US20150013687A1 - Implantable devices, systems, and methods for maintaining desired orientations in targeted tissue regions - Google Patents

Abstract

At least one implant structure is sized and configured for implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue, e.g., a genioglossus muscle. The position of the implant structure is stabilized relative to the extrinsic muscle region to maintain the tongue in a desired orientation, e.g., to maintain patency of an airway.

Description

RELATED APPLICATIONS
• This application is a continuation-in-part of copending U.S. patent application Ser. No. 11/656,699, filed Jan. 23, 2007, and entitled “Systems and Methods for Moving and/or Restraining Tissue in the Upper Respiratory System,” which is a division of U.S. patent application Ser. No. 10/236,455, filed Sep. 6, 2002, and entitled “Systems and Methods for Moving and/or Restraining Tissue in the Upper Respiratory System,” which are incorporated herein by reference. This application is also a continuation-in-part of copending U.S. patent application Ser. No. 10/718,254, filed Nov. 20, 2003, end entitled “Devices, Systems and Methods to Fixate Tissue Within the Regions of the Body Such as the Pharyngeal Conduit,” which is also incorporated herein by reference. This application also claims the benefit of U.S. Provisional Application Ser. No. 60/903,741, filed Feb. 27, 2007, and entitled “Devices, Systems, and Methods to Move or Restrain the Hyoid Bone,” which is incorporated herein by reference.
FIELD OF THE INVENTION
• The invention is directed to devices, systems, and methods for the treatment of sleep disordered breathing including snoring and obstructive sleep apnea.
BACKGROUND OF THE INVENTIONI. Characteristics of Sleep Apnea
• First described in 1965, sleep apnea is a breathing disorder characterized by brief interruptions (10 seconds or more) of breathing during sleep. Sleep apnea is a common but serious, potentially life-threatening condition, affecting as many as 18 million Americans. Snoring also can occur independent of or during a sleep apneic event.
• There are two types of sleep apnea: central and obstructive. Central sleep apnea, occurs when the brain fails to send the appropriate signal to the breathing muscles to initiate respirations, e.g., as a result of brain stem injury or damage. Mechanical ventilation is the only treatment available to ensure continued breathing.
• Obstructive sleep apnea (OSA) is far more common. Normally, the muscles of the upper part of the throat keep the airway open to permit air flow into the lungs. When the muscles at the base of the tongue and the uvula (the small fleshy tissue hanging from the center of the back of the throat) relax and sag, the relaxed tissues may vibrate as air flows past the tissues during breathing, resulting in snoring. Snoring affects about half of men and 25 percent of women—most of whom areage 50 or older.
• In more serious cases, the airway becomes blocked, making breathing labored and noisy, or even stopping it altogether. In a given night, the number of involuntary breathing pauses or “apneic events” may be as high as 20 to 30 or more per hour. These breathing pauses are almost always accompanied by snoring between apnea episodes, although not everyone who snores has the condition. Sleep apnea can also be characterized by choking sensations.
• Lack of air intake into the lungs results in lower levels of oxygen and increased levels of carbon dioxide in the blood. The altered levels of oxygen and carbon dioxide alert the brain to resume breathing and cause arousal. The frequent interruptions of deep, restorative sleep often lead to early morning headaches, excessive daytime sleepiness, depression, irritability, and learning and memory difficulties.
• The medical community has become aware of the increased incidence of heart attacks, hypertension and strokes in people with moderate or severe obstructive sleep apnea. It is estimated that up to 50 percent of sleep apnea patients have high blood pressure.
• Upon an apneic event, the sleeping person is unable to continue normal respiratory function and the level of oxygen saturation in the blood is reduced. The brain will sense the condition and cause the sleeper to struggle and gasp for air. Breathing will then resume, often followed by continued apneic events. There are potentially damaging effects to the heart and blood vessels due to abrupt compensatory swings in blood pressure. Upon each event, the sleeping person will be partially aroused from sleep, resulting in a greatly reduced quality of sleep and associated daytime fatigue.
• Although some apneic events are normal in all persons and mammals, the frequency of blockages will determine the seriousness of the disease and opportunity for health damage. When the incidence of blockage is frequent, corrective action should be taken.
II. The Anatomy of the Upper Airway
• AsFIG. 1 shows, the upper airway consists of a conduit that begins at the nasal valve, situated in the tip of the nose, and extends to the larynx, which is also called the voice box because it houses the vocal cords. The pharynx (which, in Greek, means “throat”) is a cone-shaped passageway in the upper airway that leads from the oral and nasal cavities in the head to the esophagus and larynx. The pharynx serves both respiratory and digestive functions. Both circular and longitudinal muscles are present in the walls of this organ, which are called the pharyngeal walls. The circular muscles form constrictions that help push food to the esophagus and prevent air from being swallowed, while the longitudinal muscles lift the walls of the pharynx during swallowing.
• The pharynx consists of three main divisions. The superior portion is the nasal pharynx, the back section of the nasal cavity. The nasal pharynx connects to the second region, the oral pharynx, by means of a passage called an isthmus. The oral pharynx begins at the back of the mouth cavity and continues down the throat to the epiglottis, a flap of tissue that covers the air passage to the lungs and that channels food to the esophagus. The isthmus connecting the oral and nasal regions allows humans to breathe through either the nose or the mouth. The third region is the laryngeal pharynx, which begins at the epiglottis and leads down to the esophagus. Its function is to regulate the passage of air to the lungs and food to the esophagus. Air from the nasal cavity flows into the larynx, and food from the oral cavity is routed to the esophagus directly behind the larynx. The epiglottis, a cartilaginous, leaf-shaped flap, functions as a lid to the larynx and, during the act of swallowing, controls the traffic of air and food.
• The mouth cavity marks the start of the digestive tube. Oval in shape, it consists of two parts: the vestibule and the mouth cavity proper.
• The vestibule is the smaller outer portion, delimited externally by the lips and cheeks and internally by the gums and teeth. It connects with the body surface through the rima or orifice of the mouth. The vestibule receives the secretion of the parotid salivary glands and connects when the jaws are closed with the mouth cavity proper by an aperture on both sides behind the wisdom teeth, and by narrow clefts between opposing teeth.
• The mouth cavity proper contains the tongue and is delimited laterally and in the front by the alveolar arches with the teeth therein contained. The alveolar process on the upper jaw is contained in the maxillae, whereas the alveolar process on the lower jaw is contained in the mandible. The mandible is a U-shaped bone that supports the mandibular (lower) teeth.
• The mouth cavity proper receives the secretion from the submaxillary and sublingual salivary glands. The mouth cavity proper connects with the pharynx by a constricted aperture called isthmus faucium.
• The tongue (seeFIG. 1B) is a mobile muscular organ that can assume a variety of shapes and positions. The tongue comprises extrinsic and intrinsic muscles. The extrinsic muscles (genioglossus, hyoglossus, styloglossus, and palatoglossus) (shown inFIG. 1B) have their origin in other structures and attach to the tongue. Their function is to move the tongue and, at times, change its shape. The intrinsic muscles of the tongue (superior longitudinal, inferior longitudinal, transverse, vertical) (not shown with particularity) are attached entirely within the tongue work to modify the shape of the tongue. The inferior surface of the tongue (seeFIG. 1C) is covered with a thin, transparent mucous membrane through which one can see the underlying veins. With the tongue raised (as shown inFIG. 1C), the lingual frenulum is exposed. The lingual frenulum is a large, midline fold of mucosa that connects the tongue to the floor of the mouth, while allowing the anterior part of the tongue to move freely.
• The tongue has a relatively fixed inferior part that is attached to the hyoid bone and mandible. The rest of the tongue is called the body of the tongue. It is essentially a mass of muscles (that is mostly covered by mucous membrane. The muscles in the tongue do not act in isolation. Some muscles perform multiple actions with parts of one muscle acting independently producing different, sometimes antagonistic, actions.
• The tongue is partly in the mouth or oral cavity and partly in the pharynx. At rest, it occupies essentially the entire oral cavity. The posterior part of the tongue demarcates the posterior boundary of the oral cavity. Its mucous membrane is thick and freely movable.
• The tongue is involved with mastication, taste, articulation, and oral cleansing. Its two main functions are forming words during speaking and squeezing food into the pharynx when swallowing.
• The epiglottis is a protective fold of the cartilage posterior to the base of the tongue and in front of the larynx. When a human breathes, the epiglottis stands up, allowing air to go into the larynx and lungs. During swallowing, the epiglottis folds back to cover the larynx and keep food from entering the windpipe and lungs. Once the swallowing is over, the epiglottis resumes its upright position.
• The palate forms the arched roof of the oral or mouth cavity (the mouth) and the floor of the nasal cavities (the nose). It separates the oral cavity from the nasal cavities and the nasal pharynx. The palate consists of two regions—the hard palate anteriorly and the soft palate posteriorly.
• The hard palate is vaulted and defines the space filled by the tongue when it is at rest. The hard palate is bounded in the front and laterally by the alveolar arches and gums and in the back by the soft palate. A dense structure made up by the periosteum and the mucous membrane of the mouth covers the hard palate. The linear raphé lies along the middle line of the hard palate. The hard palate has a hard bony skeleton, hence its name.
• The soft palate has no bony skeleton, hence its name. The soft palate is a movable fold, suspended from the posterior border of the hard palate and forms an incomplete dividing line (septum) between the mouth and the pharynx. The soft palate comprises a mucous membrane that envelops muscular fibers, an aponeurosis, vessels, nerves, adenoid tissue, and mucous glands. When the soft palate is relaxed and hanging, the anterior surface is concave and follows the same line as the roof of the mouth. The posterior surface of the soft palate is convex and is a continuance of the mucous membrane that covers the bottom part of the nasal cavities. The upper boundary of the soft palate attaches to the hard palate; the sides become part of the pharynx; and the lower boundary is free. The lower boundary which hangs down, separating the mouth and the pharynx is known as the palatine velum. In the middle of the lower boundary, the small, fleshy cone-shaped protuberance is called the uvula; the uvula prevents the food from entering the nasopharynx and the muscles of the soft palate push the food down into the pharynx. The arches are located laterally and downwardly from the uvula. These arches are called the glossopalatine arch (the anterior arch) and the pharyngopalatine arch (the posterior arch). The palatine aponeurosis is a thin, firm fiber-filled lamella which gives support to the muscles and makes the soft palate strong.
• The soft palate is suspended from the posterior border of the hard palate. It extends posteriorly and inferiorly as a curved free margin from which hangs a conical process, called the uvula; closely following behind the soft palate are the palatoglossal and the palatopharyngeal arches, respectively. Muscles arise from the base of the cranium and descend into the soft palate. The muscles allow the soft palate to be elevated during swallowing into contact with the posterior pharyngeal wall. The muscles also allow the soft palate to be drawn inferiorly during swallowing into contact with the posterior part of the tongue.
• The soft palate is thereby very dynamic and movable. When a person swallows, the soft palate initially is tensed to allow the tongue to press against it, to squeeze the bolus of food to the back of the mouth. The soft palate is then elevated posteriorly and superiorly against the pharyngeal wall, acting as a valve to prevent passage of food into the nasal cavity.
• Caudal to the soft palate, the hyoid bone is situated at the base of the tongue in the anterior part of the neck at the level of the C3 vertebra and in the angle between the mandible and the thyroid cartilage of the larynx, the voice box. It is a symmetric U-shaped bone (seeFIG. 2B), comprising a body with greater horns and lesser horns, which serve as points of attachment for numerous muscles in the tongue, pharynx, and the anterolateral part of the neck (seeFIGS. 3A to 3D).
