Obstructive sleep apnea affects around 20 million Americans and can lead to hypertension, heart attack, stroke, depression, muscle pain, fibromyalgia, morning headaches, and excessive daytime sleepiness.

Sunday, February 14, 2010

Tongue Reduction Surgery for Treating Obstructive Sleep Apnea

I am frequently asked by patients what the best sleep apnea surgery. I have decided to do a series of posts on surgery to treat sleep apnea. I am going to cover tongue reduction surgery today. The tongue is much more important than the soft palate when obstructive sleep apnea is being treated.

The soft palate is basically a free swinging door. When you breathe in it opens and directs air down the oropharynx and into the lungs via the bronchi. If the tongue is back against the posterior pharyngeal wall it prevents the soft palate from opening. You can reduce the soft palate thru numerous painful surgeries with associated morbidities but the airway will remain obstructed due to the position of the tongue. A second alternative is to move the tongue out of the way of the soft palate to allow it to open freely. This is the primary method that oral appliances use to open the airway. They move the jaw forward and the tongue comes forward due to the genioglossus attatchment, you use a TRD or tongue retaining device to pull the tongue forward or you use a tongue restraining device to prevent the tongue from falling back (Full Breath Appliance).

The tongue is the strongest muscle in the body and when we look in the mouth only see about 20% of the total tongue. The rest is under the floor of the mouth down to the hyoid bone. The easies way to understand how the tongue blocks the airway is compare the tongue and the mouth to a car and a garage.

If we have an economy size tongue (car) and an economy size mouth (garage) the system works fine. If we have a Hummer size tongue and a Hummer size garage it also works fine. The problems begin when we have a Hummer size tongue and try to fit it in an economy size garage.

In this example the only way a Hummer fits in the economy size garage with the door closed it to drive it thru the back wall. This is exactly what happens with sleep apnea, the tongue goes back against the posterior pharyngeal wall and and down toward the epiglottis and blocks the airway and prevents the soft palate from swinging open to allow in air.

To complicate matters inspiration or breathing in causes a vaccumn that actually sucks the tongue downward and backward it the direction of the vacumn creating the airway blockage.

There are several surgeries that can be used to reduce the size and position of the tongue.

The first is a median Rhomboid Glossectomy, which is the removal of a rhomboid shaped area in the middle of the tongue. I have never had a patient who has had this procedure but I have talked to three surgeons who each did the proceedure once and never planned on doing it again. It has been described as a nightmare surgery to me. My rule of thumb is that surgeons like to do surgery and you probably do not want a surgery they do not want to do.

The second surgical reduction is an anterior wedge removal and closure. Basically a pizza slice is taken out of the front of the tongu and the parts are sewn together. This is a very easy surgery that could be done awake in an oral surgeons or ENT's office. It is done frequently in South America because it is easy and efficient. The tongue then postures forward out of the posterior pharyngeal areas (throat). The downside to this surgery is that all the goood tastebuds are primarily in this region of the tongue and the bitter or nasty taste buds are left after the surgery. The bad news is that nothing will ever taste good again, the good news is that this will make it easier to lose weight. For red wine lovers from now on you will only taste the tannins, need I say more.

It is also possible to do a base of the tongue reduction, this is not recommended for the severely obese (see abstract at end of post). This study showed a higher morbidity with a base of tongue surgery relative to radiofrequency surgery when combined uvulopalatopharyngealplasty (UP3). The success rate was over 50% however success was defined as a 50% reduction in apnea. Even the successful cases may still require CPAP or Oral Appliance therapy because the definition for success was set very low. In obese patients the success rate was significantly lower, only 10-12 1/2 % .

This can be done as a single surgical visit where an opening is made across the back of the tongue and and the insides are grossly scooped out. The coblation proceedure is much less traumatic and can be seen at: http://www.youtube.com/watch?v=uq4WcVQg__c The somnoplasty proceedure is the least traumatic with the lowest morbidity but will require several surgeries. I do not see successful base of tongue reduction patients because they are not looking for oral appliance therapy but patients I have seen who have been thru one or two somnoplasty treatment sessions in the base of the tongue and refuse additional surgery are always very easy to treat with oral appliances. This is much different than failed UP3 surgeries which are sometimes more difficult to treat du to scarring.

Tongue advancements are another group of surgeries that we will discuss in the future but include hyoid suspension, genioglossus advancement (several types).

Whie I am not a big fan of surgery for treating sleep apnea in most patient coblation and especially somnoplasty can significantly improve sleep apnea. The Somnoplasty proceedure has the lowest risk and morbidity of all tongue reduction procedures.

There is a quote I love "There is no disease or disorder known to man that cannot be made worse by sticking a knife in it!" This does not mean not to have surgery done but ask lots of questions about the procedure, what can go wrong and if there is a problem can it be fixed. Treatment of Sleep Apnea is essential but we want the cure to improve your quality of life.

Excellent questions are:

How many surgeries have you done?
can I talk to a patient who had successful surgery?
What are possible side effects?
Can I speak to patients who had those side effects?
Are the side effects permanent if they occur?
What is the recovery time?

Make sure all of your questions and concerns are addressed before having surgery done. Bring your list of questions to your consult so you do not forget to ask them. Check them off as you go.

An excellent study on base of tongue surgery was done in Otolaryngol Head Neck Surg. 2009 Jun;140(6):917-23.

The Pub Med abstract is listed below for your convenience.

1: Otolaryngol Head Neck Surg. 2009 Jun;140(6):917-23. Epub 2009 Apr 15.Links
Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome.

Fernández-Julián E, Muñoz N, Achiques MT, García-Pérez MA, Orts M, Marco J.
Otorhinolaryngology Department, Hospital Clínico Universitario, University of Valencia, Valencia, Spain. fernandez_enr@gva.es
OBJECTIVE: To compare the effectiveness and morbidity of the tongue base radiofrequency and tongue base suspension techniques combined with uvulopalatopharyngoplasty for moderate to severe obstructive sleep apnea. STUDY DESIGN AND SETTING: Prospective and randomized surgical trial at a university hospital. METHODS: In total, 57 patients received either tongue base radiofrequency reduction (n = 29) or tongue base suspension (n = 28). Apnea-hypopnea index, lowest oxygen saturation (polysomnography), Epworth score, and side effects were assessed. Success was defined as a > or =50 percent reduction and final apneahypopnea index < 15/h, and an Epworth score < 11. RESULTS: The success rates of the two procedures were 57.1 percent and 51.7 percent, respectively (P = 0.79), but only 12.5 percent and 10 percent, respectively (P = 0.87), in obese patients. Body mass index (P = 0.0002) was the main predictor of success in a logistic regression analysis. Tongue base suspension demonstrated higher morbidity (P < 0.05). CONCLUSIONS: The effectiveness of tongue base suspension was similar to that of tongue base radiofrequency reduction, although with significantly higher morbidity, for moderate to severe obstructive sleep apnea. The effectiveness of both techniques was lower in obese patients. SIGNIFICANCE: Neither technique should be used in obese patients who have moderate to severe obstructive sleep apnea.
PMID: 19467415 [PubMed - indexed for MEDLINE]

posted by Dr Shapira at 12:15 PM