Volumetric Tongue-Base Reduction (Lingual Tonsillectomy, Coblation Midline Glossectomy, Trans Oral Robotic Surgery)

Introduction

First-line surgical treatment of obstructive sleep apnea (OSA) in both pediatric and adult patients is adenotonsillectomy and has often been uvulopalatopharyngoplasty in adults. When initial medical or surgical treatment of OSA fails to successfully treat the condition, adjunct surgical treatment may be warranted. Lingual tonsillectomy and tongue-base reduction are two of these surgical techniques that can lead to improved outcomes in patients with OSA.

In the pediatric population, adenotonsillectomy seems to be very successful initially. Months to years later, some of these initial successes present with recurrent symptoms. In these cases, lingual tonsillar hypertrophy may be the cause. In obese patients, the risk of lingual hypertrophy of the tonsil appears to be higher after adenotonsillectomy.

Lingual tonsillectomy alone can be very effective in relieving upper airway obstruction when the lingual tonsils are noted to be large and obstructive during drug-induced sleep endoscopy (DISE) or other methods of upper airway assessment. When lingual tonsils are small or absent, but there is still significant tongue-base collapse leading to upper airway obstruction, tongue-base reduction surgery may be beneficial ( Fig. 55.1 ).

Fig. 55.1, Endoscopic view demonstrating hypertrophic lingual tonsil tissue.

Various methods of video-assisted lingual tonsillectomy have been described. One such method is via suspension laryngoscopy with the use of the coblation device. This has proven to be a reliable technique that can be performed without needing any assistants for retraction.

Both procedures aim to improve the retroglossal airway during sleep, which may improve OSA symptoms. Even if OSA is not resolved, these procedures can potentially improve compliance with continuous positive airway pressure (CPAP), leading to reduced pressure settings on CPAP devices.

Key Operative Learning Points: Endoscopic Lingual Tonsillectomy

Preoperative airway assessment with DISE is advocated for proper patient selection. Some centers employ CINE MRI when sleep endoscopy is not available.
Lingual tonsillectomy is best considered in patients who have previously had adenotonsillectomy.
While nasal intubation may aid in surgical ease, it is not necessary. The procedure can be performed with oral intubation to facilitate concurrent nasal surgery.
The vallecula should be unobstructed and completely free of lingual tonsil tissue at the completion of the surgery.
The lateral lingual tissue may be more superficially removed to reduce the risk of significant peri- or postoperative bleeding.
This procedure can be performed in both pediatric and adult patients by using the appropriate pediatric and adult-sized laryngoscopes.

Preoperative Period

A comprehensive medical history remains the cornerstone of the preoperative evaluation. Once it has been determined that a patient is intolerant or unable to achieve adequate benefit with standard medical treatments, surgical options should be considered. Physical examination, upper airway endoscopy, and imaging techniques should be used to describe the anatomy of the upper airway and tailor a comprehensive surgical treatment plan. The key to success with these techniques is patient selection, and significant time should be spent with the patient preoperatively to be certain that chances for success are optimized.

Patients considered for second-line surgical treatment should be evaluated for other medical conditions that could lead to sleep disorders. In pediatric patients, CPAP is often not tolerated and, when used long term, it may lead to craniofacial abnormalities. In this population, lingual tonsillectomy may be considered without a trial of CPAP. In adults, surgery would be considered for patients who fail or are intolerant of CPAP or other medical and dental treatments.