• The hyoid bone does not articulate with any other bone. It serves a purely anchoring function for muscles. The hyoid bone is suspended from the styloid processes of the temporal bones by the stylohyoid ligaments and is firmly bound to the thyroid cartilage. Functionally, the hyoid bone serves as an attachment point for numerous muscles and a prop to keep the airway open. The primary function of the hyoid bone is to serve as an anchoring structure for the tongue.
• FIGS. 3A to 3D show some of the numerous muscles that are attached to the hyoid bone (as doesFIG. 1B). The muscles attached to the hyoid bone include the middle pharyngeal constrictor muscle (seeFIG. 3A), which attaches at the end of the greater horns. The middle pharyngeal constrictor muscle, together with the superior and inferior pharyngeal constrictor muscles (also shown inFIG. 3A), extend along the upper airway. As before stated, a change in muscle function of the pharyngeal constrictor muscles can lead to pharyngeal narrowing and collapse.
• The muscles attached to the hyoid bone also include the hyoglossus muscles (seeFIGS. 3B and 3D, as well asFIG. 1B). The hyoglossus muscles originate along the entire length of each greater horn and also from the body of the hyoid. The hyoglossus muscles are inserted into the posterior half or more of the sides of the tongue, asFIG. 3D best shows. The hyoid bone anchors the hyoglossus muscles when they contract, to depress the tongue and to widen the oral cavity, thereby opening the airway.
• The muscles attached to the hyoid bone also include the two geniohyoid muscles (seeFIG. 3C). The geniohyoid muscles originate close to the point at which the two halves of the lower jaw meet; the fibers of the muscles extend downward and backward, close to the central line, to be inserted into the body of the hyoid bone. Contraction of the geniohyoid muscles pulls the hyoid bone upward and forward, shortening the floor of the mouth and widening the pharynx.
• Inserting into the middle part of the lower border of the hyoid bone are the sternohyoids (seeFIG. 3C). The sternohyoids are long muscles arising from the breastbone and collarbone and running upward and toward each other in the neck. The sternohyoids depress the hyoid bone after it has been elevated during swallowing.
• Other muscles attached to the hyoid bone are the two mylohyoid muscles (seeFIG. 3C), which form a sort of diaphragm for the floor of the mouth, elevating the floor of the mouth and tongue during swallowing; the thyrohyoid (seeFIG. 3C), arising from the thyroid cartilage of the larynx, which elevates the larynx; and the omohyoid (seeFIG. 3C), which originates from the upper margin of the shoulder blade, which depresses, retracts, and steadies the hyoid bone.
• The position of the hyoid bone with relation to the muscles attached to it has been likened to that of a ship steadied as it rides when anchored “fore and aft.” Through the muscle attachments, the hyoid plays an important role in mastication, in swallowing, and in voice production.
• The larynx, also known as the organ of voice, is part of the upper respiratory tract. AsFIG. 1A shows, the larynx is situated between the base of the tongue and the trachea; vertically, the larynx's position corresponds to the C4, C5, and C6 vertebrae, although this location is higher in females and during childhood.FIG. 2A shows the nine cartilages of the larynx: a thyroid, a cricoid, two arytenoids, two corniculate, two cuneiform, and an epiglottis.
• The larynx comprises extrinsic ligaments which link the thyroid cartilage and the epiglottis with the hyoid bone and the cricoid cartilage with the trachea (seeFIG. 2B). The hyothyroid membrane and the lateral hyothyroid ligament attach the thyroid cartilage to the hyoid bone. The hyoepiglottic ligament connects the epiglottis to the upper border of the hyoid bone. The cricotracheal ligament attaches the cricoid cartilage to the first ring of the trachea (seeFIG. 2B).
III. Sleep and the Anatomy of Tee Upper Airway
• Although all tissue along this conduit is dynamic responsive to the respiratory cycle, only the pharynx is totally collapsible. The pharyngeal structures and individual anatomic components within this region include the pharyngeal walls, the base of the tongue, the soft palate with uvula, and the epiglottis.
• The cross-sectional area of the upper airway varies with the phases of the respiratory cycle. At the initiation of inspiration (Phase I), the airway begins to dilate and then to remain relatively constant through the remainder of inspiration (Phase II). At the onset of expiration (Phase III) the airway begins to enlarge, reaching maximum diameter and then diminishing in size so that at the end of expiration (Phase IV), it is at its narrowest, corresponding to the time when the upper airway dilator muscles are least active, and positive intraluminal pressure is lowest. The upper airway, therefore, has the greatest potential for collapse and closure at end-expiration [ref: Schwab R J, Goldberg A N. Upper airway assessment: radiographic and other imaging techniques. Otolaryngol Clin North Am 1998, 31:931-968].
• Sleep is characterized by a reduction in upper airway dilator muscle activity. For the individual who snores or has obstructive sleep apnea (OSA) and perhaps the other disorders which comprise much of the group of entities called obstructive sleep-disordered breathing (SDB), it is believed that this change in muscle function causes pharyngeal narrowing and collapse. Two possible etiologies for this phenomenon in OSA patients have been theorized. One is that these individuals reduce the airway dilator muscle tone more than non-apneics during sleep (the neural theory). The other is that all individuals experience the same reduction in dilator activity in sleep, but that the apneic has a pharynx that is structurally less stable (the anatomic theory). Both theories may in fact be contributors to OSA, but current studies seem to support that OSA patients have an intrinsically structurally narrowed and more collapsible pharynx. [Ref: Isono S. Remmers J, Tanaka A Sho Y, Sato J, Nishino T. Anatomy of pharynx in patients with obstructive sleep apnea and in normal subjects. J Appl Physiol 1997:82:1319-1326.] Although this phenomenon is often accentuated at specific sites, such as the velopharyngeal level [Isono], studies of closing pressures [Isono] support dynamic fast MRI imaging that shows narrowing and collapse usually occurs along the entire length of the pharynx. [Ref: Shellock F G, Schatz C J, Julien P, Silverman J M, Steinberg F, Foo T K F, Hopp M L, Westbrook P R. Occlusion and narrowing of the pharyngeal airway in obstructive sleep apnea: evaluation by ultrafast spoiled GRASS MR imaging. Am J of Roentgenology 1992:158:1019-1024].
IV. Treatment Options
• To date, the only treatment modality that addresses collapse along the entire upper airway is mechanical positive pressure breathing devices, such as continuous positive airway pressure (CPAP) machines. All other modalities, such as various surgical procedures and oral appliances, by their nature, address specific sectors of the airway (such as palate, tongue base and hyoid levels), but leave portions of pharyngeal wall untreated. This may account for the considerably higher success rate of CPAP over surgery and appliances in controlling OSA. Although CPAP, which in essence acts as an airway splint for the respiratory cycle, is highly successful, it has some very significant shortcomings. It can be cumbersome to wear and travel with, difficult to accept on a social level, and not tolerated by many (for reasons such as claustrophobia, facial and nasal mask pressure sores, airway irritation). These factors have lead to a relatively poor long-term compliance rate. One study has shown that 65% of patients abandon their CPAP treatment in 6 months. Other current treatments for OSA include genioglossal advancement (GA), maxillomandibular advancement (MA), and hyoid myotomy. InfluENT Medical offers a genioglossus advancement procedure where suture loop is passed through the tongue and anchored to a screw essentially inserted into the mandible. In another procedure, hyoid myotomy and suspension, the hyoid bone is advanced using a suture tied to the hyoid bone anchors the structure to two screws placed in the mandible. These treatments involve highly invasive surgical procedures and a long recovery time, and therefore have relatively low patient appeal.
• The need remains for simple, minimally invasive, cost-effective devices, systems, and methods for reducing or preventing sleep disordered breathing events.
SUMMARY OF THE INVENTION
• Devices, systems, and methods are provided by maintaining tissue regions in desired orientation in or along an airway, e.g., for reducing or preventing snoring and/or sleep disordered breathing events, such as sleep apnea.
• In one aspect, the devices, systems, and methods include at least one implant structure sized and configured for implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue. The devices, systems, and methods also include means for stabilizing the position of the implant structure relative to the extrinsic muscle region to maintain the tongue in a desired orientation.
• In one embodiment, the means for stabilizing comprises at least one anchoring component, e.g., a screw or adhesive material, sized and configured to couple the implant structure to a mandible. In this arrangement, the implant structure can comprise, e.g., a bracing member overlaying, at least in part, the extrinsic muscle region beneath the tongue, or a spring member extending within the extrinsic muscle region beneath the tongue, or an elastomeric structure extending within the extrinsic muscle region beneath the tongue.
• In one embodiment, the means for stabilizing comprises at least one anchoring component sized and configured to couple the implant structure to a tissue region. In this arrangement, the implant structure can comprise, e.g., a hooking member extending through the extrinsic muscle region beneath the tongue, or a spring member extending within the extrinsic muscle region beneath the tongue, or an elastomeric structure extending within the extrinsic muscle beneath the tongue.
• In various embodiments, the implant structure can comprise, e.g., a bracing member overlaying, at least in part, the extrinsic muscle region beneath the tongue, or a bracing member that spans the extrinsic muscle region beneath the tongue, or a bracing member sized and configured to deflect the extrinsic muscle region beneath the tongue, or a hooking member extending through the extrinsic muscle region beneath the tongue, or a hooking member overlaying, at least in part, the extrinsic muscle region beneath the tongue, or a hooking member sized and configured to deflect the extrinsic muscle region beneath the tongue.
• The extrinsic muscle region can comprise, e.g., a genioglossus muscle. In this arrangement, the implant structure can be sized and configured to deflect the genioglossus muscle caudially.
• The devices, systems, and methods can, e.g., maintaining a tongue in a desired orientation to maintain patency of an airway.
BRIEF DESCRIPTION OF THE DRAWINGS
• FIG. 1A is an anatomical sagittal cross-section of a normal human nasal airway, oral cavity, and oropharynx.
• FIG. 1B is an anatomical sagittal view of the muscles of the upper respiratory tract.
• FIG. 1C is an anatomic anterior view of an oral cavity, with the body of the tongue elevated to show the inferior side of the tongue and the floor of the mouth.
• FIG. 1D is an anatomical side view, with sections partly broken away and in section, of a human suffering from one form of sleep apnea involving the tongue and the soft palate, showing how the tongue base, the soft palate, and the uvula lean against the pharyngeal wall, effectively closing off the airway, resulting in an apneic event.
• FIGS. 2A and 2B are anatomic views of the larynx.FIG. 2A shows the cartilages of the larynx whileFIG. 2B shows an anterolateral view of the ligaments of the larynx.
• FIGS. 3A to 3D are anatomic views of the muscles attached to the hyoid bone.
• FIG. 4A is an illustrative embodiment of an elongated body sized and configured for implantation in a desired orientation in a tissue region in an airway, having an array of projections that are configured to engage tissue and resist a reorientation of the body within the tissue region out of the desired orientation.
• FIG. 4B is a view of the elongated body shown inFIG. 4A being implanted in a tissue region, showing the projections resiliently yielding by flexing inward against the body when the body is inserted through tissue in the intended implantation direction.
• FIG. 4C is a view of the elongated body shown inFIG. 4A being implanted in a tissue region, showing the projections resiliently yielding by flexing inward against the body when the body is inserted through an implantation tool in the intended implantation direction.
• FIG. 4D is a view of the elongated body shown inFIG. 4A after implantation in a tissue region, showing the resilient projections extending outward to engage tissue and serve to resist movement of the body in tissue in a direction that is different than the insertion direction.
