Otolaryngology http://oto.sagepub.com/ -- Head and Neck Surgery

Clinical Experience with Lingualplasty as Part of the Treatment of Severe Obstructive Sleep Apnea B. Tucker Woodson and Shiro Fujita Otolaryngology -- Head and Neck Surgery 1992 107: 40 DOI: 10.1177/019459989210700107 The online version of this article can be found at: http://oto.sagepub.com/content/107/1/40

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Clinical experience with lingualplasty as part of the treatment of severe obstructive sleep apnea B. TUCKER WOODSON, MD, and SHlRO FUJITA, MD, Milwaukee, Wisconsin, and Troy, Michigan

Because uvulopalatopharyngoplasty (UPPP) as the sole procedure for severe obstructive sleep apnea syndrome (OSAS) is often inadequate, multiple other procedures have been developed. These have been directed at other sites of potential collapse of the upper airway. Initial experience with midline glossectomy (MLG) has shown direct modification of the tongue base to be an effective procedure in a subset of patients with OSAS. Lingualplasty, a modification of MLG, is demonstrated to provide an improved response rate. Twenty-two consecutive patients with severe OSAS and Fujita type II airway classification (retropalatal,oropharyngeal, and hypopharyngeal compromise) underwent lingualplasty. Fourteen patients had previously undergone unsuccessful UPPP. Eight had synchronous lingualplasty and UPPP. All were selected for lingualplasty because of obstructive tongue base anatomy. Responders were defined as having a respiratory disturbance index (RDI) of less than 20 events/hour. For the entire group, 17 of 22 (77%) were classified as responders, with RDI decreasing from 58.8 2 39.5 eventslhour to 8.1 f 6.2 events/hour. Lingualplasty, as an isolated procedure, resulted in a 79% responder rate, with RDI decreasing from 50.2 events/hour to 8.6 events/hour. There were no significant changes in the RDI of the nonresponder groups. No differences were identified that discriminated respondersfrom nonresponders, including age, body mass index, or cephalometry. There were six complications (27%), including bleeding (3), tongue edema (I),prolonged odynophagia (I),and subcutaneous emphysema related to tracheotomy (1). All resolved with treatment. These results indicate that in appropriately selected patients who do not respond to UPPP, lingualplasty is a significant improvement over MLG. (OTOLARYNGOL HEAD NECKSURG 1992;107:40.)

O b s t r u c t i v e sleep apnea syndrome (OSAS) is a disorder characterized by repetitive collapse of the pharyngeal airway during sleep. The site of obstruction may involve any area of the upper airway, but in adults, the site of collapse primarily involves the upper oropharynx (retropalatal airway) or the lower oropharynx (retroglossal airway). Approximately 50% of the patients collapse above the margin of the palate, whereas the remainder collapse below this level. I Surprisingly, the actual area of obstructive collapse in many patients may be quite narrow and may involve as little as one centimeter of airway.* From the Department of Otolaryngology and Human Communication, The Medical College of Wisconsin (Dr. Woodson), and Oakland Otology & Apnea (Dr. Fujita). Presented at the Annual Meeting of the American Academy of Otolaryngology-Head and Neck Surgery, Kansas City, Mo., Sept. 2226, 1991. Received for publication Sept. 21, 1991; revision received March 5 , 1992; accepted March 18, 1992. Reprint requests: B. Tucker Woodson, MD, MCW Clinic at Froedtert Hospital, 9200 West Wisconsin Ave., Milwaukee, WI 53226. 2311l37909

40

Of the multiple options available to treat OSAS, the most effective means are nasal continuous positive airway pressure (CPAP) and tracheotomy. Alternatively, multiple-site specific upper airway procedures have been developed with varying success. Tracheotomy was the initial surgical therapy for OSAS; however, the morbidity of tracheotomy makes it difficult to accept, except for severe OSAS. As an alternative, uvulopalatopharyngoplasty (UPPP) was first introduced by Fujita et al.’ in 1981 as an alternative to tracheotomy. Initially UPPP was reported to have a better than 50% response rate. Accumulated experience using more stringent criteria to define success in severe apneic patients, however, has demonstrated a generally lower success Because failure of UPPP has traditionally been attributed to persistent lower oropharyngeal and hypopharyngeal obstruction at the base of the t ~ n g u e at,~ tempts have been made to surgically enlarge the retroglossal airway and prevent persistent airway obstruction. Multiple procedures have been proposed, including mandibular and hyoid advancement ,* bimaxillary surgery, and midline g l o ~ s e c t o m y . ~

