The Laryngoscope C 2014 The American Laryngological, V
Rhinological and Otological Society, Inc.
Transoral Robotic Surgery for Treatment of Obstructive Sleep Apnea: Factors Predicting Surgical Response Ho-Sheng Lin, MD; James A. Rowley, MD; Adam J. Folbe, MD; George H. Yoo, MD; M. Safwan Badr, MD; Wei Chen, PhD Objectives/Hypothesis: We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response. Study Design: Case series. Methods: Between June 2010 and May 2014, BOT reduction via TORS 6 partial epiglottectomy 6 uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study. Results: Mean apnea-hypopnea index (AHI) was 43.9 6 32.3 preoperatively and 21.9 6 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% 6 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 6 5.4 preoperatively vs. 5.7 6 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 6 7.0 vs. 32.4 6 7.3; P 5 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively. Conclusions: We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery. Key Words: Obstructive sleep apnea/hypopnea syndrome, transoral robotic surgery, robot-assisted, base of tongue reduction, robotic surgery, glossectomy, sleep apnea, epiglottectomy, tongue base, sleep apnea surgery. Level of Evidence: 4. Laryngoscope, 00:000–000, 2014
INTRODUCTION Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a complex disease entity involving collapse at various levels of upper airway during sleep. Treatment of OSAHS is important because its associated repetitive arousals and nocturnal hypoxemia can lead to disruption of sleep architecture and daytime hypersomnolence, as well as a multitude of neurobehavioral and cardiopulmonary derangements1,2 that significantly
From the Department of Otolaryngology–Head & Neck Surgery, Wayne State University and Karmanos Cancer Institute (H-S.L., A.J.F., G.H.Y.); the Department of Surgery (H-S.L.); the Department of Medicine (M.S.B.), John D. Dingell VA Medical Center; the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Wayne State University (J.A.R., M.S.B.); and the Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University (W.C.), Detroit, Michigan, U.S.A. Editor’s Note: This Manuscript was accepted for publication September 17, 2014. H-S.L. has a consultant agreement as a proctor with Intuitive Surgical, Inc. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ho-Sheng Lin, MD, 4201 St. Antoine Street, 5E University Health Center, Detroit, MI, 48201. E-mail: [email protected] DOI: 10.1002/lary.24970
Laryngoscope 00: Month 2014
increase risk of death.3,4 The standard treatment for patients with OSAHS is positive airway pressure (PAP). Although PAP is an extremely safe and effective treatment modality, it is not universally acceptable to all patients. For those patients who are not compliant or cannot tolerate PAP, surgical treatment may be an important option to consider. Multiple surgical approaches have been described to address obstructions at various levels of the upper airway.5–7 Surgical treatment for obstruction at the level of the base of tongue (BOT) has traditionally been challenging due to difficulty in accessing this region. Transoral robotic surgery (TORS)8–11 may overcome this limitation by offering improved visualization and surgical access to the BOT region. Although the incorporation of TORS-assisted BOT reduction for the treatment of OSAHS appears feasible and promising,12–16 appropriate patient selection remains the most important consideration for successful implementation of this surgical approach. Clinical factors associated with surgical success have been reported for various conventional surgical approaches,17–20 but none have been reported specifically for TORS-assisted approach. In this study, we reviewed our experience with the use of TORS for BOT reduction either alone or Lin et al.: Transoral Robotic Surgery for Sleep Apnea
1
TABLE I. Baseline Patient Demographics and Clinical Characteristics of 39 Robotic-Assisted Base of Tongue Reductions. Preoperative Clinical Characteristics
Number (%)
Mean (SD)
Median (Range)
Age Body mass index
46.5 (13.2) 32.9 (7.0)
48.0 (19.0–73.0) 32.4 (22.4–48.9)
Neck circumference
16.2 (1.5)
16.0 (14.0–20.0)
Friedman tongue position Tonsil size
3.2 (0.6) 0.8 (0.9)