• FIG. 4E is a view of the elongated body shown inFIG. 4A after implantation in a tissue region, showing the resilient projections extending outward to engage tissue and serve to resist movement of the body in tissue in a direction that is different than the insertion direction, which movement applies tension to the elongated body that affects a change in the shape or orientation of the tissue region in which the elongated body is implanted.
• FIGS. 5A and 5B show a method of treating sleep apnea in the soft palate.FIG. 5A shows a sagittal view of a human suffering from sleep apnea due to abnormalities in the soft palate.FIG. 5B shows the elongated body ofFIG. 4A implanted in the human ofFIG. 5A.
• FIGS. 6A and 6B show a method of treating sleep apnea in the uvula.FIG. 6A shows a sagittal view of a human suffering from sleep apnea due to abnormalities in the uvula.FIG. 6B shows the elongated body ofFIG. 4A implanted in the human ofFIG. 6A.
• FIGS. 7A and 78 show a method of treating sleep apnea in the tongue.FIG. 7A shows a sagittal view of a human suffering from sleep apnea due to abnormalities in the tongue.FIG. 7B shows the elongated body ofFIG. 4A implanted in the human ofFIG. 7A.
• FIGS. 8A and 8B show a method of treating sleep apnea in the epiglottis.FIG. 8A shows a sagittal view of a human suffering from sleep apnea due to abnormalities in the epiglottis.FIG. 8B shows the elongated body ofFIG. 4A implanted in the human ofFIG. 8A.
• FIGS. 9A and 9B show a method of treating sleep apnea in the upper respiratory muscles.FIG. 9A shows a sagittal view of a human suffering from sleep apnea due to abnormalities in the upper respiratory muscles.FIG. 9B shows the elongated body ofFIG. 4A implanted in the human ofFIG. 9A.
• FIG. 10A shows an illustrative portion of an elongated body comprising a barbed suture with unidirectional barbs.
• FIG. 10B shows an illustrative portion of an elongated body comprising a barbed suture with multidirectional barbs.
• FIGS. 11A to 11E show an instrument and a method of inserting barbed sutures in the palate.FIG. 11A shows an illustrative instrument for inserting barbed sutures into the palate.FIG. 11B is a side cross-sectional view of a portion of the hard palate and the soft palate with an illustrative instrument for inserting barbed sutures inserted in the palate.FIG. 11C is a side cross-sectional view of the hard palate and the soft palate with an illustrative instrument for inserting barbed sutures and illustrative barbed sutures threaded through the instrument.FIG. 11D is a side cross-sectional view of the hard palate and the soft palate with an illustrative end piece.FIG. 11E is a side cross-sectional view of the hard palate and the soft palate with barbed sutures and end piece inserted.
• FIGS. 12A to 12E are anatomical sagittal views of a human upper respiratory system showing a method of inserting a barbed suture in the tongue.
• FIGS. 12F and 12G are illustrative embodiments of needles used to insert barbed sutures in the tongue.
• FIGS. 13A to 13D are anatomical views of the oral cavity showing an alternate method of inserting a barbed suture in the tongue.
• FIGS. 14A to 14F are anatomical views of the oral cavity showing alternate embodiments of inserting one or more barbed suture(s) in the palate and uvula.
• FIGS. 15A and 15B are anatomical sagittal views of the muscles of the upper respiratory tract, similar to those shown inFIG. 1B andFIG. 3C, respectively, showing barbed sutures that have been implanted to affect desired tissue orientations.
• FIGS. 16A to 16C are anatomical sagittal views showing barbed sutures inserted in the epiglottis.
• FIGS. 17A to 17C are anatomical views of the oral cavity showing sutures inserted in the palate.
• FIG. 18A is an anatomical view of the oral cavity showing a device for adjusting tension in sutures.
• FIG. 18B is a perspective view of a device for adjusting tension in sutures.
• FIG. 18C is a cross-sectional view of the device ofFIG. 18B implanted in the palate as shown inFIG. 18A.
• FIGS. 19A and 19B are perspective views of an alternate device for adjusting tension in sutures.
• FIG. 20 is a side cross-sectional view of an alternate device for adjusting tension in sutures.
• FIG. 21 is a perspective view of an alternate device for adjusting tension in sutures.
• FIG. 22A is a side view of an alternate device for adjusting tension in sutures.
• FIG. 22B is a top plan view of the device shown inFIG. 22A.
• FIG. 22C is a cross-sectional view of the device ofFIG. 22A implanted in the palate.
• FIG. 23A is an anatomical view of the upper respiratory system.
• FIGS. 23B and 23C are cross-sectional views of the tongue showing a method of inserting an implant structure comprising a bracing member in an extrinsic muscled region beneath a tongue.
• FIGS. 24A to 24C are anatomical views of the upper respiratory system showing an implant structure comprising a hooking member buckle implanted in an extrinsic muscle region beneath a tongue.
• FIGS. 25A and 25B are anatomical views of the upper respiratory system showing an implant structure comprising an elastomeric structure implanted in an extrinsic muscle region beneath a tongue.
• FIGS. 26A to 26D are views of an illustrative embodiment of an elongated elastomeric body sized and configured for implantation in a desired orientation in a tissue region in an airway.FIG. 26A is a perspective view of an elastomeric body in its relaxed state.FIG. 26B is a perspective view of an elastomeric body of26A in a slightly extended state.FIG. 26C is an end view of the elastomeric body ofFIG. 26A.FIG. 26D is a perspective view of the elastomeric body ofFIG. 26A in an extended state.
• FIGS. 27A to 27D are views of an illustrative embodiment of an elongated elastomeric body sized and configured for implantation in a desired orientation in a tissue region in an airway.FIG. 27A is a perspective view of an elastomeric body in its relaxed state.FIG. 27B is a perspective view of an elastomeric body of27A in a slightly extended state.FIG. 27C is an end view of the elastomeric body ofFIG. 27A.FIG. 27D is a perspective view of the elastomeric body ofFIG. 27A in an extended state.
• FIGS. 28A to 28B are views of an illustrative embodiment of an elongated elastomeric body sized and configured for implantation in a desired orientation in a tissue region in an airway.FIG. 28A is a perspective view of an elastomeric body in its relaxed state. FIG.28B is a perspective view of the elastomeric body ofFIG. 28A in an extended state.
• FIGS. 29A to 29B are views of an illustrative embodiment of an elongated elastomeric body sized and configured for implantation in a desired orientation in a tissue region in an airway.FIG. 29A is a perspective view of an elastomeric body in its relaxed state.FIG. 29B is a perspective view of the elastomeric body ofFIG. 29A in an extended state.
• FIGS. 29C to 29G are anatomical sagittal views showing a method of inserting the elastomeric body ofFIG. 29A or29B in a human.
• FIG. 30A is perspective view of the elastomeric body ofFIG. 26D held in an extended state by a bio-absorbable material.
• FIG. 30B is perspective view of the elastomeric body ofFIG. 26D held in an extended state by an absorbable suture.
• FIG. 30C is a perspective view of the elastomeric body ofFIG. 27D held in an extended state by a bio-absorbable material.
• FIG. 30D is a perspective view of the elastomeric body ofFIG. 27D held in an extended state by an absorbable suture.
• FIGS. 30E and 30F are perspective views of the elastomeric body ofFIG. 27G held in an extended state by bioabsorbable beads.
• FIG. 31A is a perspective view of the elastomeric body ofFIG. 30B further including a stent anchor.
• FIG. 31B is a perspective view of the elastomeric body ofFIG. 30A further including a stent anchor.
• FIG. 31C is a perspective view of the elastomeric body ofFIG. 31A or31B wherein the spring has returned to its relaxed state and the stent anchor has deployed.
• FIGS. 32A to 32C are anatomical sagittal views showing a method of inserting the elastomeric body ofFIG. 31A or31B in a human.
• FIG. 33A is a perspective view of the elastomeric body ofFIG. 30B further including a daisy anchor.
• FIG. 33B is a perspective view of the elastomeric body ofFIG. 30A further including a daisy anchor.
• FIG. 33C is a perspective view of the elastomeric body ofFIG. 33A or33B wherein the spring has returned to its relaxed state and the daisy anchor has deployed.
• FIGS. 34A to 34C are anatomical sagittal views showing a method of inserting the elastomeric body ofFIG. 33A or33B in a human.
• FIG. 34D is an anatomical sagittal view showing an alternate embodiment of the elastomeric body ofFIG. 33A or33B inserted in a human.
• FIG. 35A is a perspective view of a spring expander for use with the elastomeric body ofFIG. 26A.
• FIG. 35B is a perspective view of the spring expander ofFIG. 35A with an elastomeric body threaded thereon.
• FIG. 35C shows the spring expander ofFIG. 358, wherein the tension in the elastomeric body is being adjusted by unthreading the spring expander from a portion of the elastomeric body.
• FIGS. 36A to 36E show an elastomeric body coupled to a spring expander and a method of inserting the coupled elastomeric body and spring expander.
DESCRIPTION OF PREFERRED EMBODIMENTS
• Although the disclosure hereof is detailed and exact to enable those skilled in the art to practice the invention, the physical embodiments herein disclosed merely exemplify the invention which may be embodied in other specific structures. While the preferred embodiment has been described, the details may be changed without departing from the invention, which is defined by the claims.
• This specification discloses various methods, systems, and devices to maintain or aid in maintaining a patent, or open, airway. However, while the various methods, systems, and devices have application in procedures requiring the restriction of tissue collapse in and/or around the body, such as a passageway within the body, the various devices, systems, and methods are not necessarily restricted to tissue-based applications.
• The devices, systems, and methods are particularly well suited for treating sleep disordered breathing, including sleep apnea. For this reason, the devices, systems, and methods will be described in this context. It should however be appreciated that the disclosed devices, systems, and methods are applicable for use in treating other dysfunctions elsewhere in the body, which are not necessarily sleep disorder related.
I. Anatomical Considerations and Sleep Apnea
• In human beings the tongue is an organ that undergoes a wide variety of movements, partly because it is involved in a broad range of activities, including speech, eating and swallowing. When a human is awake, the tongue normally moves in an up and forward position. When a human is asleep, the muscles of the tongue relax and the tongue is able to move in an even broader range of directions. This movement can occur laterally, posteriorly, anteriorly, cranially, caudally, in a rolling manner, or any combination thereof.
• The tongue can move in conjunction with other structures (i.e. tongue and pharyngeal wall coming together or tongue and palate coming together) or independently of other structures, such as tongue movement without palate, posterior wall, or epiglottis movement.
• Sleep apnea occurs when the airway becomes obstructed. Hypopnea occurs when the airway is partially obstructed. Sleep apnea can take many forms. The closure of the airway can occur at any number of anatomical structures along the airway, including any combination of the tongue, soft palate, epiglottis, pharyngeal walls, and hyoid bone. In particular, the tongue may collapse with respect to the pharyngeal wall, or both the base of the tongue and the pharyngeal wall may collapse at the same time. Thus, sleep apnea may be treated by preventing the collapse of the specific anatomical structures.
• FIG. 1A is a sagittal cross section view of the upper airway system in a normal patient, showing the nasal and oral cavities, tongue, hard palate, soft palate, oropharynx, chin and neck.FIG. 1B shows a side view of a patient suffering from one form of sleep apnea involving the tongue and palate. As shown inFIG. 1B, the tongue base, the soft palate, and the uvula lean against the pharyngeal wall, effectively closing off the airway. An apneic attack can occur as a result.