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Volume 107 Number 1 July 1992

Lingualplasty and severe obstructive sleep apnea 41

Riley et a1.” reported a 65% overall success rate with inferior sagittal osteotomy, hyoid suspension, and UPPP. In the same report, bimaxillary surgery (together with UPPP in 21 of 24 patients) had a 100% response rate. As an alternative to skeletal advancement, Fujita et a1.9proposed a direct modification of the tongue base and associated structures. In the midline glossectomy (MLG), a CO, laser was used to intraorally resect a portion of tongue base and redundant hypopharyngeal tissues. In the initial 12 patients-11 of whom had previously undergone unsuccessful UPPP and were treated with permanent tracheotomy-42% responded successfully to MLG. In responders, the respiratory disturbance index was reduced from 64 eventslhour to 15 events/ hour. There were no major complications and no persistent problems with speech or swallowing. This experience indicated that in selected patients a direct surgical approach might be successful in modifying the tongue base for OSAS. Midline glossectomy was subsequently modified to include lingualplasty, in which tongue excision is extended more posteriorly and laterally. The resulting defect is closed by suturing the posterior margin anteriorly, which both advances the tongue base and modifies the dorsal profile of the tongue. We report on the initial experience with this procedure. METHODS

Twenty-two consecutive patients who had lingualplasty performed at the Medical College of Wisconsin Affiliated Hospitals and Troy Beaumont Hospital were reviewed. All patients had either been unsuccessful with or unable to tolerate nasal CPAP. In order to assess surgical results and complications, as well as respiratory results, all patients with lingualplasty were reviewed. Patients were selected for lingualplasty on the basis of clinical upper airway evaluation, including upper airway evaluation and endoscopic Mueller’s maneuver. Some patients had seated and supine dynamic cephalometry. Patients classified as Fujita type Ilb or type 111 (with a combination of palatal, oropharyngeal, and hypopharyngeal obstruction) were considered potential candidates for lingualplasty. All patients demonstrated a narrowed retroglossal and lower oropharyngeal airway caused by a prominent tongue base or lingual tonsils. Additionally, candidates for lingualplasty on Mueller’s maneuver demonstrated greater than 75% collapse of the lower oropharynx. In some patients, redundancy of hypopharyngeal tissues, including the epiglottis, arytenoids, and lateral wall tissues, contributed to collapse on Mueller’s maneuver. The best candidates for lingualplasty were considered those patients with collapse caused by large lingual

tonsils or tongue base, rather than those with lateral wall collapse. Initial patients selected for lingualplasty had undergone unsuccessful UPPP. Selected patients who manifested obstructive airway anatomy primarily of the tongue base who had not undergone unsuccessful UPPP later were also selected for lingualplasty. In these patients, complete visual obstruction of the retroglossal or hypopharyngeal airway occurred during quiet respiration while patients were awake in the supine position. In the majority of these patients, associated palatal abnormalities were also observed and simultaneous UPPP was performed. All patients underwent complete nocturnal polysomnography preoperatively and at least 6 weeks postoperatively. In three patients the overnight postoperative study was performed on an Edentec model 680 multichannel cardiorespiratory monitor (Edentec, Eden Prairie, Minn.), with half-hour nursing checks for position, snoring, and the appearance of sleep. This method has been previously validated for OSA. I ’ Patients were defined as successful responders if the respiratory disturbance index (RDI) was decreased by 50% and was less than 20 events/hour. An RDI of 20 was selected because at this level patients are infrequently treated medically with nasal CPAP, hypersomnolence is resolved equivalent to the use of nasal CPAP,” and also because this level of respiratory disturbance has not been associated with significantly increased mortality. As a result of the wide range of respiratory indices, respiratory data analysis was performed using the Mann Whitney Test for nonparametric values to determine the significance of preoperative and postoperative respiratory values for the groups presented. Cephalometry was evaluated using two-tailed Student t-tests. Values were considered significant if p < 0.01. SURGICAL TECHNIQUE

Lingualplasty is performed by means of an intraoral approach. Before lingualplasty, a tracheotomy is performed and anesthesia is administered through a lasersafe endotracheal tube. The patient is placed in the Rose position. The tongue base is exposed by use of a Davis mouth gag and a small adult or child No. 3 C-ring tongue blade (Storz Instrument Co., St. Louis, Mo.). The smaller blade allows prolapse of the tongue base into the field. A midline portion of tongue is then outlined with methylene blue, approximately 2 to 2.5 centimeters in width, beginning posterior to the circumvallate papilla and extending towards the vallecula approximately 4 to 5 centimeters in length (Fig. 1, A). Care is taken to stay in the midline. If any doubt exists, laryngoscopy is performed to document the midline position. Using a CO, laser delivered through a Zeiss

