8–29) (P 5.003). There was no reported pre- or postoperative dysphagia or aspiration. No radiographic evidence of silent aspiration was seen. Hyolaryngeal movements were measured as a percentage of C2–C4 reference distance. The superior elevations were pre- and postoperatively 40% and 37% (P 5.85), anterior displacement changes 18.9% and 18.8% (P 5.23), and total motion 49% and 42% (P 5.26), respectively. Conclusions: GTA with UPF surgery did not significantly affect the hyolaryngeal function of patients. Key Words: Obstructive sleep apnea, geniotubercle advancement, uvulopalatopharyngoplasty, sleep surgery, swallow function, video fluoroscopic swallow study. Level of Evidence: 4. Laryngoscope, 125:758–761, 2015

INTRODUCTION Obstructive sleep apnea (OSA) is a fairly prevalent condition affecting approximately 4% of adult males and 2% of adult females in the United States.1 This is due to narrowing and/or excessive hypotonia of the upper airway during sleep, resulting in occlusion of the airway. There is a wide spectrum of treatment options available, ranging from continuous positive airway pressure (CPAP) treatment, maxillomandibular advancement, dental mandibular repositioning devices, to various forms of surgery to the airway. There is no universally successful, well-tolerated, and accepted form of surgical treatment to date. Traditionally, patients are offered surgery after failure of CPAP therapy.

From the Department of Otolaryngology (J.R., R.E., P.G.), and the Division of Sleep Surgery and Facial Plastic Surgery, Department of Otolaryngology (J.E.B.), San Antonio Military Medical Center, San Antonio, Texas, U.S.A. Editor’s Note: This Manuscript was accepted for publication August 20, 2014. The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Joseph W. Rohrer, MD, Department of Otolaryngology, San Antonio Military Medical Center, 3851 Roger Brooke Drive, Ft. Sam Houston, TX 78234-6200. E-mail: [email protected] DOI: 10.1002/lary.24939

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In 1984, Riley et al. described genial tubercle advancement (GTA) with the hopes of drawing the tongue forward and increasing the posterior airway space.2,3 These surgical procedures have been refined over the years to include advancing the maxilla as well as the mandible. Although the success of this operation has been studied based on anatomical changes and improvement in OSA, little has been studied on the effects the surgery has on swallowing. The tongue base and soft palate are critically important in swallowing. Altman et al. used barium swallow compared to subjective questionnaires following uvulopalatopharyngoplasty and geniohyoid advancement. Anatomical correlations seen on barium swallow and subjective feelings of swallowing difficulties did not match. Their results showed abnormal swallowing in 60% of patients in the oral or pharyngeal phase.4 One of the more common observations in dysphagia is poor hyolaryngeal complex elevation. In 1991, Lindgren and Janzon found that between 7% and 9% of adults over the age of 50 years have some level of dysphagia.5 In 2010, Allen et al. found in normal patients that 10 who were scheduled for UPF and GTA were enrolled consecutively from the senior author’s outpatient clinic (J.E.B.) between 2009 and 2012. The parameters used in this study to determine obstruction in the oropharyngeal and/or hypopharyngeal level included Fujita clinical classification, lateral cephalogram, and Muller’s maneuver. Fujita classification and Muller’s maneuver were used to determine patient candidacy for combined UPF and GTA, specifically detailing class I (oropharynx only), class II (both oropharynx and hypopharynx), and class III (only hypopharynx) patterns of obstruction. Patients were Fujita class 2 with both palatal and base of tongue obstruction visualized on flexible nasopharyngeal exam who had not had previous surgery for OSA. In addition, lateral cephalogram was used to identify oropharyngeal and hypopharyngeal narrowing in all patients compared to cephalometric norms published in the literature.7,8 In-lab polysomnography (PSG) with a minimum of 240 minutes recorded total sleep time was performed on every patient in the study. Twelve patients were enrolled, with eight completing the study due to failure to comply with the postoperative swallow study. PSG was also performed 4 months postoperatively.

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VFSS was performed preoperatively and 4 months postoperatively. Four months was chosen to allow complete absorption of suture material and for mature surgical healing. The VFSS was performed by the speech language pathologist in the radiology fluoroscopy suite using the institutional protocol. Thin barium was used as a bolus. Fluoroscopic videos were recorded, and still frames were then captured to evaluate progression of barium throughout all levels of swallow. National Institutes of Health (Bethesda, MD) freeware, Imagej64, was then used to analyze the images. Each patient had a baseline measurement from the inferior portion of C2 to the inferior portion of C4 (Fig. 1). This was used as the reference value. The displacement values were then represented as a percentage of the C2–C4 reference unit.6,9 This was chosen as an easily obtainable measurement that was unlikely to have significant congenital variation and would help eliminate scale variance from tall to short subjects. This eliminated any variance from radiograph distance at pre- and postoperative VFSS. Once the baseline was taken, this was used as a reference distance. The hyoid bone was then identified and marked at the resting state. Measurements were then made in reference to the anterior edge of the cervical spine and from a perpendicular line at the base of C4 (Fig. 2). Additional marks were annotated at the level of maximal anterior displacement and maximal superior displacement (Fig. 3). Using Pythagorean’s theorem, total maximal distance was calculated. These measurements were performed on deidentified image series independently to provide tester blinding during measurements. The data were imported into a spreadsheet, and the Student t test was performed looking for significance between pre- and postoperative measurements. The video recordings were also assessed for vallecular pooling, aspiration, and bolus movement per our institution’s standard swallow study protocol. Studies were reviewed by a speech pathologist and an otolaryngologist. The surgical technique involved in this study combined both a UPF and the GTA procedure. Retropalatal obstruction is dealt with using a UPF. The author’s technique for UPF and GTA are described in the literature.7,8