II. The Treatment of Sleep Apnea
• As described above, sleep apnea occurs when the airway becomes obstructed. Obstruction of the airway can be caused when muscles in at least a portion of the upper respiratory system lose tone and allow the airway to become obstructed. The present invention contemplates inserting various devices into various tissues of the upper respiratory system to reshape, relocate, or tension the surrounding tissue.
• Arepresentative device10 for treating sleep apnea is shown inFIG. 4A. As shown inFIG. 4A, thetreatment device10 takes the form of an elongated body that is sized and configured for implantation in a desired orientation in a tissue region. Although thebody10 may have any cross-sectional shape, in the illustrated embodiment, thebody10 has a generally circular cross-section. Theelongated body10 may be flexible to facilitate implantation of thebody10 in a targeted tissue region of an individual and thereafter conform to the orientation desired, which will depend upon the morphology of the tissue region and the particular treatment objectives. Theelongated body10 is also desirably generally non-elastic and/or otherwise has the mechanical resilience or strength capable of holding a tension, which will be in shorthand called “tension-able.” Theelongated body10 can be made of a threadlike inert plastic or metal material, e.g., nylon, polypropylene, or stainless steel. One or moreelongated bodies10 can be implanted at a selected tissue region, depending upon the treatment objectives.
• An array or plurality ofprojections12 extend from theelongated body10. As shown inFIG. 4A, theprojections12 extend radially outward at an acute angle α relative to the longitudinal axis of thebody10. Theprojections12 are sized and configured to engage tissue and anchor thebody10 within a tissue region. By their design, the projections allow theelongated body10 or a section of theelongated body10 to move more easily through tissue in one direction than the other.
• Theprojections12 are desirably resiliently coupled to thebody10 in a normally biased outward extending condition. In this arrangement, theprojections12 can be folded back upon thebody10 by application of force, and resilient return to the normally biased outward extending condition when the force is removed. Theprojections12 themselves can also be flexible.
• In the illustrated embodiment (seeFIGS. 4A and 4B), theprojections12 extend from thebody10 in a direction opposite the direction in which thebody10 is intended to be inserted into a tissue region during implantation (shown by the insertion arrow inFIG. 4B). In this manner (asFIG. 4B shows), theprojections12 are capable of yielding by flexing inward against thebody10 when thebody10 is pulled through tissue in the intended implantation direction.
• Alternatively (as shown inFIG. 4C), thebody10 can be implanted through a guide tube or needle. In this arrangement, theprojections12 are capable of flexing inward against thebody10 when carried within the guide tube, and extending outward to engage tissue when the guide tube or needle is withdrawn (asFIG. 4D shows).
• Regardless of the manner of implantation, after implantation of thebody12, theprojections12 will engage tissue and serve to resist movement of thebody10 in tissue in a direction that is different than the insertion direction (as shown by the resistance arrow inFIG. 4D). As shown inFIG. 4D, the resistance direction can lie in a range of directions angularly displaced about a direction directly opposite to the insertion direction.
• As shown inFIG. 4E, due to the orientation of theprojections12, pulling theelongated body10 either during or after implantation in a direction that lies within the range of resistance directions, applies tension to theelongated body10 and can affect a change in the shape or orientation of the tissue region in which theelongated body10 is implanted.
• In use, theelongated body10 is implanted in a desired orientation in a tissue region. The desired orientation is governed by the location of the tissue region and the treatment objectives, e.g., a desired shape or bias that is to be imparted to the tissue region, and/or the maintenance of a desired orientation of the tissue region relative to another tissue region, e.g., to keep an airway patent. The array ofprojections12 flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation. The desired orientation can include the selective application of tension to theelongated body12 during its implantation, to affect a desired change in shape, orientation, and/or other physiologic characteristic within the tissue region.
• During and after implantation of thebody10 in the desired orientation, theprojections12 serve to engage tissue, resisting a reorientation of thebody10 within the tissue region out of the desired orientation. When the orientation includes applying a tension to thebody10 during implantation, theprojections12 serve to maintain the tension, so that the tissue region itself is maintained in a desired orientation by the resistance thatprojections12 impart.
• A. Implantation within a Soft Palate
• Obstructive sleep apnea can arise when tissue of the soft palate becomes “floppy.” As shown inFIG. 5A, the floppy tissue of the soft palate may collapse upon the back of the tongue or other airway structures and thereby obstruct the airway. It is therefore desirable to tension and/or reposition the tissue of the soft palate to reduce or eliminate this obstruction of the airway.
• Thetreatment device10 described above can be used to either tension and/or reposition the tissue of the soft palate to reduce the obstruction of the airway, as shown inFIG. 5B. In this representative embodiment, one or more of theelongated bodies10 are implanted in a desired orientation in a tissue region of the soft palate. The desired orientation in this embodiment is governed by the treatment objective of maintaining the soft palate in a desired posterior and/or superior orientation away from the back of the tongue and other airway structures. Thebody10 is implanted in an orientation and with a selective tension which shapes the soft palate in this desired orientation (shown inFIG. 5B), away from the back of the tongue and other airway structures.
• In this arrangement, theprojections12 are oriented relative to thebody10 to flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation within the soft palate. After implantation, theprojections12 extend outward at the angle α from thebody10 and serve to engage tissue and resist a reorientation of thebody10 within the tissue region of the soft palate out of the desired orientation, to thereby resist collapse of the soft palate in an anterior and/or inferior direction, i.e., toward the base of the tongue.
• B. Implantation within an Uvula
• Obstructive sleep apnea can also arise when the uvula becomes “floppy” and/or misshapen, as shown inFIG. 6A. If the uvula becomes floppy, it can become positioned in a posterior direction, collapsing against the back of the tongue and/or the pharyngeal wall, and obstruct the airway as shown inFIG. 6A. It is therefore desirable to either tension and/or reposition the uvula in an anterior direction to reduce obstruction of the airway.
• Thetreatment device10 described above can be used to tension and/or reposition the uvula to reduce obstruction of the airway as shown inFIG. 6B. In this representative embodiment, one or more of theelongated bodies10 are implanted in a desired orientation in a tissue region of the uvula. The desired orientation in this embodiment is governed by the treatment objective of maintaining the uvula in a desired anterior and/or superior orientation lifted away from the back of the tongue and the pharyngeal wall. Thebody10 is implanted in an orientation and with a selective tension which shapes or urges the uvula in this desired orientation (shown inFIG. 6B), away from the back of the tongue and the pharyngeal wall.
• In this arrangement, theprojections12 are oriented relative to thebody10 to flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation within the uvula. After implantation, theprojections12 extend outward at the angle α from thebody10 and serve to engage tissue and resist a reorientation of thebody10 within the tissue region of the uvula out of the desired orientation, to thereby resist collapse of the uvula toward the base of the tongue and/or against the pharyngeal wall.
• C. Implantation within a Tongue
• Obstructive sleep apnea can also arise when the tongue muscles lose tone, causing the base of the tongue to collapse in a posterior direction against the uvula and/or pharyngeal wall, and thereby obstruct the airway, as shown inFIG. 7A. It is therefore desirable to either tension the muscles in the tongue, or otherwise reposition the tongue to reduce obstruction of the airway.
• Thetreatment device10 described above can be used to tighten the muscles in the tongue as shown inFIG. 7B. In this representative embodiment, one or more of theelongated bodies10 are implanted in a desired orientation in a tissue region of the tongue. The desired orientation in this embodiment is governed by the treatment objective of urging or maintaining the tongue in a desired anterior orientation away from the uvula and/or pharyngeal wall. Thebody10 is implanted in an orientation and with a selective tension which urges the tongue in an anterior direction (shown inFIG. 7B), away from the uvula and/or pharyngeal wall.
• In this arrangement, theprojections12 are oriented relative to thebody10 to flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation within the tongue. After implantation, theprojections12 extend outward at the angle α from thebody10 and serve to engage tissue and resist a reorientation of thebody10 within the tissue region of the tongue out of the desired orientation, to thereby resist posterior collapse of the tongue against the uvula and/or the pharyngeal wall.
• D. Implantation within an Epiglottis
• Another source of obstructive sleep apnea includes abnormalities of the epiglottis, which close off or restrict the airway, as shown inFIG. 8A. For example, the epiglottis may prolapse and fold down to close off the airway. It is also possible that the epiglottis may be misshapen and therefore restrict the airway. The epiglottis may also lose muscle tone and become “floppy.” A floppy epiglottis can restrict the airway. It is therefore desirable to either tension or reposition the epiglottis to reduce obstruction of the airway.
• Thetreatment device10 described above can be used to tension and/or reposition the epiglottis to reduce obstruction of the airway as shown inFIG. 8B. In this representative embodiment, one or more of theelongated bodies10 are implanted in a desired orientation in a tissue region of the epiglottis. The desired orientation in this embodiment is governed by the treatment objective of maintaining or urging the epiglottis in a desired anterior orientation away from the pharyngeal wall. Thebody10 is implanted in an orientation and with a selective tension which urges the epiglottis in an anterior direction (shown inFIG. 8B), away from the pharyngeal wall.
• In this arrangement, theprojections12 are oriented relative to thebody10 to flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation within the epiglottis. After implantation, theprojections12 extend outward at the angle α from thebody10 and serve to engage tissue and resist a reorientation of thebody10 within the tissue region of the epiglottis out of the desired orientation, to thereby resist posterior collapse of the epiglottis against the pharyngeal wall.
• E. Implantation in Muscles of the Upper Respiratory Tract
• Another source of obstructive sleep apnea is when the muscles in the pharyngeal wall along the upper respiratory tract lose tone. When the muscles relax, they may obstruct the airway as shown inFIG. 9A. This is particularly true in individuals with excessive relaxation of the upper respiratory muscles, or in individuals where the airway is already narrow. An individual's airway may naturally be narrow due to the individual's particular morphology, or may be narrow due to other factors such as obesity or other illness. It is therefore desirable to tension the muscles in the upper respiratory tract to reduce obstruction of the airway.
• Thetreatment device10 described above can be used to tighten the muscles of the upper respiratory tract, as shown inFIG. 9B. In this representative embodiment, one or more of theelongated bodies10 are implanted in a desired orientation in a muscle region of the upper respiratory system. The desired orientation in this embodiment is governed by the treatment objective of maintaining or urging the muscle in a desired orientation, away from collapse against other structures along the airway. Thebody10 is implanted in an orientation and with a selective tension which urges the muscle region in this orientation (shown inFIG. 9B), away from collapse against other structures along the airway.
• In this arrangement, theprojections12 are oriented relative to thebody10 to flex or otherwise yield to accommodate the implantation of thebody10 in the desired orientation within the muscle region of the upper respiratory system. After implantation, theprojections12 extend outward at the angle α from thebody10 and serve to engage tissue and resist a reorientation of thebody10 within the muscle region of the upper respiratory system out of the desired orientation, to thereby resist collapse of the muscle region against other structures along the airway.
• F. Use of the Treatment Device
• Thetreatment device10 can be used in the treatment of sleep apnea in at least one of three different ways.
• First, thetreatment device10 may be used, by itself, to effectively treat sleep apnea. It is contemplated that thetreatment device10 could be utilized in many parts of the upper airway, including, but not limited to the uvula, the soft palate, the hard palate, the tongue, the muscles of the upper respiratory tract, or the epiglottis, as previously described.
• Second, thetreatment device10 can provide temporary treatment of sleep apnea allowing the individual and the treating physician time to evaluate whether more invasive surgery intervention, e.g., uvulopalatoplasty (UPPP), may offer as results.
