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Using Tongue Surgery, Airway Stimulation to Treat OSA

Kenneth Peter Pang, MD: ‘Every time a patient with sleep apnea sleeps, (the tongue) collapses posteriorly and obstructs the airway.’

The tongue plays a key role in obstructive sleep apnea (OSA) and upper airway function. It is a fatty structure that requires skill and patience in performing dangerous surgeries needed to repair abnormalities that are linked to OSA. A September 13 Miniseminar focused on providing a variety of tips for surgical procedures as well as the option of implanting an airway stimulation system.

“Sleep surgeons need to recognize that the tongue is a crucial structure in treating sleep apnea,” said session moderator Kenneth Peter Pang, MD, of the Asia Sleep Center in Singapore. “In treating the tongue, you have to be very careful because postoperative complications can be dangerous.”

In “Pearls in the Management of the Tongue in OSA,” Dr. Pang and Peter Baptista, MD, PhD, of Clinica Universidad de Navarra in Spain used a series of videos to demonstrate techniques for radio frequency ablation, coblation, tongue suspension, tongue base surgery, and airway nerve stimulation.

The tongue is a central structure that is housed in the bone and loosely attached to the jaw, Dr. Pang said. It is soft and flexible and contains fat tissue, and its muscles are paralyzed in sleep.

“Every time a patient with sleep apnea sleeps, it collapses posteriorly and obstructs the airway. The tongue is important because there is a lot of fat in it, not just muscle. So, the idea is to not just address the muscle, but the fat that is in the tongue,” he said.

Studies show a correlation between tongue volume and body mass index. Studies also show that patients with obstructive sleep apnea most likely have hypopharyngeal obstruction, Dr. Pang said.

One approach to treating tongue abnormalities or reducing tongue volume is tongue base surgery because the severity of OSA is related to tongue base collapse. Patients with severe OSA are more likely to have tongue base obstruction. Complicating treatment is the fact that a “large number” of surgeries at the tongue base fail, he said.

Radiofrequency (RF) ablation is used to reduce fibrotic scarring and tongue volume with minimal pain and low morbidity, Dr. Pang said, adding that it can be performed as outpatient therapy. Several devices and approaches are used for RF ablation with various degrees of success. In general, results are better with more RF sessions.

Coblation tongue surgery uses a small probe that employs radiofrequency to reduce tongue volume. It is best used only at the base of the tongue, Dr. Pang said.

Tongue suspension is performed under general anesthesia and is done at the same time as palate surgery. Sutures are used to pull the tongue forward, “like a hammock,” he said. Complications include acute sialoadenitis, impaired tongue protrusion, bothersome tongue suture ends, edema of the tongue and floor of the mouth, and pain.

Selection criteria for tongue surgery patients include:

  • Moderate to severe OSA
  • A body mass index of less than 28
  • Obstruction at the base of the tongue
  • Strong post-operative care

Dr. Baptista reviewed and compared two approaches for managing OSA—transoral robotic surgery (TORS) and upper airway stimulation using a system of three implanted components.

TORS is used for tongue base reduction and partial epiglottidectomy. The upper airway stimulation system uses a small generator, a breathing sensor lead, and stimulation lead that are controlled with a handheld remote to turn the system on or off.

The two approaches can complement each other in some cases and they provide an “excellent option to a selective group of patients,” Dr. Baptista said. Those patients must have failed with the use of CPAP, have an apnea-hypopnea index of between 20 and 65, and a body mass index of less than 35.

Negative aspects of using the upper airway stimulation system are that airway obstruction can be a problem, a tracheostomy may be required, it is expensive, and the learning curve is difficult to overcome, he said.

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