Tongue Base Obstruction Research Articles

Association between Positional Dependency and Obstruction Site in Obstructive Sleep Apnea Syndrome

ObjectivesThe purpose of this study is to find out associations between positional dependency and obstructive levels based on sleep videofluoroscopy (SVF) in patients with obstructive sleep apnea syndrome (OSAS).MethodsRetrospective review was made of 91 OSAS patients who underwent polysomnography and SVF from August 2009 through June 2010. Polysomnography variables including apnea-hypopnea index (AHI), supine AHI, non-supine AHI, time spent in supine sleep position of the total sleep time and positional dependency (PD) were analyzed. Obstruction sites were evaluated as SVF variables.ResultsOf 91 patients, 65 (71.4%) were positional patients (PP) and 26 (28.6%) were non-positional patients (NPP). An analysis of polysomnography variables according to PD revealed that overall AHI, non-supine AHI and supine AHI in PP was significantly lower than that in NPP. The patients with soft palate obstruction (SP type) were more likely to have PD than the patients with tongue base obstruction (TB type; P=0.046). PD was inversely related to OSAS severity significantly (P=0.001).ConclusionThese results provide evidence that positional dependent patients may have higher success rate of soft palate OSA surgery alone than non-positional dependent patients. Although PD may be associated with obstruction site, PD only itself may not be useful in planning surgical treatment for OSAS.

Current Concepts in Tongue Surgery for OSA

Program Description: To describe the various tongue base surgical techniques that are available for patients with OSA. Why we do them, who we do them for, and when? Tongue base obstruction has been known to be one of the levels of obstruction in OSA. Surgical treatment of the palate alone has been shown to be ineffective in patients with high Mallampati grades, Friedman Stage II & III, and tongue base collapse seen on dynamic nasopharyngoscopy. Severity of OSA is currently known to correlate with degree of tongue base and lateral pharyngeal wall collapse. Patients with severe OSA are more likely to have tongue base obstruction. Airway evaluation is vital in the management and assessment of patients with OSA. The indications for tongue base surgery is pivotal in the decision making process. All the indications based on the clinical examination would be explored and discussed. Various tongue base surgical techniques are discussed, ranging from radiofrequency of the tongue base, genioglossus advancement, hyoid suspension, laser midline glossectomy, tongue suspension, coblator channeling techniques, and robotic tongue base surgery. The surgical steps are illustrated, success rates are presented, and complications are discussed. Educational Objectives: 1) Apply the appropriate airway evaluation. 2) Choose the correct procedure. 3) Understand the technique behind each procedure.

Multicenter study of a novel adjustable tongue-advancement device for obstructive sleep apnea

Objective The safety and clinical effect of a new surgical device for tongue suspension for obstructive sleep apnea (OSA) was assessed. Study Design Multicenter phase 2 prospective case series. Setting Multicenter academic and private. Subjects and Methods Surgically naïve patients with moderate-to-severe OSA and tongue base obstruction (body mass index < 32, apnea/hypopnea index [AHI] 15-60) underwent surgical insertion of a midline tissue anchor into the posterior tongue and connected to an adjustable mandibular bone anchor with a flexible tether. Outcomes included changes in AHI, sleepiness (Epworth Sleepiness Scale), sleep-related quality-of-life (Functional Outcomes of Sleep Questionnaire), snoring, swallowing, speech, and pain (0-10 visual analog scale). Results After the implant, 42 patients (mean age 50 years, body mass index 28) noted improvement at six months for AHI (mean [SD]: 35.5 [20.4] to 27.3 [18.8]), Epworth Sleepiness Scale (11.5 [3.9] to 7.8 [4.7]), and Functional Outcomes of Sleep Questionnaire (15.5 [2.6] to 17.5 [2.6], all P < 0.01). Snoring VAS scores improved (7.3 [2.1] to 4.7 [2.9], P < 0.01). Postimplant pain scores were mild to moderate (4.4) at day one and resolved by day five. Post-titration pain scores were mild (< 2). Device-related adverse events included wound infection (7%) and edema or seroma (5%), which resolved. However, in 31 percent of patients, asymptomatic tissue anchor barb fractures were observed radiographically. Conclusion The tissue anchor failure rate of the tested device precludes its clinical use; however, the study results support that a titratable, tongue-suspension device with low direct surgical morbidity in patients with moderate-to-severe sleep apnea significantly improves multiple measures of sleep apnea. Further investigation is warranted.