• Third, thetreatment device10 can be used in conjunction with other types of sleep apnea treatment, such as the magnetic force systems disclosed in U.S. patent application Ser. No. 10/656,861, filed Sep. 6, 2003, and entitled “Magnetic Force Devices, Systems, and Methods for Resisting Tissue Collapse Within the Pharyngeal Conduit.” Due to individual anatomical constraints, a system consisting of ferromagnetic structures may benefit from being supplemented by the use of thetreatment device10 to provide additional tension in specific upper respiratory tissue locations.
III. Representative Examples of the Treatment Device
• A. Barbed Sutures
• Thetreatment device10 as described above can be constructed in various ways. In one representative embodiment, thetreatment device10 takes the form of abarbed suture110, as shown inFIGS. 10A and 10B. Thebarbed suture110 comprises an elongated body that is sized and configured for implantation in a desired orientation in a tissue region of an airway. The suture100 can comprise a flexible threadlike plastic or metal material, such as nylon, polypropylene, or stainless steel, which is, desirably, essentially tension-able, as earlier defined.
• Thebarbed suture110 includes an array of projections orbarbs112. Theprojections112 extend from the elongated suture body at the angle α and are sized and configured to engage tissue and anchor the elongated suture body in the tissue region. The array of projections orbarbs112 thereby resists a reorientation of the elongated suture body within the tissue region out of the desired orientation.
• The projections orbarbs112 can be produced, for example, by cutting at a slant into the elongated suture body to form sharp projections that bend back. The projections orbarbs112 can run either in the same direction (i.e., unidirectionally)(as shown inFIG. 10A) or two different directions (i.e., bidirectionally) (as shown inFIG. 10B) from the elongated suture body midpoint. An un-barbed section can follow the barbed sections at both ends of thesutures110.
• B. Representative Instrument and Method for Implanting a Barbed Suture in an Uvula
• As generally described above, one or morebarbed sutures110 can be implanted in auvula14.FIG. 11A shows arepresentative instrument16 for use in inserting thebarbed sutures110. Theinstrument16 comprises a hollowsharp needle18 with a large enough bore20 to pass asuture110. The hollowsharp needle18 may be attached to ahandle22. Preferably, theneedle18 has a gently curved shape, similar to thesoft palate24. Theneedle18 includes a proximal end by thehandle22 and a distal end spaced from the handle.
• As shown inFIG. 11C, thesuture110 comprises a series oftissue grasping barbs112, as previously described. Thesuture110 also includes an adjustable, slidingtoggle anchor26 at one end (seeFIG. 11C). The slidingtoggle anchor26 will be described in more detail below. As an alternative, aneedle18 may be suaged to thebarbed suture110, without a handle.
• The implantation procedure can be performed under general or local anesthesia. As seen inFIG. 11B, with the individual's mouth open, the distal end of theneedle18 is placed submucosally into thesoft palate24, starting at theuvula14, to penetrate into muscle tissue. The distal end of theneedle18 is then advanced to the soft and hard palate junction area. The distal end of the needle exits back into the oral cavity, asFIG. 11B shows. The tissue at the needle exit site in the vicinity of the hard/soft palate junction is firm fibromuscle.
• Prior to the needle exiting the mucosa, a small transverse incision is made through the mucosa at the needle exit site to develop a small submucosal pocket30 (whichFIG. 11B shows).
• As seen inFIG. 11C, once the distal end of theneedle18 has exited the mucosa, thebarbed suture110 with an adjustabletoggle end anchor26 is fed retrograde through the distal end of the needle18 (i.e., the suture end that does not carry thetoggle anchor26 being inserted into the distal end of the needle end first), exiting at theuvula entrance site32 near the proximal end of the needle. As seen inFIG. 11D, thehollow needle18 is then withdrawn, leaving thesuture110 in place in thesoft palate24. In this orientation of the suture body, thebarbs112 are oriented to engage tissue and resist movement of the suture body when the end of thesuture110 carrying thetoggle anchor26 is pulled.
• Alternatively, acurved needle18 suaged to the end of thebarbed suture110 could penetrate thepalate24 near the hard palate-soft palate junction, exit at the distal end of theuvula14, and draw thebarbed suture110 into position behind it (not shown).
• Regardless of the suture insertion method used, the portion of thesuture110 visible at theuvula14 may then be trimmed. The end of thesuture110 carrying thetoggle anchor26 is pulled to pull the opposite end of thesuture110 antegrade, to bury the opposite end lined withbarbs112 in submucosal uvula tissue. This begins to place the suture body into tension, as thebarbs112 resist movement of the suture body in the pulling direction. The tension begins to lift and curve the uvula in anterior and superior directions.
• The individual's mouth is then closed, leaving the toggle end of thesuture110 protruding out of the mouth. With the individual in a supine position, a flexible nasopharyngoscope is passed trans-nasally to view the retropalatal airway.
• The toggle end of thesuture110 is pulled further in an anterior direction (antegrade in the palate), further engaging thebarbs112 and further placing the suture in the desired orientation within the uvula. Placing the suture into the desired orientation also applies more localized tension in the tissue region. In response, the uvula and, with it, the soft palate in general, move toward the desired forward-curved orientation to attain an appropriate posterior palatal airway space, as shown inFIG. 6B. The orientation of the airway space continues to be viewed by nasopharyngoscope as tension is selectively applied by pulling on the toggle end of thesuture110. If the patient is awake, this is done at end expiration, and verified with Mueller maneuvers. If asleep under anesthesia or sedation, palate flaccidity and obstruction will be evident.
• The mouth is then reopened, and as shown inFIG. 11E, thetoggle26 is slid down the suture and cinched down on thesuture110 at the previously made hard/soft palatesubmucosal junction pocket30.
• The procedure is finalized by closing thesubmucosal junction pocket30. Thesubmucosal junction pocket30 may be closed using any medically accepted devices and methods.
• The implantation procedure may consist of placing one or morebarbed sutures110, depending on the clinical need. The number ofbarbed sutures110 placed will be determined by the physician based on the individual patient morphology.
• The implantation of an elongated body with projections, such as abarbed suture110, makes possible a less morbid, less damaging and less invasive alternative to a surgical uvulopalatoplasty. The implantation of an elongated body with projections, such as abarbed suture110, can also serve as an alternative to existing treatments for habitual snoring. When tensioning of the elongated body is done under sedated endoscopy, it has the capability of being a one-stage titratable suspension procedure. Presently available approaches (laser resection, radiofrequency stiffening, and Pillar implant stiffening) do not have that capability.
• An elongated body with projections such as abarbed suture110, can be removed under local anesthesia by freeing thesubmucosal toggle26, localizing the uvula end of thesuture110, and pulling the suture body out retrograde, as will be described in more detail below.
• C. Representative Instrument and Method of Implanting a Barbed Suture in the Tongue
• One or morebarbed sutures110 can be inserted in thetongue34 to pull thetongue34 anteriorly and retain a patent airway. The tongue base can be pulled anteriorly by use ofbarbed sutures110 in various ways.
• In one representative embodiment (as shown inFIGS. 12A to 12E), an incision is made in the skin and a small hole is drilled in themandible36 at the attachment point for the genioglossus muscle38 (seeFIG. 12A). As seen inFIG. 12A, access to this drill hole in the bone can be made either at the front of the chin or intra-orally.
• A length of either unidirectional or bidirectionalbarbed suture110 with a stop orbutton40 attached at one end is threaded through aneedle42. Thebutton40 is desirably sized so that it is too large to fit through the hole in the jaw. Theneedle42 andsuture110 is inserted into anapplication shaft44. Theapplication shaft44 is inserted into the hole in the jaw. Using aplunger46, the needle is then pushed through the tongue34 (as shown inFIG. 12A) and removed from the posterior portion of the tongue34 (as shown inFIG. 12B). The needle is removed through the mouth. Theplunger46 and theapplication shaft44 are then removed from the hole in the jaw, leaving thesuture110 behind within the tongue.
• Thesuture110 is then pulled in an anterior direction through the jaw (as shown inFIG. 12C). Because thebarbs112 are oriented to engage tissue and resist movement of the suture body in the pulling direction, the suture body is placed into tension within the tongue, pulling the posterior region of the tongue in an anterior direction. Securing thebutton40 to thesuture110 in a position resting against the jaw bone or mandible36 (seeFIG. 12D) holds the tension. The tension holds the posterior region of the tongue in an anterior direction, resisting posterior movement in the direction of the airway. Thetongue34 is thereby positioned so that thesuture barbs112 hold it in a forward position, so as to open the airway.
• As seen inFIG. 12E thesuture110 is trimmed slightly below the surface of thetongue34. The tissue is then closed over thebutton40 to complete the procedure.Multiple sutures110, possibly attached to thesame button40, could be advantageous. It is also contemplated that theneedle42 could be inserted through the jaw without the use of theapplication shaft44 andplunger46.
• To aid in the removal of theneedle42, theneedle42 desirably is flexible, short and attached to a longer application shaft (FIG. 12F), or of a type used with sewing machines (FIG. 12G). Aflexible needle42 can be easily bent to facilitate pulling it out of the posterior part of thetongue34. Ashort needle42 would be removed from the application shaft and taken out through the mouth, while the application shaft would be withdrawn through the jaw hole. Alternatively, the sewing machine-style needle142 would allow thesuture110 to be removed from the needle at the back of thetongue34.
• In another representative embodiment (as shown inFIGS. 13A and 13B), an incision is made with acurved needle242 close to thelingual frenulum48 at or near the inferior base of thetongue34 and into extrinsic muscle (e.g., the genioglossus muscle) beneath the tongue. Abarbed suture110 threaded through the hole of thecurved needle242 follows the curvilinear path of theneedle242. As a result, thesuture242 is implanted in a curved or curvilinear orientation (a loop50) in the extrinsic muscle at the inferior base of the tongue, asFIG. 13B shows. By pulling on the end of thesuture110 extending from the needle entrance site in a direction opposite to the direction of insertion (as shown inFIG. 13c), tension is applied to the suture, because thebarbs112 extend outward at an angle α to engage tissue and resist movement in this direction. The tension cinches the suture loop into a more tightly curved orientation, and thebarbs112 resist a reorientation of the suture out of this orientation. The tension tightens up the extrinsic muscle at the inferior base of the tongue. In response, thetongue34 is moved anteriorly, as shown inFIG. 13D. More than one barbed suture100 can be implanted in extrinsic muscle at or near the inferior base of the tongue in this manner.
• In a different approach, one or more barbed sutures can be implanted with curved needle(s) through an incision under the chin on the inside edge of themandible36. In this arrangement, thecurved needle242 is directed through both the geniohyoid and genioglossus muscles, forming theloop50. Cinching the loopedbarbed suture110 in the manner just described will tighten up the genioglossus and the geniohyoid muscles, thereby moving thetongue34 anteriorly.
• One or more looped barbed sutures, implanted in extrinsic muscles at or near the inferior base of the tongue create an anterior tension in the tongue similar to genioglossal advancement, but without requiring attachment to a mandible. Barbed sutures in the geniohyoid muscle could affect a hyoid advancement, as will be discussed later.
• D. Representative Instrument and Method of Implanting Barbed Sutures in the Palate and Uvula
• One or morebarbed sutures110 can be implanted in thepalatal arch52 to improve the tone of thepalate24, and reduce what is called a “floppy palate.”
