Transoral Endoscopic Coblation Tongue Base Surgery in Obstructive Sleep Apnea: Resection versus Ablation

Evaluation of modified coblation endoscopic lingual lightening in multilevel surgery for obstructive sleep apnea hypopnea syndrome: an open intervention study

PURPOSE

To evaluate the efficacy and safety of modified coblation endoscopic lingual lightening to address retrolingual obstruction in multilevel surgery for obstructive sleep apneae (OSA).

METHODS

Patients with OSA due to retropalatal and retrolingual obstructions were enrolled. Group 1 consisted of patients who underwent modified coblation endoscopic lingual lightening combined with H-uvulopalatopharyngoplasty, while group 2 comprised patients treated by H-uvulopalatopharyngoplasty alone. Objective parameters and subjective evaluations were recorded preoperatively and at 6 months postoperatively.

RESULTS

The mean (standard deviation) apnea-hypopnea index (AHI) declined from 51.5 (18.9) to 14.3 (7.2) in group 1, and from 51.7 (15.8) to 28.5 (16.9) in group 2. The mean (standard deviation) percentage change in AHI was higher in group 1 than in group 2 (73.2 [10.9] vs. 48.9 [22.4], P < 0.01). The surgical response rate differed significantly between groups 1 and 2 (88.5 [23/26] vs. 46.7 [14/30], P < 0.01). Other outcomes, including the lowest oxygen saturation, Epworth Sleepiness Scale score, snoring visual analog scale score, and subjective improvement rate, were also significantly better in group 1 than in group 2.

CONCLUSION

Without increasing complications, modified coblation endoscopic lingual lightening significantly improved surgical outcomes as part of multilevel surgery in patients with OSA due to multilevel obstruction.

One-Stage Multilevel Surgery for Treatment of Obstructive Sleep Apnea Syndrome

We report the results of one-stage multilevel upper airway surgery for patients who could not tolerate continuous positive airway pressure (CPAP). Patients treated with multilevel surgery at a University Hospital in 2015–2019 were identified from a prospectively maintained database. The inclusion criteria were aged 18–70 years, body mass index (BMI) < 35 kg/m², apnea–hypopnea index (AHI) > 20, and lingual tonsil hypertrophy grade 3 or 4. Drug-induced sleep endoscopy was performed before surgery in all patients. Multilevel surgery was performed in one stage and included expansion sphincter pharyngoplasty (ESP), coblation tongue base reduction (CTBR), and partial epiglottectomy (PE) as required. The outcome measures were postoperative AHI, time percentage oxygen saturation < 90%, and Epworth Sleepiness Scale (ESS) score. A total of 24 patients were included: median age 49.1 years, average BMI 27.26 kg/m², and 90% men. Ten patients received ESP plus CTBR plus PE, eight received ESP plus CTBR, and six received ESP plus PE. The mean preoperative AHI was 33.01 at baseline and improved to 17.7 ± 13 after surgery (p < 0.05). The ESS score decreased from 11 ± 5.11 to 7.9 ± 4.94 (p < 0.05). The surgical success rate according to Sher’s criteria was 82.3%. The median follow-up was 23.3 months (range 12–36). These findings suggest that multilevel surgery is a safe and successful treatment of OSAHS.

Effect of Cooling Irrigating Saline in Tongue Base Ablation in Obstructive Sleep Apnea

Objective

Plasma is formed by creating a high-density energy field within an electrically conductive fluid such as saline. Sometimes ablated bits of tissue get stuck between the electrodes of the wand, obstructing the suction channel. The purpose of this study is to investigate the effect of cooling the irrigating saline during ablation of the hypertrophied tongue base in patients with obstructive sleep apnea.

Study Design

Prospective randomized controlled trial.

Setting

An otorhinolaryngology department in Main University hospitals.

Methods

Sixty adult patients with obstructive sleep apnea and tongue base hypertrophy underwent tongue base ablation surgery. Patients were randomly divided into 2 groups of 30 patients each: cooled saline and room temperature saline. The Coblation wand used was the EVac 70 Xtra HP (Smith & Nephew).

Results

In this study, a significant difference in operative time (mean ± SD) was seen between groups: 21.2 ± 5.5 minutes in the cold group and 47 ± 9.5 minutes in the control group (P = .001). The wands in the cold group did not obstruct, while all the wands in the control group were obstructed by tissue clogs with variable degrees, hence wasting more time to clean the wands’ tips.

Conclusion

Cooling the irrigating saline overcame the problem of wand clogs, and the wand tip did not occlude at all during the procedures, thus saving time lost in wand cleaning and demonstrating a faster and safer surgical procedure. Further studies are needed to identify the hemostatic effect of the cooled saline over the regular one.

Comparison of transoral robotic surgery with other surgeries for obstructive sleep apnea

This study compared the characteristic surgical parameters and clinical effects of transoral robotic surgery (TORS) and other available methods used to alleviate obstructive sleep apnea. Articles on TORS and other surgeries for obstructive sleep apnea were identified in the PubMed and EMBASE databases. Two investigators independently reviewed the articles and classified the data for meta-analysis. The pooled effect sizes of TORS (standardized mean difference; SMD = − 2.38), coblation tongue base resection (CTBR; SMD = − 2.00) and upper airway stimulation (UAS; SMD = − 0.94) revealed significant improvement in the apnea–hypopnea index (AHI; p < 0.05). The lowest O₂ saturation reported was significantly increased following TORS (SMD = 1.43), CTBR (SMD = 0.86) and UAS (SMD = 1.24, p < 0.05). Furthermore, TORS (SMD = − 2.91) and CTBR (SMD = − 1.51, p < 0.05) significantly reduced the Epworth Sleepiness Scale (ESS) score. No significant difference in operation time, success rate, or instances of complication were observed between TORS and the other compared interventions. The use of TORS in obstructive sleep apnea has the same rate of success and failure as other methods of surgical intervention for obstructive sleep apnea with no statistical difference in operation times. The reported clinical effects on the AHI, lowest O₂ saturation, and ESS scores of TORS were similar to those of other surgeries.