History

1.
History of present illness
- a.
  Symptoms and impact on quality of life including snoring, apnea, gasping, choking, oropharyngeal pain, dysphagia, and cognitive dysfunction
- b.
  Timing, duration, and onset of symptoms. The severity and duration of symptoms should be carefully assessed. It is important to make the determination that removing hypertrophied lingual tonsils will alleviate the symptoms.
- c.
  Prior history of treatments, both medical and surgical, including detailed information on side effects and treatment response, should be gathered.
2.
Past medical history
- a.
  Comorbidities associated with upper airway obstruction should be sought (hypertension, diabetes, myocardial infarction, atrial fibrillation, cerebrovascular event, depression, gastroesophageal reflux disease, erectile dysfunction).
- b.
  Chronic neck pain, trismus, and other conditions that may negatively impact exposure of the base of the tongue
- c.
  History of dysphagia
- d.
  History of neuromuscular disease
3.
Past surgical history
- a.
  Prior surgery or injury to the tissues of the neck may be contraindications to tongue-base reduction surgery and need to be evaluated on an individual basis.
- b.
  Prior maxillofacial surgery that may lead to difficulty with exposure and/or injury to the teeth
4.
Medications
- a.
  Anticoagulants
- b.
  Opiate pain medication, benzodiazepines, or other medications that can alter nocturnal control of breathing
5.
Family history
- a.
  A strong family history of OSA may provide insight into the anatomic/structural vulnerability.
6.
Social history
- a.
  Alcohol: Excessive alcohol use in adults can lead to postoperative withdrawal and complications.
- b.
  Tobacco: Smoking has been shown to independently increase the risk of pulmonary disease and hence anesthesia-associated complications. Also, in older patients with an extensive smoking and drinking history, the risk of malignancy in the oropharynx should also be considered.

Physical Examination

1.
Evaluation of the facial skeleton
- a.
  Significant maxillary or mandibular hypoplasia may be associated with increased difficulty in exposure.
- b.
  Occlusion:
  - 1)
    Angle’s classification
  - 2)
    Degree of overjet and overbite
2.
Oral cavity
- a.
  Tongue ridging or scalloping suggests relative macroglossia for the available mandibular size.
- b.
  Quality and quantity of dentition have implications on the potential for injury to the teeth during the surgery.
- c.
  Height and width of the hard palate. A narrow high-arched soft palate may increase the difficulty of soft tissue work on the soft palate and may negatively affect treatment outcomes.
- d.
  The presence of large palatal tori may reduce operative exposure and make palatal surgery more technically challenging.
3.
Oropharynx
- a.
  Tonsil size
- b.
  Crowded nature of the oropharynx
- c.
  Modified Mallampati (MM) or Friedman tongue position (FTP)
- d.
  Size and structure of the lateral oropharyngeal wall
4.
Examination of the neck
- a.
  Neck circumference
- b.
  Hyoid bone position: A low or inferiorly positioned hyoid bone suggests a longer pharyngeal airway.
5.
Cranial nerve examination with specific attention to the functional status of the hypoglossal nerve and glossopharyngeal nerves
6.
General health
- a.
  Blood pressure
- b.
  Cardiovascular
- c.
  Respiratory
- d.
  Mental
7.
Flexible fiberoptic laryngoscopy
- a.
  Awake
- b.
  DISE

Imaging

1.
Chest radiograph
- a.
  Preoperative screening
- b.
  Evaluate for cardiopulmonary disease
- c.
  Rule out immobility of the hemidiaphragm
2.
Computed tomographic imaging: may be indicated preoperatively to assess the extent of lingual tonsil hypertrophy and oropharyngeal crowding
3.
Modified barium swallow study may be indicated prior to surgery for patients with baseline dysphagia, particularly in those with swallowing problems after prior pharyngeal surgery ( Fig. 55.2 ).

Indications

1.
Patients with enlarged lingual tonsils with symptoms of either hypertrophy of the lingual tonsil leading dysphagia/odynophagia or OSA
2.
DISE is currently recommended to evaluate the anatomic location and pattern of pharyngeal collapse prior to proceeding with tongue-base reduction surgery. Particular attention is paid to the pattern of palatal collapse and the degree of multilevel coupling between the tongue protrusion and enlargement of the retropalatal space.

Contraindications

1.
Patient factors
- a.
  High perioperative risk due to comorbidities
- b.
  Patient taking anticoagulants
- c.
  Poor nutritional status
2.
Anatomic factors
- a.
  Craniofacial abnormalities prevent access to the lingual tonsils or tongue base.

Preoperative Preparation

1.
Anesthesiology consultation if there is a concern for difficult airway or intubation
2.
Hold anticoagulation if possible
3.
Request that the patient bring CPAP or an oral appliance (if still available and in use) to the day of surgery in the event that airway support is needed in the hospital setting.

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