• In a representative embodiment of a palatal procedure (seeFIGS. 14A and 14B), one or morebarbed sutures110, each threaded to acurved needle242, is passed through thesoft palate24 perpendicular to themidline54 of the palate26 (seeFIG. 14A). By pulling on the end of thesuture110 extending from the needle entrance site in a direction opposite to the direction of insertion (as shown inFIG. 14B), tension is applied to the suture, because thebarbs112 extend outward at an angle α to engage tissue and resist movement in this direction. The tension creates tone in the soft palate24 (seeFIG. 14C). The exposed ends of the suture are desirably trimmed, so that the two ends do not stick out of the mucosa of thesoft palate24. Similarly,barbed sutures110 can be placed in an orientation to tension thepalatal arch52 upward toward the hard palate. Thesutures110 may or may not be attached to the hard palate.
• The oral cavity can be the site for a number of additional or alternative procedures. For example, asFIG. 14D shows, one or morebarbed sutures110 running along themidline54 of thesoft palate24 can shorten theuvula14. Eachsuture110 is inserted by acurved needle242 in an orientation parallel to themidline54 of theuvula14. Again, both ends of thebarbed suture110 are trimmed so as not to stick out of the mucosa. A loop ofbarbed suture110 can be inserted in the same fashion starting in thehard palate28, continuing into theuvula14, and then returning to thehard palate28. The tension in the loop will retract theuvula14.
• As shown inFIGS. 14E and 14F, one or more barbed sutures can be each inserted by acurved needle242 to pass in a desired orientation through either or both pharyngopalatine andglossopalatine arches52, based upon the individual patient's needs.
• E. Representative Instrument and Method of Implanting Barbed Sutures in the Upper Respiratory Tract Muscles
• Implanting one or morebarbed sutures110 in one or more desired orientations to tension any combination of the lateral pharyngeal wall muscles, including the stylohyoid, hyoglossus, stylopharyngus, palatoglossus, palatopharyngeus and pharyngeal constrictor muscles (shown inFIG. 15A), can help eliminate lateral airway wall collapse. The desired orientation in this embodiment is governed by the treatment objective of tensioning thebarbed sutures110 to shorten the muscles in an axial (i.e., generally inferior to superior) direction, or tensioning the muscle(s) laterally by attachment to the underlying structures, for example the prevertebral fascia. A combination of techniques, such asaxial sutures110 that run laterally into the underlying structures at one end, could also be used.
• Implanting one or morebarbed sutures110 in one or more desired orientations to tension any of the muscles that attach to the hyoid (e.g. the strap muscles, omohyoid, geniohyoideus, etc.) (seeFIG. 15B) can serve to advance, or re-position the hyoid to open the airway. Combination ofsutures110, e.g., placed in the palatine arch (as previously described) as well as placed in muscles along the upper respiratory tract, can treat broad sections of the airway.
• F. Representative Instrument and Method of Implanting Barbed Sutures in the Epiglottis
• One or morebarbed sutures110 can be implanted in anepiglottis56 to retain a patent airway (seeFIGS. 16A and 16B).Barbed sutures110 can help treat a “floppy epiglottis” in various ways.
• As shown, for example, inFIG. 16A, thesuture110 could be placed so that it lends tone to theepiglottis56 without significant tensioning. As shown inFIG. 168, thesutures110 could create tension within theepiglottis56 by attaching to other structures or simply “bunching” the tissues of theepiglottis56. As shown inFIG. 16C, thesutures110 could be placed through theepiglottis56 and attached to other structures (e.g. thyroid cartilage, hyoid bone, geniohyoid muscle, etc.) to re-position theepiglottis56.
IV. Standard Sutures and the Treatment of Apnea
• Traction stitch uvuloplasty on thesoft palate24 may also be performed using standard, non-barbed sutures forming asuture loop50 seeFIG. 17A. Thestandard suture loop50 can be applied using a needle that would be inserted in thehard palate28 and then exit briefly at theuvula14, and then continue back up through theuvula14 tissue, to return for the final exit through and eventual attachment to thehard palate28.
• As another alternative shown inFIG. 17B, thesuture loop50 could run directly through the soft tissue at the junction of thehard palate28 andsoft palate24. A sliding knot could allow tensioning of theloop50 to adjust uvular position; however, it is desirable to also use anadditional device58, as described in the section that follows, to affect this tension.
• The uvula end of thesuture loop50 may require using apledget60 to prevent the tissue from tearing or reforming, seeFIG. 17C. Thepledget60 would desirably be buried through a mucosal incision attached to the surrounding tissue or contain barbs (not shown) to help thepledget60 grip to the tissue. In the preferred embodiment, thepledget60 is formed as a pad that sits between the tissue of the patient and the suture. In an alternative embodiment, the suture may run through thepledget60.
• In order to facilitate potential removal of the traction stitch, thepledget60 should desirably contain ferromagnetic/magnetic or radio-opaque material. Desirably, the termination of theloop50 at thehard palate28 will permit adjustability to fine-tune the stitch tension, both interoperatively and via a simple in-office procedure.
V. Adjustment and Removal of Method of Sutures in the Oral Cavity and Upper Respiratory Tract
• A. Adjustment of Sutures
• The tension in thesutures110/210 may be adjusted in various ways. As seen inFIGS. 18A to 18C, one of the means for adjustment of the tension in thesuture210 involves a taperedpeg58. In this method, abase plate62 containing ahole64 is attached to thehard palate28. As seen inFIG. 18B, thesuture210 is threaded through and tied to a taperedpeg58 fitted for thehole64 in thebase plate62. The length of thesuture210 is then adjusted to maximize its therapeutic result by twisting the taperedpeg58 to wrap the end of thesuture210, around it and then inserting and securing the taperedpeg58 into thehole64 in the base plate62 (as shown inFIG. 18C). This type of adjustment may also be used withbarbed sutures110. The barbed part of thesuture110 is passed through the soft tissue to its desired anchoring point (e.g., the uvula), as previously described. In the case ofbarbed sutures110, the smooth end is threaded through and tied to the taperedpeg58. The rest of the adjustment remains the same as forstandard sutures210.
• Alternative embodiments of tensioning means include a peg and a hole that have grooves or other surface features to improve the grip, tapering that is applied to either the peg or the hole, but not both, the peg and the hole can have relatively straight profiles, e.g. no tapering, but have significant features that allow them to interlock, in a similar fashion to gear teeth. As shown inFIGS. 19A and 19B, one embodiment includes afirst structure162 through which thesuture110 is threaded. A second peg-like structure158 screws into thefirst structure162 and, by screwing into thefirst structure162, forces thesuture110 to deviate from its normal straight path (seeFIG. 19B). The deviation of thesuture110 shortens thesuture110 in the soft tissue and thus, serves to tighten thesuture110.
• As shown inFIG. 20, another alternative includes asecond structure258 that can lock into thefirst structure262 in such a manner as to grip thesuture110/210 between the twostructures258/262. One or both of thestructures258/262 would desirably be tapered to grip thesuture110/210, arranged so that tension in thesuture110/210 tightens the interface between thestructures258,262.
• In yet another embodiment shown inFIG. 21, aminiature cam cleat358 would be used to grip the suture.
• As thesuture110/210 is pulled in the direction indicated by the arrows, thecam cleat358 is pulled into tighter engagement and thesuture110 is secured between thecam cleats358. Other suture-gripping devices include devices designed to grip ropes in mountain climbing or sailing, in a miniature version.
• As seen inFIGS. 22A,22B, and22C, another means of adjusting thebarbed sutures110/210 involves using a plastic or titanium mushroom-type device458.FIG. 22A shows a mushroom-type device458 which includes astem466 with ahole468 through which asuture110/210 will be threaded. Thestem466 of the mushroom-type device458 is placed in a pocket either in the oral cavity tissue itself or in a base structure that is attached to the oral cavity tissue, seeFIGS. 22B and 22C. Thesuture110 will be twisted around themushroom stem466 to adjust the tension. Thehead470 of the mushroom will be stapled, sutured, or attached to either an additional hole in thehard palate28 or at the junction of thesoft palate24 andhard palates28, so as to stabilize its rotation. Themushroom shape458 has the advantage of presenting a smooth profile over which the mucosa can easily heal. Although themushroom458 is preferably made of plastic or titanium, it should be clear to one of skill in the art that themushroom458 could be made of any medically acceptable material.
• B. Removal of Sutures
• Removal of sutures is a particularly important issue with respect tobarbed sutures110.Barbed sutures110 cannot be removed like conventional sutures which, in the absence of knots, can be moved freely in either direction. Thebarbed sutures110 are free to move in one direction—from the initiation point to the anchoring point (e.g., from the hard palate to the uvula). Therefore it is desirable to be able to easily identify the anchoring point. One solution involves placing an identifiable marker close to the anchoring point, such as apledget60, seeFIG. 17C. The identifiable marker must be easy to find either by palpation or by using a probe. For example, the marker may be X-ray locatable, or the marker may comprise a ferromagnetic bit which could be located using a magnetic probe. Another alternative involves using an ultrasonic probe that will set off a resonant frequency.
• Once the marker is located, the surgeon may cut through the surrounding tissue to get to the marker and stabilize it. An incision is then made at the insertion point to snip thebarbed suture110 at its attachment point. Then, while holding on to the identifiable marker, thebarbed suture110 is pulled through its anchoring point.
VI. Systems and Methods for Implanting Structures in, on, or Near an Extrinsic Muscle Region of a Tongue
• It is also contemplated that other devices and methods could be utilized to stabilize and maintain a patient's airway in order to treat sleep apnea. For example, an implant structure can be sized and configured for implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue. Examples of such extrinsic muscles include, e.g., the genioglossus, hyoglossus, styloglossus, and palatoglossus, as shown inFIG. 1B. The position of the structure is stabilized relative to the extrinsic muscle region to maintain the tongue in a desired orientation.
• An implant structure having these technical features can take various forms, representative examples of which follow.
• A. Bracing Member for an Extrinsic Muscle Region
• FIGS. 23A to 23C show, as one representative example, an implant structure comprising a bracingmember72 that is sized and configured for implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue. As shown inFIG. 23A, the bracingmember72 is sized and configured to overlay, at least in part, an extrinsic muscle region beneath the tongue.
• As shown inFIG. 23A, an incision is made in the skin on one side of themandible36. A hook-like device78 is inserted that extends up and over thegenioglossus muscle38 and then comes back down on the other side of themandible36, asFIG. 23B shows. Through the same skin incision, the bracingmember72 is inserted and the first end of thebrace72 is attached to the first side of themandible36, as shown inFIG. 23C. The bracingmember72 uses the same incision as thehook78, and is inserted such that thebrace72 extends on top of an extrinsic muscle region (which, inFIGS. 23A to 23B, includes the genioglossus muscle38) and continues to be inserted until it reaches the opposite side of themandible36. A second incision is made in the skin under the second side of themandible36 and the second end of the bracingmember72 is attached to the second side of themandible72. The hook-like device78 is then removed from thetongue34.
• The bracingmember72 may be attached to themandible36 using any medically proven and accepted methods and materials including, but not limited to, small screws and/or biocompatible adhesives.
• The bracingmember72 is sized and configured to deflect the extrinsic muscle region (i.e., the genioglossus muscle38) caudally, causing thetongue34 to move anteriorly, thus maintaining a patent airway.
• B. Booking Member for an Extrinsic Muscle Region
• FIGS. 24A to 24C show, as another representative example, an implant structure comprising a hookingmember80 that is sized and configured for implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue. As shown inFIG. 23B, the hookingmember80 is sized and configured to extend through an extrinsic muscle region beneath the tongue.