Pediatric obstructive sleep apnea—base of tongue obstruction

Various anterior glossectomy techniques have been used in the past for airway obstruction at the base of the tongue due to glossoptosis and/or macroglossia. This has largely focused on treating the enlarged, anteriorly protruding tongue. However, these procedures do not address the posterior and base of tongue areas that are more often the problem in pediatric sleep disordered breathing and obstructive sleep apnea. Techniques to evaluate for site of obstruction as well as current possible surgical approaches for treating the base of tongue and glossoptosis are discussed in this article.

Radiofrequency surgery for the treatment of obstructive sleep apnea: Short-term and long-term results

Objective To compare the short-term and long-term results in patients undergoing radiofrequency (RF) for obstructive sleep apnea (OSA). Study Design Case series and planned data collection. Setting Tertiary referral center. Subjects and Methods A study was undertaken on 72 OSA patients with palatal and tongue base obstruction based on radiography and physical findings. Multilevel RF was conducted to reduce the tissue. Results Patients had a mean age of 35.8 ± 10.9 years and a mean body mass index (BMI) of 28.8 ± 2.4 kg/m 2. The mean follow-up was 14.2 ± 1.8 months, with a range of 12 to 16 months. Mean baseline apnea-hypopnea index (AHI), short-term AHI, and long-term AHI were 35.6 ± 9.2, 12.5 ± 4.8, and 16.8 ± 3.2, respectively. Mean baseline lowest oxygen saturation (LSAT), short-term LSAT, and long-term LSAT were 85.6 ± 3.4 percent, 88.7 ± 2.9 percent, and 88.2 ± 1.7 percent, respectively. The change in BMI was significantly different in the patients with and without recurrence (2.8 ± 1.8 vs 0.3 ± 0.2 kg/m 2, P < 0.01). Forty (55.6%) patients had long-term success, and eight (16.7%) patients with short-term success failed in the long term. Serious complications were not encountered. Conclusion RF is a minimally invasive and effective procedure that results in long-term success for patients with a relatively low BMI and mild to moderate OSA without nasal obstruction. However, a recommendation concerning weight control and a regular follow-up are important because some patients will relapse in the long term.

Comparison between tongue base and soft palate obstruction in obstructive sleep apnea

Conclusions. In obstructive sleep apnea syndrome (OSAS), respiratory disturbances are more serious in tongue base-associated obstructions (TBOs) than in soft palate-associated obstructions (SPOs), and the proportion of TBO was predicted by average duration of apnea and hypopnea, and inversely by percentage time of snoring. Objective. To compare the polysomnographic characteristics of two main obstruction sites of OSAS, the soft palate and tongue base, and to identify those variables correlated with tongue base obstructions in patients with OSAS. Patients and methods. Thirty-one patients (28 men and 3 women) with OSAS were enrolled in this study. To identify airway obstruction levels upper airway pressure manometry was applied during polysomnography. Airway obstructions were categorized as SPO and TBO by observing pressure patterns. All analyses of events were performed in the supine position. Results. Average duration of apnea and hypopnea, percentage of apnea among apnea-hypopneas, average O2 desaturation, and percentage of event-related arousals were significantly higher in TBOs compared with SPOs (all p<0.05). The percentage of TBO among total obstructions (TBO%) was independently associated with average duration of apnea and hypopnea (=0.38, p<0.05) and percentage time of snoring (=–0.44, p<0.01) (adjusted R2=30%, p<0.01).

