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persistent OSA after initial therapy, children with OSA without tonsil or adenoid
hypertrophy, or children with signicant craniofacial anomalies.
Sleep surgery is considered as one of the important treatment strategies for
patients who cannot tolerate CPAP [10], and the success rates of uvulopalatopharyngoplasty (UPPP) in moderate and severe OSA patient groups were 42.5% and
26.5%, respectively [11]. However, the UPPP success rate is unsatisfactory in
patients with small tonsils and a bulky tongue base. Additional therapy for the
tongue base is recommended, particularly for patients with anatomical tongue-base
obstruction during sleep [12]. At the same time, failure to recognize epiglottic collapse along with tongue base collapse is one of the most common reasons for the
failure of OSA surgery and poor CPAP compliance.
Various surgical methods have been adopted for bulky tongue base treatment,
including transoral robotic surgery, coblation endoscopic lingual reduction, submucosal minimally invasive lingual excision, tongue base radiofrequency reduction,
and tongue base suspension [13, 14]. In all the above-described procedures, the
epiglottic collapse has to be addressed according to the type and pattern of collapse
along with the tongue base surgery. When base of the tongue collapses onto the
epiglottis and obstructs the airway, it is called secondary epiglottic collapse and in
these cases, tongue base surgery helps to prevent airway obstruction by the epiglottis.
V. Agrawal et al.
23.2 Relevant Surgical Anatomy oftheTongue Base
In the vast majority of OSA cases, the soft tissue in the middle part of the tongue
base causes collapses on the epiglottis to cause airway obstruction, though in a few
cases, the lateral part of the tongue also contributes to the obstruction.
The tongue base is made up of intrinsic muscles and is covered by a layer of
lymphoid tissue. Accordingly, the obstruction can be caused by either lymphoid
hypertrophy (lingual tonsils) or hypertrophic muscular tongue base. In a few subjects with OSA, a high amount of fat also accumulates in the tongue base, which
adds to the volume.
The neurovascular bundle, which consists of the lingual vessels and the hypoglossal nerve (HLNVB), is situated at a distance of 1.5–2cm from the midline and
1.5–2cm deep from the surface (Fig.23.1). The lingual artery is an important component in tongue base surgery and care is to be taken for the lingual artery due to the
susceptibility of damage during surgery. Injury to the lingual artery during surgery
can lead to a life-threatening hemorrhage, and if both lingual arteries are damaged,
necrosis of the tongue can occur [15]. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at
the tongue base [16]. The results indicate the position of the HLNVB in the base of
tongue is signicantly inferior and lateral, that is, 2.7cm inferior and 1.6cm lateral
to the foramen caecum, 0.9cm superior to the hyoid bone, and 2.2cm medial to the
mandible. This inferolateral location allows the potential for aggressive tongue base
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Fig. 23.1 Cadaver
dissection of the tongue
showing the Neurovascular
bundle and its relation to
the midline
291
resection without neurovascular compromise. Cohen etal. [17] have measured the
distance of the neurovascular bundle from the foramen caecum in surgical simulated positions. Measurements from foramen cecum to palatoglossus muscle
(P<0.042) were signicantly different when comparing anatomical to surgically
simulated positions. Importantly, the location of the lingual artery in reference to the
surface landmarks measured was dramatically altered with tongue retraction. With
retraction, the branches of the dorsal lingual artery were not encountered posterior
to a horizontal line between midway circumvallate papilla (mCVP). This explains
that the HLNVB surface landmarks in the base of tongue differs signicantly
between resting and a surgically simulated tongue position. Also the dorsal branch
of the lingual artery seems more supercial in the base of tongue than previously
described. A safe zone may exist posterior to an imaginary horizontal line
between mCVP.
23.3 Addressing Secondary Epiglottic Collapse withTongue
Base Surgery
23.3.1 Patient Selection
Patients are selected based on the ndings of DISE, as discussed in the previous
chapters, or by dynamic MRI.
However, an assessment of the type of obstruction, whether it is lymphoid tissues
of the tongue base (lingual tonsils) or by hypertrophic muscular tissue in the tongue
base, is of paramount importance, as the technique of surgery, intraoperative and
postoperative monitoring, and possible complications are different in the two subsets of patients.
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V. Agrawal et al.