3.0 (2.0–4.0) 1.0 (0.0–4.0)
3.0 (0.6)
3.0 (1.0–4.0)
96.9% (13.1%)
100% (25–100%)
Gender Female Male
15 (38.5%) 24 (61.5%)
Race White Hispanic
26 (66.7%) 2 (5.1%)
African American
11 (28.2%)
Prior surgery Tonsillectomy
18 (46.2%)
UPPP
8 (20.5%)
BOT* Tracheostomy†
4 (10.3%) 4 (10.3%)
Any
21 (53.8%)
Lingual tonsil size Small Large
9 (23.1%) 30(76.9%)
Friedman stage Sleep endoscopy findings % VP collapse (AP) % VP collapse (L)
51.3% (34.4%)
50% (0–100%)
% BOT collapse (AP) % BOT collapse (L)
89.1% (19.7%) 49.4% (29.5%)
100% (25–100%) 50% (0–100%)
% epiglottic collapse (AP)
96.2% (14.7%)
100% (25–100%)
Apnea–hypopnea index
43.9 (32.3)
34.2 (7.0–140.5)
Lowest oxygen saturation (%) Epworth Sleepiness Scale
81.6 (8.1) 15.6 (5.4)
84.0 (57.0–92.0) 15.0 (3–24)
Mean (SD)
Median (Range)
Sleep endoscopy findings VP collapse (AP) 75%
38 (97.4%)
VP collapse (L) 75%
12 (30.8%)
BOT collapse (AP) 75% BOT collapse (L) 75%
34 (87.2%) 11 (28.2%)
Epiglottic collapse 75% Passive Active
37 (94.9%) 26 (66.7%)
Intraoperative Clinical Characteristics
Number (%)
BOT only BOT 1 UPPP
11 (28.2%) 2 (5.1%)
BOT 1epiglottectomy
7 (17.9%)
BOT 1 UPPP 1 epiglottectomy Robot setup time (min)
19 (48.7%) 24.2 (7.7)
20 (15–45)
Robotic surgical time (min)
59.5 (20.6)
60 (20–100)
Total blood loss (ml) BOT volume removed (ml)
12.9 (9.0) 22.2 (11.7)
10 (5–50) 20 (4.4–57.0)
3.5 (1.5)
3 (1–7)
Hospital stay (days)
*BOT procedures include hyoid advancement, coblation-assisted lingual tonsillectomy, and/or repose tongue suspension. † All four patients were successfully decannulated after surgery. AP, anterior–posterior; BOT, base of tongue; L, lateral; min, minutes; ml, milliliter; SD, standard deviation; UPPP, uvulopalatopharyngoplasty; VP, velopharynx.
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Lin et al.: Transoral Robotic Surgery for Sleep Apnea
TABLE II. Comparison of Preoperative and Postoperative BMI, AHI, Lowest Oxygen Saturation, and ESS. Preoperative Mean (SD)
Postoperative Mean (SD)
P Value (paired Student t test)
Body mass index
32.9 (7.0)
32.4 (7.3)
Apnea–hypopnea index Lowest oxygen saturation (%)
43.9 (32.3) 81.6 (8.1)
21.9 (23.5) 83.4 (7.3)
Rhinological and Otological Society, Inc.
Transoral Robotic Surgery for Treatment of Obstructive Sleep Apnea: Factors Predicting Surgical Response Ho-Sheng Lin, MD; James A. Rowley, MD; Adam J. Folbe, MD; George H. Yoo, MD; M. Safwan Badr, MD; Wei Chen, PhD Objectives/Hypothesis: We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response. Study Design: Case series. Methods: Between June 2010 and May 2014, BOT reduction via TORS 6 partial epiglottectomy 6 uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study. Results: Mean apnea-hypopnea index (AHI) was 43.9 6 32.3 preoperatively and 21.9 6 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% 6 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 6 5.4 preoperatively vs. 5.7 6 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 6 7.0 vs. 32.4 6 7.3; P 5 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively. Conclusions: We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery. Key Words: Obstructive sleep apnea/hypopnea syndrome, transoral robotic surgery, robot-assisted, base of tongue reduction, robotic surgery, glossectomy, sleep apnea, epiglottectomy, tongue base, sleep apnea surgery. Level of Evidence: 4. Laryngoscope, 00:000–000, 2014
INTRODUCTION Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a complex disease entity involving collapse at various levels of upper airway during sleep. Treatment of OSAHS is important because its associated repetitive arousals and nocturnal hypoxemia can lead to disruption of sleep architecture and daytime hypersomnolence, as well as a multitude of neurobehavioral and cardiopulmonary derangements1,2 that significantly
From the Department of Otolaryngology–Head & Neck Surgery, Wayne State University and Karmanos Cancer Institute (H-S.L., A.J.F., G.H.Y.); the Department of Surgery (H-S.L.); the Department of Medicine (M.S.B.), John D. Dingell VA Medical Center; the Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Wayne State University (J.A.R., M.S.B.); and the Biostatistics Core, Karmanos Cancer Institute, Department of Oncology, Wayne State University (W.C.), Detroit, Michigan, U.S.A. Editor’s Note: This Manuscript was accepted for publication September 17, 2014. H-S.L. has a consultant agreement as a proctor with Intuitive Surgical, Inc. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Ho-Sheng Lin, MD, 4201 St. Antoine Street, 5E University Health Center, Detroit, MI, 48201. E-mail: [email protected] DOI: 10.1002/lary.24970