Lingual Tonsillectomy for Persistent Pediatric Sleep Apnea

Objective 1) To describe our experience with a technique of lingual tonsillectomy using coblation with endoscopic visualization. 2) To document its utility for treating children with persistent sleep apnea after adenotonsillectomy who on sleep endoscopy have enlarged lingual tonsils and tongue base obstruction. Methods Retrospective cohort study in a tertiary pediatric medical center. Between 2005 and 2007, 20 patients (ages 3 -18), who had a previous adenotonsillectomy (T&amp;A) for obstructive sleep apnea (OSA), were diagnosed with persistent OSA by polysomnography (PSG). These children had both in-office unsedated fiberoptic laryngoscopy and dynamic anesthesia-assisted sleep fiberoptic laryngoscopy, both of which demonstrated lingual tonsillar hypertrophy contributing to tongue base obstruction of the hypopharynx. With a visually confirmed site of lesion, these children underwent endoscopic lingual tonsillectomy for treatment. Pre- and post-operative PSG data were paired and analyzed statistically. Results Statistically significant reductions in respiratory distress index (RDI) were observed when pre- and post-operative data were compared (mean 14.9 vs. 7.8, median 12.6 vs. 3.3). There were similar reductions in the number of apneas and hypopneas. The mean and median low O2 saturations did not change significantly. Conclusions Endoscopic lingual tonsillectomy is an effective technique for the treatment of lingual tonsillar hypertrophy causing persistent obstructive sleep apnea after T&amp;A. Anesthesia-assisted sleep endoscopy is key to diagnosing the obstructive contribution of the enlarged lingual tonsils. The combination of endoscopic access with the near bloodless technique for ablation of the lingual tonsils provides a consistently reproducible method of treating children with this uncommon problem.

High energy single session radiofrequency tongue treatment in obstructive sleep apnea surgery

To evaluate the safety and outcomes of a high-energy single session treatment as an alternative to a cumulative energy multiple staged approach when using temperature-controlled radiofrequency tissue ablation (TCRFTA) for tongue base obstruction in sleep apnea surgery. Retrospective study of 176 consecutive Fujita II (tongue and palate level obstruction) patients undergoing single session palate, tonsil, and nasal surgery, and concurrent tongue base TCRFTA by the application of 10,500 J of energy. Median follow-up was 156.5 days. There were no serious complications. There were five (2.8%) superficial tongue ulcers, and three (1.7%) persistent taste disturbances after treatment; 174 patients were on sustainable oral intake and adequate oral pain control within 24 hours of surgery; 98 had comparable post operative sleep studies. Apnea-hypopnea indexes decreased from 35.3 +/- 23.9 to 22.6 +/- 21.5 (P < 0.0001). Epworth Sleepiness Scale scores improved from 11.2 +/- 4.9 to 5.9 +/- 4.6 (P < 0.000001). High energy single session tongue base TCRFTA is a safe procedure with low morbidity.

Does an oral appliance reduce palatal flutter and tongue base snoring?

Oral appliances are designed to treat snoring and sleep apnea by advancing the mandible and tongue. We test the hypothesis that an oral appliance affects palatal snoring as well as tongue base obstruction. Prospective observational cohort study. Sixty patients with a chief complaint of snoring with or without apnea were enrolled. Each patient underwent a home sleep test followed by 3 weeks sleeping with an oral appliance. Each patient then underwent a repeat home sleep test while using the device. There was a statistically significant improvement in the snores per hour (P = 0.0005), the maximum snoring loudness (P = 0.0001), average snoring loudness (P = 0.00001), and the percentage of palatal snoring (P = 0.0007). There was also a significant decrease in oxygen desaturation events (P = 0.003). This study suggests oral appliances may be effective treatment for both palatal and tongue base snoring.

Submucosal minimally invasive lingual excision (SMILE): Technique for tongue base reduction

Submucosal minimally invasive lingual excision is a technique for treating tongue base obstruction in both pediatric and adult patients. Invasive tongue base procedures are mucosal destructive, leading to significant postoperative pain. The submucosal minimally invasive lingual excision (SMILE) technique provides for a mucosal sparing approach while allowing aggressive tissue removal using a plasma-mediated radiofrequency device (coblation) under ultrasonic and endoscopic guidance. Postoperative risks and care are simplified due to the minimally invasive approach.