Statistical Analysis A paired, two-tailed Student t test was used to compare preoperative and postoperative mean scores within groups for

Rohrer et al.: GTA With a Uvulopalatal Flap


Fig. 4. Average displacements are shown as percentage of C2–C4 reference value. Statistical significance was not seen between the pre- and postoperative measurements based on the Student t test. For superior displacement, P 5.85; for anterior displacement, P 5.23; and for total motion, P 5.26.

Fig. 3. Lateral view captured at maximal hyoid displacement during the swallow. Superior and anterior references are marked, and the anterior border of the hyoid is also outlined. apnea-hypopnea index (AHI), superior and anterior hyoid displacement, and total hyolaryngeal motion.

changes were 18.9% 6 0.19 and 18.8% 6 0.10 postoperatively (P 5.23). Mean preoperative total motion was 49% 6 0.12 compared to 42% 6 0.09 postoperatively (P 5.26) (Fig. 4). Trace penetration without aspiration or cough was seen in one patient pre- and postoperatively but considered a variant of normal. Two other patients had trace residual in the vallecula cleared with the second swallow on initial study. One of these patients had resolution, and trace residual cleared with additional swallow was seen in one patient who did not have it noted preoperatively. These were all considered variants of normal, not causing symptoms, nor were any therapy, treatment, or dietary changes recommended.

RESULTS Preoperative demographics of the eight patients included mean age of 50.4 years (range, 26–68 years) and a mean body mass index (BMI) of 30.2 (range, 27– 33). Preoperatively, the mean AHI was 48.3 events per hour, with a median of 48.5 (range, 12.4–76). Postoperatively, the mean AHI was 11.6 events per hour, with a median of 10.75 (range, 3.8–29) (Table I). Pre- and postoperative AHI reduction was statistically significant (P 5.003). There was no reported pre- or postoperative dysphagia or aspiration. Subjects reported normal swallowing function as determined by the 10-item Eating Assessment Tool questionnaire. There was no radiographic evidence of silent aspiration in any patient. Pharyngeal bars or strictures were not seen. Preoperatively, the mean hyolaryngeal superior elevation was 40% 6 0.14 of the C2–C4 height and 37% 6 0.07 postoperatively (P 5.85). Preoperative anterior displacement

DISCUSSION GTA with UPF was effective at reducing AHI at 6 months in this patient group. This is comparable to previous studies with GTA and palatal surgery. There is a low risk for side effects including mandibular fracture,

TABLE I. Values of the Eight Patients Showing Changes in AHI in Events per Hour and Hyolaryngeal Displacement Measurements as Percentages of the C2–C4 Reference Value. Preoperative Age, yr/Sex





AHI Reduction















3 4

26M 58M

29.0 28.4

28.6 26.9

76 72

8 22.4






6 7

27M 39M

28.4 33.0

27.4 31.6

22 76






Patient No.

Superior Displacement


Anterior Displacement

Total Motion

Superior Displacement

Anterior Displacement

Total Motion













68 49.6

0.14 0.66

0.31 0.27

0.34 0.71

0.28 0.5

0.05 0.18

0.28 0.53









3.8 29

18.2 47

0.315 0.443

0.174 20.26

0.35 0.51

0.366 0.313

0.195 0.07

0.41 0.32









AHI 5 apnea-hypopnea index; BMI 5 body mass index.