23.3.2 Technology
Trans Oral Robotic Surgery (TORS) and coblation-assisted tongue base ablation are
the two major technologies being used for base tongue resection, besides others.
The coblation technology (Smith & Nephew, USA) involves the creation of a plasma
eld with bipolar radiofrequency that leads to soft tissue dissolution at a lower temperature with simultaneous hemostasis.
23.4 Surgical Technique
Under general anesthesia with nasotracheal intubation, the patient is positioned
supine with the surgeon sitting on the head end with a mild extension of the neck.
The authors’ preference is the Trendelenburg position by 5–10°, which helps for the
saline used in the coblation technology to accumulate in the nasopharynx and not to
pool in the hypopharynx.
A FK retractor or Boyle Davis mouth gag with appropriate size tongue blade is
applied in order to visualize the base of tongue. However, 1–0 silk stay suture is
placed in the middle of the dorsum of the tongue to retract for proper visualization
of the surgical site (Fig.23.2).
Angled endoscopes preferably 30 or 70° rigid Hopkins endoscopes have been
used. The authors prefer to use 45° endoscopes.
Procise max or Evac 70 extra HP coblation wand is being used. For better access
to the surgical site, the wand is bent 30–40° gently without making a sharp angle
which may block the suction and irrigation ow (Fig.23.3). The generator settings
are kept at 7–9 for ablation and 3–4 for coagulation, depending on the surgeon’s
preference.
The extent of dissection is marked, starting from the midline at foramen caecum
and lateral limits are marked 1.5cm on each side. Anteriorly, it is limited to the
imaginary line drawn at the level of foramen caecum and posteroinferiorly up to the
level of the median glossoepiglottic ligament. The wedge-shaped ablation is performed layer by layer under direct visualization with a 45° endoscope starting from
the surface of the tongue base down in the midline up to a depth of 1–1.5cm and
laterally up to 1.25–1.5cm on each side where a depth of 0.5–0.75cm is maintained
(Figs.23.4 and 23.5).
Fig. 23.2 Silk suture is in
place on the dorsum of the
tongue in the midline to
pull the tongue out for
proper exposure of
tongue base
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Fig. 23.3 The coblation
wand is bent 30–40° gently
without making a sharp
angle
Fig. 23.4 The
hypertrophied tongue base
being ablated using
coblation at the beginning
of the procedure
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Fig. 23.5 The resected
tongue base down to the
level of median
glossoepiglottic ligament
using coblation at the end
of the procedure
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Fig. 23.6 The position of the lingual vessels in relation to the dissecting instruments monitored in
real-time intraoperatively by the use of color doppler ultrasonography imaging
V. Agrawal et al.
The position of the lingual vessels in relation to the dissecting instruments and
the extent of the dissection are monitored in real-time intraoperatively by the use of
color doppler ultrasonography imaging (Fig.23.6).
The volumetric reduction of the base of the tongue is calculated by measuring the
thickness of tongue at the start of the procedure using ultrasonography and again
measuring at the end of the procedure (Figs.23.7 and 23.8). The volumetric reduction achieved by the excision of the obstructing tongue base indirectly prevents the
epiglottic collapse.
The above-described procedure is mainly used for excising hypertrophic lingual
tonsils, but can also be performed to address muscular hypertrophy of the tongue
base. The other commonly performed techniques are radiofrequency or coblation
channelling of the tongue base and various submucosal approaches to the tongue
base have been described.
Radiofrequency channelling of the tongue base for patients with macroglossia can be performed with monopolar or bipolar radiofrequency, or with
coblation. A series of patients who underwent a combination of coblation
tongue channelling and modified uvulopalatopharyngoplasty demonstrated
that patients with Friedman stage III (Friedman tongue position III and IV,
tonsil sizes 0, 1 or 2, BMI <40) showed more encouraging response, with
71% surgical success, compared to the reported 8% surgical success in
Friedman stage III patients who underwent UPPP alone as shown by Friedman
etal. [18].