• As shown inFIGS. 24A to 24C, ananchoring component74 is coupled to the hookingmember80. As shown inFIGS. 24A to 24C, the assembly of theanchoring component74 hookingmember80 have the appearance of a hook (i.e., the hooking element80) coupled to a buckle (i.e., the anchoring component74), and these components will therefore in shorthand be referred to as such.
• Thehook80 can be formed as a separate piece which couples to thebuckle74, or can be formed as a part of thebuckle74.
• As shown inFIG. 24A, an incision is made under the skin to create a pocket sized to fit thebuckle74. Thebuckle74 may then be inserted into the pocket, under the extrinsic muscle region (which, inFIGS. 24A to 24C includes thegenioglossus muscle38. Thehook80 is opened to place it over the extrinsic muscle region (i.e., the genioglossus muscle38), asFIG. 24B shows.
• Because thehook80 is attached to thebuckle74, thegenioglossus muscle38 is deflected caudally, causing thetongue34 to move in an anterior direction, thus maintaining a patent airway.
• In another representative embodiment, as shown inFIG. 24C, thehook80 can be reattached on the other side of thebuckle74 using achin attachment clamp82. A second skin incision on the other side of themandible36 might be necessary in order to attach thehook80 on the other side of thebuckle74. In this arrangement, thebuckle74 includes achin attachment clamp82. The first end of thechin attachment clamp82 is coupled to the end of thebuckle74. The second end of thechin attachment clamp82 is attached to at least a portion of the chin ormandible36. Desirably, thechin attachment clamp82 will be adjustable in length either interoperatively or under local anesthesia so as to permit the surgeon to adjust the position of thebuckle74 to achieve optimal therapeutic effects based on each individual patient's needs. The bend angle on the clamp section can be between 0° and 70°, depending on the individual's needs. Depending on the individual's anatomy, thechin clamp82 may need to be screwed onto themandible36. Once thehook80 is attached to thebuckle74, thegenioglossus muscle38 is deflected caudally, causing thetongue34 to move in an anterior direction.
• C. Elastomeric Structure for an Extrinsic Muscle Region
• FIG. 25A shows, as another representative example, an implant structure comprising anelastomeric structure76 that is sized and configured for implantation in an extrinsic muscle region affecting movement and/or shape of a tongue. As shown inFIG. 25A, theelastomeric structure76 takes the form of a spring.
• As shown inFIG. 25A, the extrinsic muscle region includes the genioglossus muscle. Thespring76 extends in the muscle region to pull thetongue34 forward. Thespring76 is coupled to a tissue grasping member, which, in the illustrated embodiment, takes the form of ahook77 implanted in thetongue34. Thespring76 implanted in the extrinsic muscle region maintains gentle tension on thehook77. A bar orbutton40 may be attached to thespring76 on the outer portion of themandible36 to retain thespring76 in its position. As an alternative to thespring76, an elastomeric band may be used.
• Alternatively (as shown inFIG. 25B), a needle can be placed all the way through thetongue34. Apocket79 may be formed in the submucosa in the vicinity of the needle exit point. In this arrangement, aclip81 can be fastened to thespring76 in the pocket. This arrangement could eliminate thebar40.
• D. Tissue-Tensioning Elastomeric Structure
• FIGS. 26A,27A and28A show additional representative examples of an implant structure comprising anelastomeric structure500 sized and configured for implantation in a tissue region affecting movement and/or shape of a tongue. As shown inFIGS. 26A and 27A, the treatment device takes the form of an elongatedelastomeric structure500 that is sized and configured for implantation in a desired orientation in the tongue or an extrinsic muscle of the tongue. Theelastomeric implant structure500 is adapted to reshape or move the tongue when implanted in the tongue of an extrinsic muscle of the tongue.
• As shown inFIGS. 26A to 26D and27A to27D, theelastomeric structure500 may take the form of a spring. Although thestructure500 may have any cross-sectional shape, in the illustrated embodiments, the elastomeric structure has a generally circular (for example, thecoiled spring structure510 shown inFIG. 26C) or semicircular cross-section (for example, thesemicircular spring structure520 shown inFIG. 27C).
• The elongatedelastomeric structure500 is also desirably generally elastic. The illustrated embodiments containcoils512 orperforations522 which allow the elastomeric structure to switch between a relaxed state (seeFIGS. 26A and 27A) and an extended, stressed state (seeFIGS. 26D and 27D).
• As shown inFIGS. 28A to 28B, theelastomeric structure500 may take the form of abraided tube501 that resembles Chinese finger cuffs. As seen inFIG. 28A, in its relaxed position, thetube501 has a relatively wide diameter and shorter length. As seen inFIG. 288, in its elongated position thetube501 has a relatively narrow diameter and is significantly longer than in the relaxed position.
• The elongatedelastomeric structure500 can be made of metal material, e.g., Nitinol, other shape-memory alloys, shape-memory polymers, or titanium, as well as any other material known in the art to exhibit similar characteristics of biocompatibility, elasticity, and resilience.
• The elongatedelastomeric structure500 may further be flexible to facilitate its implantation in a targeted tissue region of an individual and thereafter conform to the desired tension and orientation. The desired tension and orientation will depend upon the morphology of the tissue region and the particular treatment objectives.
• In use, the elastomeric structure desirably is implanted in the tissue when the structure is in a stressed or extended state (seeFIGS. 26D,27D and28B).
• In this manner, after the structure is implanted into the tongue, the structure will revert to its natural, unstressed position, thus pulling the tongue into a more forward position. The elongated elastomeric structure may, but does not necessarily need to, be anchored to the mandible.
• In use, one or more elongatedelastomeric structures500 can be implanted at a selected tissue region, depending upon the treatment objectives. The number of implanted elongatedelastomeric structures500 is governed by the location of the tissue region and the treatment objectives, e.g., a desired shape or bias that is to be imparted to the tissue region, and/or the maintenance of a desired tension in the tissue region, and/or the maintenance of a desired orientation of the tissue region relative to another tissue region, e.g., to keep an airway patent.
• The desired orientation comprises the selective application of tension to the elongatedelastomeric structure500 after its implantation to affect a desired change in shape, orientation, and/or other physiologic characteristic within the tissue region.
• The desired orientation in this embodiment is governed by the treatment objective of urging or maintaining the tongue in a desired anterior orientation away from the uvula and/or pharyngeal wall. The relaxed/shortenedstructure500 serves to maintain tension, so that the tissue region itself is maintained in a desired orientation, to thereby resist posterior collapse of the tongue against the uvula and/or the pharyngeal wall.
• It is desirable to place the elastomeric structure into an extended or stressed position (seeFIGS. 30A to 30F), and retain the structure in that position for at least the period of time during which the implant is being implanted into the tongue. The elongatedelastomeric structure500 can be placed into an extended or stressed position (seeFIGS. 30A to 30F) in various ways.
• In a first representative example the implantedelastomeric structure500 can comprise a shape memory metal material that assumes a predetermined, remembered shape in response to an applied activation energy. The activation energy can comprise thermal energy, as well as electrical energy, mechanical energy, electromagnetic energy, acoustic energy, or light energy.
• The shape memory material can comprise an alloy, e.g., Nitinol® alloy (an alloy consisting of nickel and titanium), and copper based alloys, most commonly Cu—Zn—Al and Cu—Al—Ni. Theshape memory material44 can also comprise a shape memory polymer.
• FIG. 29B shows anelastomeric structure500 made of a Nitinol® shape memory alloy. Thestructure500 is implanted in the tongue (seeFIGS. 29D to 29G). As shown inFIG. 29B, thestructure500 possesses relatively compliant mechanical properties at certain temperature conditions (in this case, 25° Celsius), which is sometimes called the soft martensitic phase. Sincestructure500 is soft during the martensitic phase, it is maintained in an elongated shape using an internal support within thedelivery cannula570, which may take the form of aplunger device581 witharms582 that are released upon implantation within the tongue tissue, seeFIGS. 29D to 29E. Alternatively, as will be described in the following section,structure500 in the martensitic phase may also be maintained in an elongated state using various biodegradable materials or structures.
• In response to increased temperature conditions, thestructure500 assumes less compliant mechanical properties (seeFIGS. 29F and 29G), accompanied by accelerated shape change. This is sometimes called the hard austenitic phase. In this phase (as shown inFIGS. 29F and 29G), thestructure500 provides a dynamic resistance to shape change. In the illustrated embodiment, the change in temperature conditions is brought about by an external activation energy source that is used when activation is desired. The activation source can comprise a source of heat, in this case, implantation into tongue tissue. Upon raising the temperature of theelastomeric structure500 to normal body temperature (approximately 37° Celsius), theelastomeric structure500 shortens in length and, in the process tensions the tongue tissue causing the airway to remain patent when the muscles otherwise relax during sleep.
• In the case of theelastomeric structure500 that resembles Chinese finger cuffs, the structure also enters a martensitic phase at approximately 25° Celsius. During this martensitic phase,structure500 is weakened and can be elongated. As with the previous example, during themartensitic phase structure500 needs to be supported by aplunger device581, or similar device. Oncestructure500 has been implanted in the tongue tissue, its internal temperature rises to approximately 37° Celsius, and the structure enters the austenitic phase, wherestructure500 once again becomes rigid and shortens in length. As seen inFIG. 28B, during the martensitic phase the angle β, between two braids that cross over each other and where the angle faces either one of the two hollow ends ofstructure500, is less than 90°. Asstructure500 re-enters the austenitic phase, the same angle widens considerably to return to its pre-set value of over 900. Again, upon raising the temperature of theelastomeric structure500 to normal body temperature (approximately 37° Celsius), theelastomeric structure500 shortens in length and, in the process tensions the tongue tissue causing the airway to remain patent when the muscles otherwise relax during sleep.
• In a second representative example the structure is placed in a stressed position by stretching thestructure500 and filling the space created betweencoils512 of structure510 (FIG. 30A) or within the openedperforations522 of structure520 (FIG. 30C), with abio-absorbable material530 capable of quick absorption by the body. The bio-absorbable material may include substances such as collagen, fibrin glue, or polyglycolic acid (PGA). Desirably, the mass absorption period of thebio-absorbable material530 used to fill the perforations or the space between the coils ofstructure510 will be less than the amount of time necessary for tissue in-growth to start between the coils512 (FIG. 30A) or in the perforations522 (FIG. 30C) (usually about three weeks). In this manner, when the bio-absorbable material is absorbed by the surrounding tissue, the elongated structure will return its relaxed state.
• In an alternative embodiment,structure500 is placed in an extended stressed position by usingabsorbable sutures540 wrapped around thecoils512 of structure510 (seeFIG. 30B) or threaded through the perforations of structure500 (seeFIG. 30D). Desirably, the mass absorption period of theabsorbable sutures540 used to fill theperforations522 ofstructure520 or the space between thecoils512 ofstructure510 will be less than the amount of time necessary for tissue in-growth to start in theperforations522 of structure520 (FIG. 30D) or between thecoils512 of structure510 (FIG. 30B) (usually about three weeks). In this manner, when the absorbent sutures are absorbed by the surrounding tissue, the elongated structure will return to its relaxed state.
• In yet another alternative embodiment seen inFIGS. 30E and 30F,structure500 may be placed in an extended state by interspersing beads of material that biodegrades at different rates. As anexample PGA beads512 may be interspersed between poly-L-lactic acid (PLLA)beads511, seeFIG. 30E.PGA beads512 will biodegrade at a much faster rate thanPLLA511 beads, thus allowing for a gradual return ofstructure500 from a stressed/extended state to a relaxed/shortened state, seeFIG. 30F.