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Rohrer et al.: GTA With a Uvulopalatal Flap

tooth numbness, or hematoma.10,11 There were no complications in our study group. The UPF creates a stiffer palate positioned more anteriorly. A potential swallowing complication is velopalatal insufficiency with nasal regurgitation. This was not noted subjectively or seen on the VFSS. Hyoid myotomy was not performed, as we had efficacious results without it, and previous work has shown it to have low efficacy and increased complication risks.9 Hypopharyngeal obstruction is treated with tracheostomy, GTA, or maxillomandibular advancement (MMA). GTA is a simple technique that does not move the teeth or jaw and therefore does not affect the dental bite. GTA is a procedure performed as a solitary hypopharyngeal procedure or in combination with MMA. The technique places the genioglossus and geniohyoid under tension, and this tension may be sufficient to keep the base of tongue anteriorly positioned during sleep. Our published clinical outcomes for cure rates for phase one soft tissue surgery is 42% to 75% depending on the severity of the disorder. Other centers have reported similar results with this procedure.10,11 GTA primarily advances the genioglossus, with a secondary effect on the geniohyoid. The geniohyoid is attached at the inferior mental spine and is likely not always included in the geniotubercle window. Avoiding the hyoid myotomy creates less impact on the hyolaryngeal complex. This can explain the absence of dysphagia compared to previous studies.12 This procedure does not appear to affect the ability of the base of tongue to interact with the posterior pharyngeal wall or to obtain closure of the nasopharynx in the oral and propulsion phase of swallowing. Additionally, although some change in hyolaryngeal position is measurable, it does not appear to have any significant effects on the hyoid movement following surgery and did not cause aspiration or dysphagia in this study. Of note, subclinical features of trace penetration and vallecular residual were encountered. Also, it did not support the hypothesis that GTA altered the swallow mechanics enough to make a clinical difference in patients with poor hyolaryngeal elevation. Video fluoroscopic swallow study was chosen, because this allowed examination of the hyolaryngeal complex, tongue base, and soft palate, as they are involved real time in the swallow process. We did not see velopalatal insufficiency or oral phase dysfunction of bolus preparation and propulsion. The GTA UPF procedures were performed without any documented complication at 6 months.

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This study does have limitations. It is a small cohort. Initial enrollment was complicated by participant failure to attend their preoperative swallow study, which excluded them from further analysis. Overall, 14 patients initially enrolled, with four subjects failing to attend their initial swallow study and two dropping out of the study after multiple scheduled attempts to attend the postoperative study. Additionally, multiple patients elected not to participate following informed consent for fear of fluoroscopy radiation exposure. Due to the high dropout rate, there could be a selection bias. Additionally, this study only had men complete all aspects, whereas three women were initially enrolled but did not complete the study.

CONCLUSION GTA with UPF surgery did not significantly affect the hyolaryngeal function of patients. It did not worsen dysphagia, and there were no clinically significant complications of swallowing function seen.

BIBLIOGRAPHY 1. Lee W, Nagubadi W, Kryger MH, Mokhlesi B. Epidemiology of obstructive sleep apnea: a population-based perspective. Expert Rev Respir Med 2008;2:349–364. 2. Riley RW, Guilleminault C, Powell NB, Derman S. Mandibular osteotomy and hyoid bone advancement for obstructive sleep apnea: a case report. Sleep 1984;7:79–82. 3. Li KK, Riley RW, Powell NB, Troell RJ. Obstructive sleep apnea surgery: genioglossus advancement revisited. J Oral Maxillofac Surg 2001;59: 1181–1184. 4. Altman JS, Halpert RD, Mickelson SA, Senior BA. Effect of uvulopalatopharyngoplasty and genial and hyoid advancement on swallowing in patients with obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg 1999;120:454–457. 5. Lindgren S, Janzon L. Prevalence of swallowing complaints and clinical findings among 50-79-year-old men and women in an urban population. Dysphagia 1991;6:187–192. 6. Allen JE, White CJ, Leonard RJ, Belafsky PC. Prevalence of penetration and aspiration on videofluoroscopy in normal individuals without dysphagia. Otolaryngol Head and Neck Surg 2010;142:208–214. 7. Barrera JE, Riley R, Powell N. Facial Skeletal Surgery in the management of adult obstructive sleep apnea syndrome. Clin Plast Surg 2007;34: 565–573. 8. Riley R, Guilleminault C, Powell N, Simmons FB. Palatopharyngoplasty failure, cephalometric roentgenograms, and obstructive sleep apnea. Otolaryngol Head Neck Surg 1985;93:240–244. 9. Steele CM, Bailey GL, Chau T, et al. The relationship between hyoid and laryngeal displacement and swallowing impairment. Clin Otolaryngol 2011;36:30–36. 10. Lewis MR, Ducic Y. Genioglossus muscle advancement with the genioglossus bone advancement technique for base of tongue obstruction. J Otolaryngol 2003;32:168–173. 11. Emara TA, Omara TA, Shouman WM. Modified genioglossus advancement and uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Otolaryngol Head Neck Surg 2011;145:865–871. 12. Bowden MT, Kezirian EJ, Utley D, Goode RL. Outcomes of hyoid suspension for the treatment of obstructive sleep apnea. Arch Otolaryngol Head Neck Surg 2005;131:440–445.

Rohrer et al.: GTA With a Uvulopalatal Flap


Geniotubercle advancement with a uvulopalatal flap and its effect on swallow function in obstructive sleep apnea.

Evaluate swallowing characteristics before and after geniotubercle advancement (GTA) with a uvulopalatal flap (UPF)...
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