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Fig. 23.7 The thickness
of the base of the tongue at
the level of foramen
caecum at the start of the
procedure is 2.56cm
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Fig. 23.8 The thickness of the base of the tongue at the level of foramen caecum at the end of the
procedure is 1.17cm, thereby denoting that the reduction was 1.39cm
23.4.1 Intubation andExtubation
Nasal intubation is preferred as it provides space at the tongue base area for better
exposure and dissection. Patients with grade 2 and 3 lingual tonsil hypertrophy and/
or minimal muscular hypertrophy with incomplete collapse during DISE can be
extubated on the table. Gross muscular hypertrophy cases are kept in intensive care
unit with nasal intubation for 24h and then extubated after visualising the surgical
site with exible laryngoscopy and making sure there is no edema or bleeding. The
patient has to be fully awake and extubation is done in a sitting position.
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V. Agrawal et al.
23.4.2 Complications
Minor complications are not uncommon in these airway procedures. However, they
can be sometimes potentially severe, causing hemorrhage and airway compromise
requiring reintubation or tracheostomy [19–21]. Primary bleeding within 24h from
the lingual artery or one of its branches can occur if dissection is done in-depth
beyond 1.5cm and 1.25–1.5cm lateral to the midline. Bleeding from the dorsal
lingual artery is more common since it is more supercial. In between the 7th and
14th postoperative day, secondary bleeding can occur at the surgical site, because of
infection which can lead to granulations.
23.4.3 Post-Operative Management
An intravenous antibiotic like second-generation cephalosporin along with steroids
is given 30minutes prior to the surgery. In the immediate post-operative period,
intravenous uids are to be continued and vitals to be monitored. Intravenous antibiotic, pain killers and steroids to be given for the next 2days, then switched to oral
medications except for steroids. Cold clear uids and ice cream to be started after
6–8h of extubation. Soft diet after 24–48h till 2weeks. A normal diet can be started
after 2–3weeks.
23.5 Conclusion
Tongue base ablation surgery with coblation for secondary epiglottic collapse is a
successful surgical treatment option for patients with OSA. In our experience
increased total sleep time, reduced daytime sleepiness, and improved sleep efciency along with a signicant reduction in respiratory arousal index were observed
in the successful surgery group. Though the procedure has limited but dreadful
complications like secondary bleeding into the airway, proper technique and hospital setting can be a life-saving.
References
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5. Fernández-Julián E, García-Pérez MÁ, García-Callejo J, et al. Surgical planning after
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10. Woods CM, etal. Long-term quality-of-life outcomes following treatment for adult obstructive
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11. Friedman M, Vidyasagar R, Bliznikas D, Joseph N. Does severity of obstructive sleep
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12. Li HY, Lee LA, Kezirian EJ.Efcacy of coblation endoscopic lingual lightening in multilevel
surgery for obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. 2016;142:438–43.
13. Lin HS, etal. Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea
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14. Babademez MA, etal. Comparison of minimally invasive techniques in tongue base surgery in
patients with obstructive sleep apnea. Otolaryngol Head Neck Surg. 2011;145:858–64.
15. Mun MJ, Lee CH, Lee BJ, Lee JC, Jang JY, Jung SH, Wang SG. Histopathologic evaluations of the lingual artery in healthy tongue of adult cadaver. Clin Exp Otorhinolaryngol.
2016;9(3):257–62.
16. Lauretano AM, Li KK, Caradonna DS, Khosta RK, M P Fried MP. Anatomic location of
the tongue base neurovascular bundle. Laryngoscope. 1997;107(8):1057–9. https://doi.
org/10.1097/00005537- 199708000- 00010.
17. Cohen DS, Low GM, Melkane AE, Mutchnick SA, Waxman JA, Patel S, Shkoukani MA, Lin
HS.Establishing a danger zone: an anatomic study of the lingual artery in base of tongue surgery. Laryngoscope. 2017;127(1):110–5. https://doi.org/10.1002/lary.26048.
18. Friedman M, Ibrahim H, Bass L. Clinical staging for sleep-disordered breathing. Otolaryngol
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19. Wee JH, Tan K, etal. Evaluation of coblation lingual tonsil removal technique for obstructive
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20. Leitzbach SU, Bodlaj R, etal. Safety of cold ablation (coblation) in the treatment of tonsillar
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Transoral Robotic Surgery (TORS)
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24
FilippoMontevecchi andClaudioVicini
24.1 Introduction
Transoral robotic surgery (TORS) for obstructive sleep apnea (OSA) is just one
more of the many applications of robotic surgery in the otolaryngology literature.
