Is maxillomandibular advancement (MMA) surgery a viable treatment option for a patient with severe obstructive sleep apnea (OSA), generalized anxiety disorder, bipolar I disorder, hypothyroidism, gastroesophageal reflux disease (GERD), and moderate gambling disorder, who has tried or failed other treatments like continuous positive airway pressure (CPAP) therapy?

Maxillomandibular Advancement Surgery for Severe OSA After CPAP Failure

Maxillomandibular advancement (MMA) surgery is a highly effective and appropriate treatment option for this patient with severe OSA who has failed CPAP therapy, with success rates of 85-90% and mean AHI reductions of approximately 80%. 1, 2

Treatment Hierarchy for Severe OSA

The treatment algorithm for severe OSA follows a clear stepwise approach:

• CPAP remains the gold standard first-line therapy for moderate to severe OSA, which this patient has appropriately attempted and failed 3, 1, 4
• MMA surgery is specifically recommended as a salvage therapy for patients with severe OSA who cannot tolerate or refuse CPAP, according to the American Academy of Sleep Medicine and European Respiratory Society 1, 4
• MMA should be considered before or instead of hypoglossal nerve stimulation in this patient, as the patient's AHI of severe OSA may exceed the typical HNS eligibility criteria (AHI 15-65 events/hour) 1, 5

Evidence Supporting MMA for Severe OSA

MMA demonstrates superior efficacy compared to other surgical alternatives:

• A meta-analysis of 518 patients showed surgical success rates of 85.5% (defined as >50% AHI reduction to <20 events/hour) and cure rates of 38.5% (AHI <5 events/hour) 2
• Mean AHI reductions of 47.8 events/hour (80.1% reduction) were achieved, with 98.8% of patients showing improvement 2
• Oxygen saturation nadir improved from 70.1% to 87.0%, and Epworth Sleepiness Scale scores decreased from 13.5 to 3.2 2
• Long-term follow-up data (43.7 months) confirms sustained success rates of 89% 6

Why MMA Over Other Alternatives

MMA is superior to other non-CPAP options for severe OSA:

• Mandibular advancement devices (MADs) are inappropriate for severe OSA, as they are significantly less effective than CPAP for AHI reduction in severe disease and represent a therapeutic step-down 1
• Hypoglossal nerve stimulation (HNS) has stricter eligibility criteria (AHI 15-65, BMI <32 kg/m²) that may exclude patients with very severe OSA, whereas MMA can treat patients across the full severity spectrum 1, 5
• Patients with preoperative AHI >60 events/hour still experience large and substantial improvements with MMA despite modest cure rates, making it effective even in very severe disease 2

Mechanism of Action

MMA works by physically expanding the skeletal framework:

• The procedure enlarges both the retropalatal and retrolingual airway spaces by advancing the maxillomandibular complex forward 6, 7
• Forward movement increases tissue tension, decreasing collapsibility of the velopharyngeal and suprahyoid musculature 6
• This addresses lateral pharyngeal wall collapse, a significant component of upper airway obstruction in OSA 6

Patient-Specific Considerations

This patient's comorbidities do not contraindicate MMA:

• The psychiatric conditions (generalized anxiety disorder, bipolar I disorder) and other medical comorbidities (hypothyroidism, GERD, gambling disorder) are not contraindications to MMA surgery 3, 1
• Weight optimization should be pursued concurrently with surgical planning, as lower BMI predicts better anatomical features and surgical efficacy 5
• The patient should undergo comprehensive preoperative evaluation including cephalometric analysis and assessment of craniofacial anatomy 5

Important Caveats

Key considerations before proceeding:

• 73.5% of MMA patients had undergone prior OSA surgery, indicating MMA is often used as salvage therapy after other procedures fail 2
• The procedure requires specialized surgical expertise in maxillofacial surgery and should be performed at centers with experience in this technique 1
• Comprehensive CPAP optimization should be documented before proceeding to surgery, including mask refitting, pressure adjustments, heated humidification, and behavioral interventions 1, 5
• Patients should be counseled about perioperative considerations including recovery time and potential complications, though MMA has demonstrated long-term stability 6, 7

Alternative Consideration: Hypoglossal Nerve Stimulation

If the patient's AHI falls within HNS eligibility criteria (15-65 events/hour):

• HNS could be considered as an alternative, with the advantage of being less invasive than MMA 1, 5, 8
• However, HNS requires strict anatomical candidacy confirmed by drug-induced sleep endoscopy (DISE), with absence of complete concentric collapse at the soft palate level 5
• HNS adherence is superior to CPAP, making it an attractive option for patients with adherence issues 8
• The patient must meet BMI criteria (<32-40 kg/m² depending on guideline) for optimal HNS outcomes 1, 5

For severe OSA with very high AHI (>65 events/hour), MMA remains the more appropriate surgical option over HNS. 1, 2