Laryngoscope 00: Month 2014
increase risk of death.3,4 The standard treatment for patients with OSAHS is positive airway pressure (PAP). Although PAP is an extremely safe and effective treatment modality, it is not universally acceptable to all patients. For those patients who are not compliant or cannot tolerate PAP, surgical treatment may be an important option to consider. Multiple surgical approaches have been described to address obstructions at various levels of the upper airway.5–7 Surgical treatment for obstruction at the level of the base of tongue (BOT) has traditionally been challenging due to difficulty in accessing this region. Transoral robotic surgery (TORS)8–11 may overcome this limitation by offering improved visualization and surgical access to the BOT region. Although the incorporation of TORS-assisted BOT reduction for the treatment of OSAHS appears feasible and promising,12–16 appropriate patient selection remains the most important consideration for successful implementation of this surgical approach. Clinical factors associated with surgical success have been reported for various conventional surgical approaches,17–20 but none have been reported specifically for TORS-assisted approach. In this study, we reviewed our experience with the use of TORS for BOT reduction either alone or Lin et al.: Transoral Robotic Surgery for Sleep Apnea
1
TABLE I. Baseline Patient Demographics and Clinical Characteristics of 39 Robotic-Assisted Base of Tongue Reductions. Preoperative Clinical Characteristics
Number (%)
Mean (SD)
Median (Range)
Age Body mass index
46.5 (13.2) 32.9 (7.0)
48.0 (19.0–73.0) 32.4 (22.4–48.9)
Neck circumference
16.2 (1.5)
16.0 (14.0–20.0)
Friedman tongue position Tonsil size
3.2 (0.6) 0.8 (0.9)
3.0 (2.0–4.0) 1.0 (0.0–4.0)
3.0 (0.6)
3.0 (1.0–4.0)
96.9% (13.1%)
100% (25–100%)
Gender Female Male
15 (38.5%) 24 (61.5%)
Race White Hispanic
26 (66.7%) 2 (5.1%)
African American
11 (28.2%)
Prior surgery Tonsillectomy
18 (46.2%)
UPPP
8 (20.5%)
BOT* Tracheostomy†
4 (10.3%) 4 (10.3%)
Any
21 (53.8%)
Lingual tonsil size Small Large
9 (23.1%) 30(76.9%)
Friedman stage Sleep endoscopy findings % VP collapse (AP) % VP collapse (L)
51.3% (34.4%)
50% (0–100%)
% BOT collapse (AP) % BOT collapse (L)
89.1% (19.7%) 49.4% (29.5%)
100% (25–100%) 50% (0–100%)
% epiglottic collapse (AP)
96.2% (14.7%)
100% (25–100%)
Apnea–hypopnea index
43.9 (32.3)
34.2 (7.0–140.5)
Lowest oxygen saturation (%) Epworth Sleepiness Scale
81.6 (8.1) 15.6 (5.4)
84.0 (57.0–92.0) 15.0 (3–24)
Mean (SD)
Median (Range)
Sleep endoscopy findings VP collapse (AP) 75%
38 (97.4%)
VP collapse (L) 75%
12 (30.8%)
BOT collapse (AP) 75% BOT collapse (L) 75%
34 (87.2%) 11 (28.2%)
Epiglottic collapse 75% Passive Active
37 (94.9%) 26 (66.7%)
Intraoperative Clinical Characteristics
Number (%)
BOT only BOT 1 UPPP
11 (28.2%) 2 (5.1%)
BOT 1epiglottectomy
7 (17.9%)
BOT 1 UPPP 1 epiglottectomy Robot setup time (min)
19 (48.7%) 24.2 (7.7)
20 (15–45)
Robotic surgical time (min)
59.5 (20.6)
60 (20–100)
Total blood loss (ml) BOT volume removed (ml)
12.9 (9.0) 22.2 (11.7)
10 (5–50) 20 (4.4–57.0)
3.5 (1.5)
3 (1–7)
Hospital stay (days)
*BOT procedures include hyoid advancement, coblation-assisted lingual tonsillectomy, and/or repose tongue suspension. † All four patients were successfully decannulated after surgery. AP, anterior–posterior; BOT, base of tongue; L, lateral; min, minutes; ml, milliliter; SD, standard deviation; UPPP, uvulopalatopharyngoplasty; VP, velopharynx.
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Lin et al.: Transoral Robotic Surgery for Sleep Apnea
TABLE II. Comparison of Preoperative and Postoperative BMI, AHI, Lowest Oxygen Saturation, and ESS. Preoperative Mean (SD)
Postoperative Mean (SD)
P Value (paired Student t test)
Body mass index
32.9 (7.0)
32.4 (7.3)
Apnea–hypopnea index Lowest oxygen saturation (%)
43.9 (32.3) 81.6 (8.1)
21.9 (23.5) 83.4 (7.3)