Tongue suspension suture in obstructive sleep apnea

Tongue base obstruction is widely acknowledged to be the most difficult level of obstruction to treat in obstructive sleep apnea. A number of methods to correct surgically the tongue base collapse have been proposed. The tongue base suspension suture was introduced as a minimally invasive technique for tongue base stabilization. The technique uses a screw as a bone anchor inserted intraorally into the mandible with an attached Prolene number 1 suture (Ethicon Endo-Surgery, Inc, Cincinnati, OH) that is passed through the tongue. The suture not only provides a sling-like effect in the tongue base but also incorporates into the tongue musculature, imparting rigidity to the airway. This procedure can be performed alone or as part of a multilevel surgical algorithm in the treatment of obstructive sleep apnea.

One-phase management of severe obstructive sleep apnea: Tongue base reduction with hyoepiglottoplasty plus uvulopalatopharyngoplasty

To describe the results of a 1 phase surgical procedure for the treatment of severe obstructive sleep apnea (OSA) attributable to tongue base obstruction. A retrospective nonrandomized study at S Orsola Malpighi University Hospital of Bologna, Italy. Ten male patients affected by severe OSA (mean apnea/hypopnea index [AHI] of 54.7), underwent uvulopalatopharyngoplasty (UPPP) associated with tongue base reduction and hyoepiglottoplasty (TBRHE). The indications to this surgical procedure were based on the presence of hyolingual abnormalities and absence of craniofacial deficiencies determined by preoperative assessment. Mean AHI decreased from 54.7+/-11.5 to 9.4+/-5.4 whereas the mean low SaO2 value went from 77%+/-6.2 to 90.7%+/-3 and the time of sleep with SaO2<90% improved from 53%+/-17.2 to 7.3%+/-8. The overall success rate was 100%. TBRHE is an effective and safe treatment in patients with severe OSA attributable to tongue base obstruction and in absence of craniofacial deficiencies.

Radiofrequency Tongue Reduction Through a Cervical Approach: A Pilot Study

The objective of this prospective cohort study was to determine the feasibility, safety, and efficacy of radiofrequency tongue base reduction through a cervical approach in patients with obstructive sleep apnea syndrome (OSAS). Patients with moderate to severe OSAS and predominant tongue base obstruction by physical examination were included at our institution from 1999 to 2003. A sonogram was obtained to identify the lingual arteries, and an electrode was inserted through the neck and into the tongue under fluoroscopic guidance. Adverse events were recorded as well as efficacy on snoring (visual analog scale), daytime sleepiness (Epworth score), and polysomnography. The 10 patients received a mean of 14,288 +/- 3,251 J per session. No cases of tongue palsy or infection occurred. During the first 7 days, mean pain score (0-10 scale) was 1.3 +/- 1.5. Snoring volume (0-10 scale) decreased from 6.2 +/- 2.3 to 3.9 +/- 2.6 (P = .017) and sleepiness (0-24 scale) from 8.7 +/- 5.6 to 4.7 +/- 3.3 (P = .011). The respiratory disturbance index (events/hour) decreased from 52.0 +/- 19.6 to 33.6 +/- 24.4 (P = .016). Mean minimal oxygen saturation (%) increased from 64.2 +/- 13.0 to 75.8 +/- 10.3 (P = .003). Sleep architecture improved although not significantly. Radiofrequency tongue base reduction through a cervical approach proved feasible and safe despite the large energy doses used. Fluoroscopic guidance enables to place the electrode at the desired site of treatment. Although OSAS improved in nine of 10 patients, greater efficacy might be achieved in patients with less severe OSAS at baseline. Studies are needed to correlate objective clinical efficacy with the dose per lesion site and the number of lesion sites per session.

Cine magnetic resonance imaging: evaluation of persistent airway obstruction after tonsil and adenoidectomy in children with Down syndrome.