• Other methods (not illustrated) also contemplate placing a tube over an extended elongatedelastomeric structure500 and embedding the structure in a bioabsorbable material, while maintaining a centrally-located channel through the bioabsorbable material to allow the insertion of an anchor to be attached to one end of thestructure500. The tube covering the embedded elongated elastomeric structure would then be removed and thestructure500 would be implanted in the tongue tissue or muscle.
• The elongatedelastomeric structure500 may be coupled to a tissue grasping member, which, in a first illustrated embodiment, takes the form of ananchor550 implanted in thetongue34. Thisanchor550 secures the structure to the tongue. The anchor may be of any type known in the art. Representative examples include a stent anchor (seeFIGS. 31A to 31C) and a daisy anchor (seeFIGS. 33A to 33C).
• As shown inFIGS. 31A to 31C, astent anchor560, a shortened version of an angioplasty cardiovascular stent, can be used for securing the elastomeric structure in the tissue region.FIG. 31A shows the coil-shaped embodiment of the elastomeric structure retained in its extended position by the use of sutures, as described above. A stent anchor, shown in its undeployed position, is attached to one end of the coil.FIG. 31B shows the coil-shaped embodiment of the elastomeric structure retained in its extended position by the use of bio-absorbable material, as described above. A stent anchor, shown in its undeployed position, is attached to one end of the elongated elastomeric structure.FIG. 31C shows an elongatedelastomeric structure500 where thestent anchor560 has been deployed and the elastomeric structure has returned to its relaxed state because bio-absorbable material or sutures were absorbed by the body.
• FIGS. 32A to 32C show a method of inserting the elongatedelastomeric structure500 with an attached stent anchor into the tissue of the tongue. First, a hole is formed through the mandible into the tongue tissue (seeFIG. 32A). Next, a cannula pre-loaded with an elongatedelastomeric structure500 and attachedstent anchor560 is inserted into the hole such that the stent anchor is located at the posterior end of thetongue34. As seen inFIG. 32C, once the implant is in its desired location, thestent anchor560 is then deployed using any method (including but not limited to, self expansion or balloon expansion) known and practiced by those in the field of interventional cardiology involving neuro, peripheral vessels and the cannula is removed. A bar orbutton40 may be attached to the elongatedelastomeric structure500 on the outer portion of themandible36 to retain the elongatedelastomeric structure500 in its position, as shown inFIG. 32C.
• As seen inFIG. 34D, it is also contemplated that two self-deployable stent anchors560 could be used, one on each end of the elongatedelastomeric structure500. This arrangement could eliminate the bar orbutton40 shown inFIG. 32C.
• As thebio-absorbable material530 orabsorbable sutures540 are absorbed within the tissue region, the elongatedelastomeric structure500 implanted in the extrinsic muscle region develops gentle tension on thestent anchor560, keeping the tongue tissue from collapsing posteriorly and thus maintaining the airway patent.
• It is contemplated that the stent anchor may be deployed by collapsing the stent under pressure and enclosing it in a sheath. Once the implant is in its desired location, the sheath is pulled back and the stent anchor starts to return to its original expanded position, penetrating through and embedding itself further into the surrounding tissue. As thebio-absorbable material530 orabsorbable sutures540 are absorbed within the tissue region, the elongatedelastomeric structure500 implanted in the extrinsic muscle region develops gentle tension on thestent anchor560, keeping the tongue tissue from collapsing posteriorly and thus maintaining the airway patent.
• The stent anchor can be removed by re-inserting a cannula-type device over the elongated elastomeric structure, collapsing the stent anchor and re-sheathing it.
• Alternatively, (as shown inFIGS. 33A to 33C), the elongatedelastomeric structure500 may come equipped with at least one self-deployable daisy-type anchor580, hereinafter “daisy anchor” for use in securing the elastomeric structure to the selected tissue region. FIG.33A shows anelastomeric structure500 retained in its expanded position bybio-absorbable material530 with anundeployed daisy anchor580 attached to one end.FIG. 33B shows anelastomeric structure500 retained in its expanded position byabsorbable sutures540 with anundeployed daisy anchor580 attached to one end. As seen inFIGS. 33A and 33B, thedaisy anchor580 comprises a plurality of “petals” or arms. When thedaisy anchor580 is in its undeployed position the arms are held in an essentially vertical position (seeFIGS. 33A and 34B).
• FIG. 31C shows anelastomeric structure500 where thedaisy anchor580 has been deployed and theelastomeric structure510 has been returned to its relaxed state because thebio-absorbable material530 orsutures540 have been absorbed by the body. As shown inFIG. 33C, when thedaisy anchor580 is deployed the “petals” or arms “bloom” or expand and thus penetrate the surrounding tissue to secure theelastomeric structure500 in its desired position. The daisy anchor can be removed by re-inserting a cannula-type device over the elongated elastomeric structure and re-sheathing the anchor.
• FIGS. 34A to 34C shows a method of inserting the elongatedelastomeric structure500 into the tissue of the tongue. First, a hole is formed through the mandible into the tongue (seeFIG. 34A). As shown inFIG. 348 acannula570 pre-loaded with an elongatedelastomeric structure500 and adaisy anchor580 attached on the end is then inserted into the tongue such that thedaisy anchor580 is located at the posterior end of thetongue34. As seen inFIG. 34B, the elongatedelastomeric structure500 should be put in its extended stated, as was described above. Thecannula570 maintains the arms in the “deployment-ready” state, which is in an essentially vertical position.
• As seen inFIG. 32C, once the implant is in its desired location, thedaisy anchor580 is then deployed by pulling out the cannula. When the cannula is retracted, thedaisy anchor580 arms expand and penetrate into the surrounding tissue to anchor the elongatedelastomeric structure500 into its desired location. A bar orbutton40 may be attached to the elongatedelastomeric structure500 on the outer portion of themandible36 to assist in retaining the elongatedelastomeric structure500 in its position.
• As the bio-absorbable material or absorbable sutures are absorbed within the tissue region, the elongatedelastomeric structure500 implanted in the extrinsic muscle region develops gentle tension on thestent anchor560, keeping the tongue tissue from collapsing posteriorly and thus maintaining the airway patent.
• As seen inFIG. 34D, it is also contemplated that two self-deployable daisy anchors580 could be used, one on each end of the elongatedelastomeric structure500. This arrangement could eliminate the bar orbutton40 shown inFIG. 34C.
• It is also contemplated that the inside of the cannula can contain a plunger device, as is well known in the art, that pushes theelastomeric structure500 with attacheddaisy anchor580 into the tissue before the retraction of the cannula.
• E. Tension Adjuster for the Tissue-Tensioning Elastomeric Structure
• FIGS. 35A to 35C show a representative example of a spring expander that may be used with the coiled spring structure510 (as shown inFIG. 26A to 26D). As seen inFIG. 35A, thespring expander590 is a flexible cylindrical shaft with a helical ridge or thread wrapped around it. The helical ridge begins near the proximal end of the flexible cylindrical shaft and mates with the complementary helix formed by thecoiled spring structure510. The flexiblecylindrical shaft592 is desirably made from a material such as titanium, Nitinol, or a polymer.
• As seen inFIG. 35B, the process of inserting/twisting thecylindrical shaft592 into thecoiled spring structure510 causesstructure500 to switch to its stressed, expanded position. As seen inFIGS. 35B and 35C, twisting part of thecylindrical shaft592 out of the elongated elastomeric structure causes the corresponding part of thecoiled spring structure510 to switch to its relaxed position. The process of twisting in and out thecylindrical shaft590 with respect to thecoiled spring structure510 allows the surgeon to control the tension exerted by and/or the elasticity of thestructure510 on the tissue where it has been implanted and to adjust this tension to maximize the therapeutic benefit.
• AsFIG. 35C shows, thecylindrical shaft592 attached to an anchoring device610. In use, theshaft592 would extend through the mandible and the anchoring device would be located on the outside the mandible (seeFIG. 36D). The anchoring device610 may take any suitable forms already well-known in the art, such as buttons, sockets, etc. In the representative embodiment shown inFIG. 35C, thecylindrical shaft592 may include an externally threaded portion at the distal end of thecylindrical shaft592. The anchoring device610 may include an internally threaded portion, such that the anchoring device610 may be secured to thecylindrical shaft592 by screwing the anchoring device610 to thecylindrical shaft592. Essentially, the length of thecylindrical shaft592 may be adjusted at any of various locations of at the attachment point to the anchoring device610.
• In use, thecoiled spring structure510 will desirably come with a pre-inserted spring expander590 (seeFIG. 36C). However, it is also contemplated that during the surgery, the physician will twist thespring expander590 into thecoiled spring structure510 to extend thecoiled spring structure510. Thecoiled spring structure510 is placed and then maintained in a stressed, extended position by the twisting in of a flexiblecylindrical shaft592 with a complementary helix.
• FIGS. 36A to 36E show a method of inserting a spring expander590-coiledspring structure510 assembly.FIG. 36C shows a spring expander with a pre-insertedcoiled spring structure510 with an anchor. The anchor may be of different types, including thestent anchor560 and thedaisy anchor580; desirably, it will be self-deployable. In the illustrated embodiment, adaisy anchor580 is be used, which can be deployed in the tissue region.
• As seen inFIG. 36A, a hole is formed in the mandible.FIG. 36B shows the insertion of a trocar andcannula570 assembly pre-loaded with: an elongatedelastomeric structure510, adaisy anchor580 attached to the distal end ofstructure510, and aspring expander590 twisted into the proximal end (to be located in the anterior portion of the oral cavity) ofstructure510.
• As seen inFIGS. 36D and 36E, once the implant is in its desired location, thedaisy anchor580 is then deployed by pulling out the cannula causing thedaisy anchor580 to “bloom”, where the “petals”/arms penetrate into the surrounding tissue to anchor the elongatedelastomeric structure500 into its desired location. Once thedaisy anchor580 at the distal end of thecoiled spring structure510 is self-deployed, it secures the distal end of thecoiled spring structure510. The surgeon then adjusts the tension exerted by thecoiled spring structure510 on the tissue where it has been implanted to maximize the therapeutic benefit and attaches the flexible cylindrical shaft to the hole in the mandible by any of a variety of means familiar to those experienced in this art (seeFIGS. 36D and 36E).
• As seen inFIG. 36D, abutton40 may be attached to thespring expander590 on the outer portion of themandible36 to retainspring expander590 and associatedcoiled spring structure510 in its position.
• Future adjustments to the tension in the elongated elastomeric structure can be easily performed under local anesthesia in the surgeon's office. To perform adjustments, thebutton40 would be removed from the end of thespring expander590. Thespring expander590 would then be rotated to adjust thecoiled spring structure510 as needed. Rotating thespring expander590 in a first direction would cause more of thespring structure510 to be in the relaxed position and would increase the tension in thespring structure510. Rotating thespring expander590 in an opposite, second direction would cause more of thespring structure510 to be in the extended position and would decrease the tension in thespring structure510. The foregoing is considered as illustrative only of the principles of the invention. Furthermore, since numerous modifications and changes will readily occur to those skilled in the art, it is not desired to limit the invention to the exact construction and operation shown and described. While the preferred embodiment has been described, the details may be changed without departing from the invention, which is defined by the claims. The scope of this invention shall be determined from the scope of the following claims, including their equivalents.

Claims (1)

1. An implant system comprising:

at least one implant structure sized and configured for surgical implantation in, on, or near an extrinsic muscle region affecting movement and/or shape of a tongue, and

means for stabilizing the position of the implant structure relative to the extrinsic muscle region to maintain the tongue in a desired orientation, wherein the means for stabilizing is adapted to be surgically implemented.

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