The tongue is primarily composed of muscle. During sleep, the muscle can relax, contributing to blockage of breathing in the Tongue Region. The genioglossus is the largest muscle of the tongue, and it attaches on the central area on the inner side of the lower jaw. Genioglossus advancement captures this area of bony attachment and moves it forward. By moving the major anchor point for the tongue forward, the procedure creates more room for the tongue to relax during sleep without obstructing the passages for breathing in the throat. The result is an enlargement and stabilization of the airway.
How is genioglossus advancement sleep apnea surgery performed?
This procedure is performed for patients with obstructive sleep apnea, and it is performed in the operating room under general anesthesia. An incision is made inside the lower lip. The chin muscle and other soft tissues are cleared away to expose the central part of the lower jaw. Small rectangular cuts (roughly 1 x 2 cm, or less than ½ x 1 inch) are made in the lower jaw below the lower front teeth to capture the area of attachment of the genioglossus muscle. This rectangle of bone is moved forward and turned slightly. A small titanium screw is used to hold the bone fragment in place by securing it to the remainder of the lower jawbone. The chin muscle and soft tissues are replaced, and stitches are used to close the incision. The teeth and lower jawbone are not moved.
Bone fragment of the lower jaw pulled forward and secured in place with a titanium screw
Side view of the head and neck, after the genioglossus advancement procedure
The following video presents a discussion of Tongue Region procedures, including genioglossus advancement:
As with any procedure, there is a risk of bleeding. Bleeding in this area can be serious if it occurs underneath the tongue and is significant enough to push the tongue backwards. Typically, however, there is only minor oozing from the incision inside the lower lip. 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. Strict control of blood pressure also decreases the risk of bleeding, and patients undergoing this procedure have close monitoring the first night after surgery for blood pressure control.
Infection typically occurs after genioglossus advancement only if the incision inside the lower lip comes apart. To prevent this from happening, it is very helpful for patients to avoid talking unless absolutely necessary for three days following surgery (see postoperative instructions section). Patients also typically receive antibiotics at the time of surgery to reduce the chance of infection.
Prior to surgery, all patients undergoing this procedure will have a special X-ray (Panorex) performed to evaluate the bone of the lower jaw and the roots of the lower front teeth. Only patients without abnormalities of this area are candidates for the procedure. In spite of all precautions, it is possible for the lower front teeth to be injured during the procedure. In rare cases, this may require special dental care or a procedure such as an extraction or root canal.
This procedure involves cutting the lower jawbone below the tooth roots. There are very small nerves that travel through the bone up to these four lower front teeth. These nerves are unavoidably cut during the procedure, and therefore these teeth are numb immediately following the surgery. Over time, these nerves can re-grow, or other nerves in the area can grow to provide sensation to these teeth. During this period of the first 6-12 months following surgery, there can be tingling, sensitivity, or other unusual feelings in these teeth. Approximately one-third of patients have some degree of permanent numbness of these four teeth, but permanent tingling and sensitivity of the teeth are rare.
Chin and lower lip numbness
There are two large nerves that travel inside the lower jawbone and exit roughly at the sides of the chin to provide the sense of touch to the chin and lower lip. These nerves are not cut during the procedure, and the surgery does not typically involve dissection to the area where they do exit the bone. However, in moving the chin muscle and other soft tissue aside to perform the procedure, these nerves are also moved slightly. Some patients experience numbness of one or both sides of the chin and lower lip following surgery. This can be due either to swelling of the area or stretching of the nerves. It typically recovers over the course of days or weeks, but it can take months or be permanent.
Change in appearance
By moving a small rectangular piece of bone forward, the chin has a slight change in appearance. The best way to describe this change is that the chin becomes “stronger.” The jawbone has three layers, and the outer two layers are removed from this piece of bone so that the changes in appearance are less dramatic. Importantly, the chin muscle is relatively thick and drapes over this piece of bone to smooth the appearance of the chin. Many patients enjoy this minor change in appearance, but the goal of surgery is to minimize the effects because this is not the purpose of the procedure.
Weakening of the lower jawbone
The jaw’s thickest, strongest portion is along the lower edge. This procedure is designed so that this part of the bone is not disturbed. Nevertheless, the jawbone is weakened somewhat by the piece of bone that is cut out and moved forward. All patients should be careful to avoid significant trauma to the lower jawbone after this procedure because there is an increased risk of fracture.
The tongue is critical to swallowing, and swelling that occurs after any tongue procedure can present some difficulty. This should not be a permanent problem. The nerves responsible for tongue movement are not in the area where the surgery is performed and should not be affected by this procedure.
Need for additional procedures
Genioglossus advancement 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.
NOTIFY DR. KEZIRIAN IMMEDIATELY IF YOU HAVE ANY TROUBLE BREATHING OR IF ANY BLEEDING DEVELOPS!
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. Many people ask if they need someone to stay with them at home. 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.
Like most surgeries, there is pain in the recovery period. However, we want to control your pain to make you comfortable during your recovery. Some people try to “hang in there” or suffer without taking pain medications. 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. You will not receive a prescription for pain medications before surgery, as we will send you home with the type of medication and the amount that worked well for you in the hospital.
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 are running out of medication and need more, please call the office in advance to obtain another prescription. 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.
Ice in the mouth
Holding ice in the mouth while they melt and cool the surgical area can help with pain control. Doing this for the first 2-3 days after surgery is somewhat similar to applying ice to a sprained ankle. It is one of the safest ways to reduce pain and can make the healing process easier.
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 or Gatorade®. 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, nutritional supplements like Muscle Milk® or Ensure®, or protein shakes. Dr. Kezirian may order a nutritional supplement like this while you are in the hospital. 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. Otherwise, you can advance your diet according to your own schedule, being careful not to cause too much pain. Dr. Kezirian wants his patients to maintain their nutrition so that they do not lose weight in the few weeks right after surgery.
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. Take the antibiotics as directed. If you develop a rash or diarrhea (possible risks of antibiotics and other medications), stop the antibiotics and contact Dr. Kezirian immediately.
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. Not walking enough is a major cause of fevers after surgery, so please do remember to walk at least 3 times every day. 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.
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 or other chemicals 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.
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).
Sleep with head elevated (at 45 degrees) 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 in other ways. Therefore, we recommend elevating your head during sleep at 45 degrees for at least three days following the procedure.
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 Dr. Kezirian if you feel constipated or have not had a bowel movement in any 3 days after surgery.
Dr. Kezirian likes to see his patients 1-2 weeks after surgery. If a postoperative appointment has not been scheduled, please contact the office at 323-442-5790 to schedule this when you return home after your surgery.
For any emergencies, please call 911. For other questions, please contact Dr. Kezirian at [email protected]. If you would like to speak with someone, please call the Call Center at 323-442-5790 and ask to speak to Dr. Kezirian or whomever is answering calls for his patients.