Although usually successful, not all obstructive sleep apnea is cured by removal of the tonsils and adenoids (T&A). This is particularly true in children with Down syndrome and craniofacial anomalies. This is because of the multiple levels of obstruction in their airways, with obstruction present not only at the level of the tonsils and adenoids but also from base of tongue obstruction, soft palate collapse, and hypopharyngeal collapse. The cine magnetic resonance image (MRI) is useful in evaluating the upper airway in those patients who have not achieved a normal polysomnogram after T&A surgery. Prospective case series. Fifteen children with Down syndrome who had previously undergone a T&A but continued to have abnormal postoperative polysomnograms underwent a cine MRI with fast gradient cine MRI images. The cine MRI identified different areas and levels of obstruction that ultimately affected the children's treatment courses. Recurrent adenoid tissue, glossoptosis, soft palate collapse, hypopharyngeal collapse, and enlarged lingual tonsils were identified. The results as well as several illustrative cases are presented. Cine MRI evaluates upper airway obstruction in children who may have multiple sources of obstruction causing their obstructive sleep apnea. This is particularly helpful in children with Down syndrome and craniofacial anomalies. This technology is useful in all children with complex upper airway obstruction.

Radiofrequency reduction of the tongue base for obstructive sleep apnea

Objectives: To determine if radiofrequency reduction of the base of tongue (BOT) utilizing the ENTec Coblator Plasma Surgery System at a specific setting is an effective treatment for obstructive sleep apnea (OSA) in patients clinically determined to have retroglossal obstruction. To quantify the BOT volumetric reduction utilizing MRI imaging and to correlate this to various clinical outcome measures. To identify any physical characteristic(s) that may have a high predictive value for patients that may benefit from BOT reduction. Methods: A prospective clinical trial of 50 consecutive patients with OSA and BOT obstruction was performed at a tertiary care medical center. Each patient received a single radiofrequency treatment to 6 BOT sites under general anesthesia with ∼10,200 joules delivered over 2 minutes (6 × 20seconds). Uvulopalatopharyngoplasty (UPPP) was also performed when retropalatal obstruction was present. Pre- and postoperative overnight polysomnograms, nasopharyngeal endoscopy, and MRI imaging of the upper airway, including volumetric measurement of the tongue, were performed. Careful and comprehensive pre- and postoperative evaluation also included photographic documentation and grading of the BOT, recording of Epworth Sleepiness Scale (ESS) scores, body-mass index (BMI), modified Mallampati grade, tonsil size, and all complications. Multiple regression analysis was performed to determine variables predictive of the best candidates for BOT. Results: Patients clinically determined to have BOT obstruction on physical exam and endoscopy had statistically significant improved outcomes compared with the expected results from UPPP alone. No serious complications occurred. Conclusions: Radiofrequency reduction of the BOT is a safe, quick, and effective adjunct in the treatment of OSA for selected patients.

An adjunctive method of radiofrequency volumetric tissue reduction of the tongue for OSAS

Temperature-controlled radiofrequency volumetric reduction (TCRF), a minimally invasive procedure, has been used to treat tongue base obstruction in Obstructive Sleep Apnea Syndrome (OSAS). An adjunctive method was objectively evaluated. A prospective, nonrandomized clinical study was undertaken on 20 consecutive OSAS patients with isolated tongue base obstruction. Under local anesthesia, multiple lesions of the ventral tongue (genioglossus insertion) and dorsal tongue were given at each treatment session. A visual analog scale was used to assess changes in speech and swallowing. Polysomnography and Epworth Sleepiness Scale (ESS) were used to assess outcome. Patients were maintained on nasal continuous positive airway pressure after each treatment. Patients received a mean 4.6 +/- 0.6 treatments for a mean total of 7915 +/- 1152 joules. There was no significant change in speech or swallowing at 3 months after completion of treatment. Patients reported a significant decrease in sleepiness with a mean change in ESS from 12.4 +/- 2.9 to 7.3 +/- 3.0 (P < 0.001). Mean apnea/hypopnea index decreased from 35.1 +/- 18.1 to 15.1 +/- 17.4 (P < 0.001). Transient mild to moderate pain and swelling occurred after each treatment. There were no significant complications (ulceration, paresthesia, infection). TCRF can successfully treat the OSAS patient with tongue base obstruction. Combined treatment of the ventral (genioglossus insertion) and dorsal tongue appears safe and may improve outcome with less total energy when compared with traditional dorsal-only applications.

