Position Statement: Midline Glossectomy for OSA
Midline partial glossectomy is an effective surgical modality for the treatment of select pediatric and adult patients with mild to severe obstructive sleep apnea with significant macroglossia. Midline partial glossectomy can either be performed as a stand-alone procedure or as part of multi-level pharyngeal surgery using a variety of techniques.
The Apnea Hypopnea Index (AHI) is a metric for OSA, easily quantified, and is associated with morbidity and mortality at level above 20/hr. Reduction of the AHI to levels below 20 is used in part for successful outcome assessment.
The initial description by Fujita et. al. on 12 patients, utilizing the CO2 laser, reduced the Respiratory Distress Index (RDI) by over 50% in 42% of patients. The RDI in responders decreased from 50.2 to 8.6. Two different studies combining UPPP and midline glossectomy demonstrated a success rate of 60%, defined as a reduction in RDI or AI of more than 50% (Elasfour 1998, Andsberg 2000). In a study combining midline laser glossectomy and extended uvulopalatal flap, an 83.3% success rate was reported, defined as a decrease in RDI to <20 and greater than 50% decrease (Li 2004). A study combining midline glossectomy and epiglottidectomy in morbidly obese patients who had failed palatal surgery showed an overall success rate of 25%, defined as a decrease in RDI to <20. However the RDI of responders decreased from 69.7 to 10 (Mickelson 1997). Woodson and Fujita, using a technique described as lingualplasty in a group of patients who previously underwent failed UPPP, demonstrated a 67% success rate, defined as a decrease in RDI to <20. Hou and colleagues performed midline glossectomy and uvulopalatopharyngoplasty in 34 patients with resultant successful AHI outcome of 74%, assessed 5 years post-operatively (Hou 2012).
Excisional approaches utilizing a plasma wand device under endoscopic visualization to obtain significant volumetric tongue base reduction have been recently described, including a submucosal minimally invasive lingual excision (SMILE) procedure in adult and pediatric patients (Maturo 2006) and open approaches (Robinson 2003, Woodson 2007). In a study of 48 patients utilizing the SMILE approach (Friedman 2008), 65% of patients had successful AHI outcome. The open approach of plasma wand glossectomy combined with palatoplasty in 39 patients resulted in AHI decrease from 49 to 19 (Woodson 2013) and in another study performed on 50 patients the AHI declined from 52 to 18 (Suh 2013). In a study in 27 patients who underwent midline glossectomy with lingualplasty using plasma wand or laser, and concurrent palatopharyngoplasty, the AHI was reduced from 44 to 13, with successful outcome reported at 74% (Gunawardena 2013).
Robot-assisted midline glossectomy approaches have also been successfully used for the treatment of OSA. Vicini and colleagues performed robot-assisted glossectomy in 24 patients, 8 of which underwent prior upper airway surgeries, and obtained AHI reduction from 36 to 16 (Vicini 2012). Friedman and colleagues performed robot-assisted glossectomy with palatopharyngoplasty in 27 patients, resulting in AHI reduction from 55 to 19, and a success rate of 67% (Friedman 2012). In a study of 12 patients who underwent robot-assisted glossectomy as their sole treatment, the AHI was reduced from 44 to 18 (Lin 2013).
The literature thus supports the role of midline partial glossectomy in the treatment of OSA, demonstrating reduction of the AHI to levels which reduce the risk of adverse sequelae. Successful surgical outcome from midline glossectomy has been demonstrated using a variety of techniques.
- Fujita S, Woodson BT, Clark JL, Wittig R. Laser midline glossectomy as a treatment for obstructive sleep apnea. Laryngoscope 101(8):805-9, 1991.
- Elasfour A, Miyazaki S, Itasaka Y, Yamakawa K, Ishikawa K, Togawa K. Evaluation of uvulopalatopharyngoplasty in treatment of obstructive sleep apnea syndrome. Acta Otolaryngol Suppl 537:52-6, 1998.
- Andsberg U, Jessen M. Eight years of follow-up-uvulopalatopharyngoplasty combined with midline glossectomy as a treatment for obstructive sleep apnea syndrome. Acta Otolaryngol Suppl 543:175-8, 2000.
- Li HY, Wang PC, Hsu CY, Chen NH, Lee LA, Fang TJ. Same-stage palatopharyngeal and hypopharyngeal surgery for severe obstructive sleep apnea. Acta Otolaryngol 124(7):820-6, 2004.
- Mickelson SA, Rosenthal L. Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome. Laryngoscope 107(5):614-9, 1997.
- Hou J, Yan J, Wang B, et al. Treatment of obstructive sleep apnea-hypopnea syndrome with combined uvulopalatopharyngoplasty and midline glossectomy: outcomes from a 5-year study. Respir Care.57(12):2104-10, 2012.
- Woodson BT, Fujita S. Clinical experience with lingualplasty as part of the treatment of severe obstructive sleep apnea. Otolaryngol Head Neck Surg 107(1):40-8, 1992.
- Robinson S, Lewis R, Norton A, et al. Ultrasound-guided radiofrequency submucosal tongue-base excision for sleep apnoea: A preliminary report. Clin Otolaryngol 28:341-5, 2003.
- Maturo SC, Mair EA. Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction. Ann Otol Rhinol Laryngol 115(8):624-30, 2006.
- Woodson, BT. Innovative technique for lingual tonsillectomy and midline posterior glossectomy for obstructive sleep apnea. Operative Techniques in Otolaryngology Head and Neck Surgery 18(1):20-8, 2007.
- Friedman M, Soans R, Gurpinar B, Lin HC, Joseph N. Evaluation of submucosal minimally invasive lingual excision technique for treatment of obstructive sleep apnea/ hypopnea syndrome. Otolaryngol Head Neck Surg 139(3):378-84, 2008.
- Woodson BT, Laohasiriwong S. Lingual tonsillectomy and midline posterior glossectomy for obstructive sleep apnea. Oper Tech Otolaryngol Head Neck Surg 23(2): 155-161, 2012
- Suh GD. Evaluation of open midline glossectomy in the multilevel surgical management of obstructive sleep apnea syndrome. Otolaryngol Head Neck Surg. 148(1):166-71, 2013.
- Gunawardena I, Robinson S, MacKay S, et al. Submucosal lingualplasty for adult obstructive sleep apnea. Otolaryngol Head Neck Surg. 148(1):157-65, 2013.
- Vicini C, Dallan I, Canzi P, et al. Transoral robotic surgery of the tongue base in obstructive sleep Apnea-Hypopnea syndrome: anatomic considerations and clinical experience. Head Neck. 34(1):15-22, 2012.
- Friedman M, Hamilton C, Samuelson CG, et al. Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 146(5):854-62, 2012.
- Lin HS, Rowley JA, Badr MS et al. Transoral robotic surgery for treatment of obstructive sleep apneahypopnea syndrome. Laryngoscope. 123(7):1811-6, 2013.
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