The rst case of TORS used in humans for cancer resection was described by
Weinstein in 2006. The rst TORS for OSA was carried out in 2008in Forlì by
Vicini & Montevecchi. It was performed after more than one year of training in
Italy, France (IRCAD, Strasbourg), and the US (PENN University, Philadelphia).
Transoral robotic tongue base reduction and supraglottoplasty have been deeply
inspired by Chabolle’s tongue base reduction with a hyoid-epiglottoplasty procedure [1] and by Weinstein-O’Malley’s transoral robotic tongue base and supraglottic cancer resection [2, 3]. The rst pilot series of TORS for OSA was reported in
2010. At that time, the most effective tongue base (TB) procedure for moderate to
severe OSA in Europe was Chabolle’s operation, while in the US the most popular
approaches to TB reduction were either transoral endoscopic Coblation® resection
or radiofrequency ablation. In less than 10years, TORS for OSA has spread over the
world and this diffusion is illustrated by an increasing number of published papers
in the literature. Nowadays, there are three meta-analyses and a multicentric study
about the efcacy and safety of TORS for OSA [4–7]. The unsurpassed
Supplementary Information The online version contains supplementary material available at
https://doi.org/10.1007/978-3-031-34992-8_24. The videos can be accessed individually by click-
ing the DOI link in the accompanying gure caption or by scanning this link with the SN More
Media App.
F. Montevecchi (*)
Forlì Private Hospitals, Forlì, Italy
C. Vicini
Department of Otolaryngology and Head-Neck Surgery, Morgagni-Pierantoni Hospital,
Forlì, Italy
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2023
M. Delakorda, N. de Vries (eds.), The Role of Epiglottis in Obstructive Sleep
Apnea, https://doi.org/10.1007/978-3-031-34992-8_24
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visualization, dexterity, and control provided by the Da Vinci Surgical System®
offers the following benets for the surgeon: superior exposure and 3D HD visualization of the target anatomy inside the pharynx, more precise dissection and
improved preservation of intra-lingual vessels and nerves, shorter learning curve,
shorter operating time, and a more reproducible approach as compared to traditional
open as well as endoscopic techniques. It also offers signicant patient benets:
excellent cosmetic outcomes, no neck scars (except for tracheostomy, if necessary),
reduced likelihood of iatrogenic injury to vessels and nerves, better and faster functional recovery compared to the trans-cervical approach, reduced operating room
time, and shortened length of hospital stay.
F. Montevecchi and C. Vicini
24.2 Indications
Endoscopic ndings are essential to guide surgical decision-making. During awake
endoscopy, it is possible to evaluate an unstable/oppy epiglottis by asking the
patient to breathe fast and assess the movement of epiglottis. It has to be acknowledged that awake endoscopy may frequently underestimate the degree of the hypopharyngeal and laryngeal obstruction. Drug-induced sleep endoscopy (DISE) is a
beroptic examination of the upper airway under controlled sedation to determine
the exact site(s) of upper airway collapse in patients with sleep disordered breathing. Quantifying the location and mechanism of upper airway collapse with DISE
in OSA patient can be used to tailor surgical treatments and improve surgical outcomes. In 2010, a retrospective study on 250 consecutive patients was published
making a comparison between awake and DISE ndings [8]. In this study, signicant differences were found between hypopharyngeal degree and pattern of obstruction (59% and 49%, respectively), while up to 30% of cases demonstrated laryngeal
obstruction by DISE.Laryngeal obstruction was classied as primary if the collapse
was produced by intrinsic instability of the larynx, or secondary if the tongue base
or the lateral pharyngeal walls were responsible for the supraglottic collapse. As
observed in the larynx, we have also seen retropalatal obstruction during DISE, that
either was primary or secondary.
24.3 Surgical Technique
24.3.1 Exposure
The patient is always in supine position with neck exed and head extended in order
to achieve the best exposure. If needed external laryngeal compression is allowed
during the dissection (e.g., hyoid compression or other maneuvers). Tongue base
exposure is achieved by using a tongue tip traction (with a 0-0 silk horizontal mattress suture) (Fig.24.1) and tongue body displacement by Davis Meyer® mouth gag
under direct visualization. Tongue blades of different sizes with integrated suction
tubes (for smoke and blood) are important during the procedure. A combination of
tongue base traction and the right mouth gag blade length is the key for exposure.
Usually, the short or the medium blade (such as Storz blade number 1 and 2) is very
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