Discussion

Airway evaluation for surgical treatment of obstructive sleep apnea syndrome (OSA) remains a difficult problem. Although clear differences between normal snorers and those with OSA exist in both skeletal and soft tissue measures, the usefulness of these measures for surgical prediction or treatment planning remains limited. 1 Sher AE Schechtman KB Piccirillo JF The efficacy of surgical modifications for the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996; 19: 156 Crossref PubMed Scopus (988) Google Scholar Problems are myriad. Correlating arbitrary criterion (often using subjective measures) performed in awake patients to complex processes that occur during sleep are recognized as difficult. 2 Woodson BT Wooten MR Comparison of upper-airway evaluations during wakefulness and sleep. Laryngoscope. 1994; 104: 821 Crossref PubMed Scopus (69) Google Scholar A less obvious problem has been a lack of terminology to describe anatomy, the upper airway, and airway obstruction. The only widely used system is that described by Fujita. 3 Fujita S Pharyngeal surgery for management of snoring and obstructive sleep apnea. Snoring and Obstructive Sleep Apnea. Raven Press, New York, NY1987 Google Scholar The article by Moore and Phillips provides an interesting and novel approach to address the lower pharyngeal airway. In their study, a relatively large patient population with documented OSA was evaluated with upright lateral cephalometric x-rays. Four different anatomic patterns of narrowing were then described. These include type A (high tongue-base obstruction), type C (low tongue-base obstruction), and type B-1/B-2 (combined high tongue-base, diffuse tongue-base, and retroepiglottic narrowing).

Distraction Osteogenesis of the Mandible for Airway Obstruction in Children

Objectives of the study were to determine the effectiveness of distraction osteogenesis of the mandible to relieve airway obstruction in children with tongue-base airway obstruction and to describe the new surgical techniques developed for use in infants and young children. Prospective, nonrandomized study. Analysis of 11 children with severe airway obstruction secondary to tongue-base obstruction was performed. Patients were between 2 weeks and 5.5 years of age. All patients underwent distraction osteogenesis of the mandible. Twelve distraction procedures in the 11 children in the study were accomplished; decannulation or extubation was successful in all children. Distraction osteogenesis of the mandible can be used to treat tongue-base airway obstruction in appropriately selected children.

Management of tongue base obstruction in obstructive sleep apnoea syndrome.

Studies have shown that the obstruction in OSA is more often than not multicentric. Tongue base obstruction is relatively more difficult to diagnose accurately and treat effectively. In this presentation, an effort is made to suggest two methods of management of this problem. One deals with the surgical management and the second, an alternative non-surgical method.

Tongue base reduction with hyoepiglottoplasty: a treatment for severe obstructive sleep apnea.

To describe a surgical procedure for the treatment of severe obstructive sleep apnea syndrome (OSAS), the procedure's indications, and its results. A retrospective study of 10 male patients with OSAS treated by tongue base reduction with hyoepiglottoplasty (TBRHE) at the Foch Hospital (Suresnes, France) between 1994 and 1997. Patients had a mean body mass index (BMI) of 32 kg/m2, a mean respiratory disturbance index (RDI) of 70 events/h, and a mean minimal oxygen saturation of 78%. They had refused positive airway pressure therapy or wished to discontinue it. Subtotal tongue base reduction preceded by lingual neurovascular bundle identification and derouting, epiglottal verticalization, mouth floor horizontalization, and hyoid bone repositioning was performed, associated in some cases to uvulopalatopharyngoplasty (UPPP). Indications were based on a site-related obstruction, on the absence of craniofacial deficiencies, and on the presence of hyolingual abnormalities determined by cephalometry and magnetic resonance imaging. TBRHE associated to UPPP in most cases had an 80% success rate, based on a postoperative RDI below 20 events/h and a reduction of the preoperative RDI of more than 50%. Snoring and excessive daytime sleepiness decreased or disappeared, respectively, in 100% and 90% of the cases. No neurovascular complications occurred. TBRHE is a safe procedure for the neurovascular bundle. Associated to a pharyngotomy, it is an effective treatment for severe OSAS attributable to tongue base obstruction. These results require confirmation in a larger series of patients.