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OtolaryngologyHead and Neck Surgery

42 WOODSON and FUJITA

Fig. 1. Lingualplasty is performed by first, excision of a midline segment of tongue posterior to the circumvallate papillae (A). The prolapsing tissue (5) is then excised in a wedge shape (5, inset). Posterior tissue is then sutured anteriorly (C). Partial epiglottectomy is shown (C, inset).

operating microscope (or a KTP laser delivered through a fiberoptic source), the area outlined is deeply excised. Upon approaching the vallecula, a hyoid branch of the lingual artery is often encountered, and it is coagulated with electrocautery. After removal of the midline tongue, a laser laryngoscope can be used to expose the vallecula and remove any additional lingual tonsils or redundant tissue of the epiglottis or arytenoids. If the epiglottis is omega-shaped as a result of tissue redundancy, it is conservatively trimmed (Fig. 1 , C, inset). Lingualplasty is then performed after replacement of the mouth gag and the No. 3 tongue blade. Beginning at the anterior comer of excision, an additional centimeter-long wedge of lateral tongue is excised in order to create a defect (Fig. 1 , B ) . The anterior to posterior size of this excision may vary. The posterior margin of the tongue should be kept thick, both to preserve its blood supply and not devascularize the posterior margin of preserved tongue,and to retain suture (a thin posterior margin may not). It is important that the wedge excision

laterally be superficial to ensure preservation of neurovascular structures. A 2-0 vicryl suture is then used to suture the medial posterior margin anteriorly and laterally. This advances and lateralizes the tongue base (Fig. 1, C). A single suture placed laterally is usually adequate. Multiple sutures may be difficult to place and may only tear tissue. Tissue advancement and lateralization may produce a visible increase in retroglossal airway size. One must be constantly aware that overly aggressive soft tissue excision or advancement may impair tongue mobility. Bending the needle into a horseshoe-shape facilitates placement. Although posterior tissue is lateralized, it should be appreciated that the midline defect collapses medially, obliterating the defect after withdrawal of the tongue blade or laryngoscope. Preoperative antibiotics and 10 mg dexamethasone were administered to all patients. In the later part of the series on all patients (even with no history of gastroesophageal reflux), an anti-reflux regimen was be-

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Volume 107 Number 1 July 1992

Lingualplasty and severe obstructive sleep apnea 43

Lingualplasty Only 190

(n=14)

1

100

n

a

P,

\

d 30

....

..........

-

---

m......

10

-

Pre Responders

Post

- -- - Non Responders

Fig. 2. Respiratoty disturbance index (RDI) of individual patients who had lingualplasty alone or after unsuccessful UPPP

gun. Diet was advanced as tolerated. Liquids were started on postoperative day number I . and adequate oral fluid intake is usually obtained by day 3. Planned swallowing therapy to maximize function appeared to speed recovery. Patients were decannulated at the discretion of the surgeon. This was performed before discharge if the patient was able to tolerate CPAP and endoscopic evaluation showed an adequate airway. Otherwise, tracheotomy was capped daily, starting on postoperative day 2 or 3, until the postoperative polysomnogram was performed. One patient did not have a tracheotomy and did well. Swallowing therapy to diminish aspiration, using techniques similar to supraglottic laryngectomy, was used if necessary. All patients were discharged when adequate liquid intake was tolerated and tracheotomy care was demonstrated. RESULTS

Lingualplasty was performed on 21 men and one woman, with a mean age of 48 ? 15 years for the entire group. Fifteen patients had previously undergone unsuccessful uvulopalatopharyngoplasty and fourteen had lingualplasty alone. Severe obstructive sleep apnea had developed in one patient after mandibular osteot-

Table 1. Respiratory parameters for lingualplasty as part of the treatment of OSAS (N = 221

RDI Al O,SAT

Preoperative

Postoperative

p value

586 2 366 ? 41 8 786 2 9 7

163 5 172 9 6 ? 15 6 a73 73

Clinical experience with lingualplasty as part of the treatment of severe obstructive sleep apnea.

Because uvulopalatopharyngoplasty (UPPP) as the sole procedure for severe obstructive sleep apnea syndrome (OSAS) is often inadequate, multiple other ...
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