Double Mandibular Osteotomy for Access to High-Carotid Pathology

Background: Anecdotal experience demonstrates the existence of patients with superiorly located carotid stenosis, neoplasms, or aneurysms where the mandible obstructs effective surgical access using standard techniques. As carotid pathology extends anatomically beyond the limits of standard operative technique, additional exposure becomes paramount to safely and effectively address the lesion. Double mandibular osteotomy (DMO) is one of several techniques to obtain additional exposure to high-carotid pathology however there is no large series to address the outcomes of patients undergoing this procedure.

Patients and methods: A retrospective case series was performed of all patients undergoing surgery for carotid pathology from 2011 - 2019 that could not be approached with standard cervical incision. The primary predictor variable was high anatomic carotid pathology necessitating DMO. The primary outcome variable was early and late complications sustained by patients.

Results: Fifteen patients met study criteria and underwent 16 DMOs to access high-carotid pathology including carotid stenosis (n=8 patients), carotid aneurysm (n=2 patients), and carotid body tumor (n=8 patients). Two patients had dual ipsilateral pathology with one patient having both carotid artery stenosis and aneurysm, and the other patient diagnosed with carotid artery stenosis and carotid body tumor. One patient had bilateral carotid artery stenosis, each requiring high anatomic exposure for treatment. Early complications occurred in eight patients. Five patients experienced significant dysphagia requiring enteral feeding and two patients developed malocclusion directly related to the double mandibular osteotomy. One patient experienced contralateral cortical watershed infarcts. Late complications included one patient developing osteomyelitis of the mandible and this patient also developed distal mandibular segment screw exposure. The comparison of the outcome groups for categorical predictor variables using Fisher's Exact Test detected no statistically significant differences for gender, hypertension, hyperlipidemia, type 2 diabetes, COPD, tobacco use, chronic kidney disease, or cerebrovascular disease. For the continuous variable comparisons, independent-samples t-tests detected no difference between the complication groups for age, operative time, or years of follow-up. No significant differences were found between the groups for body mass index, or intraoperative blood loss.

Conclusion: The double mandibular osteotomy provides excellent exposure and surgical access to the distal internal carotid artery for repair of vascular pathology with acceptable outcomes and long-term complications compared to previously reported techniques. Due to the early complications realized with the DMO, we recommend the procedure for symptomatic patients with a high risk of failing medical therapy alone and not appropriate for endovascular treatment as well as those patients with tumors requiring surgical intervention.