Position Statement: Submucosal Ablation of the Tongue Base for OSAS

Adult patients with mild to severe obstructive sleep apnea (OSA) can be successfully treated with submucosal radiofrequency tongue base ablation.(Powell 1999 and refs below) The majority of studies demonstrating effectiveness of tongue base submucosal radiofrequency ablation  (RFA) have been performed in patients with mild to moderate OSA and without morbid obesity, often as part of multilevel pharyngeal surgical therapy.

A randomized, CPAP and placebo controlled trial of tongue base and palate (RFA) for mild to moderate OSA demonstrated significant improvements following radiofrequency compared with sham-placebo in quality of life (QOL), airway volume, apnea index, and respiratory arousal index (all P < 0.05).(Woodson 2003, Level 1 evidence).  Comparison between CPAP and RFA showed no significant differences in improvements in QOL or daytime sleepiness.(Woodson 2003).

Additional prospective study comparing CPAP to radiofrequency submucosal ablation for mild to moderate obstructive sleep apnea showed similar effectiveness of both therapies suggesting a role for primary treatment of mild to moderate OSA with submucosal ablation (Ceylan 2009, Level 2 evidence).

Prospective study with extended follow-up of patients treated with RFA demonstrates persistent improvements in daytime sleepiness and OSAS-related quality of life (both P < 0.001). Median reaction time testing and apnea-hypopnea index (AHI) were also significantly improved at long-term follow-up (P = 0.03 and 0.01).(Steward 2005, Level 2 evidence)

Cumulative meta-analysis of submucosal RFA found a 31% reduction in short-term ESS (odds ratios (OR) 0.69, 95% confidence interval (CI) 0.63-0.75), which was maintained beyond 12 months (OR 0.68, 95% CI 0.43-0.73). Likewise, RFA resulted in a 31% reduction in short term (<12 month) (OR 0.69, 95% CI 0.61-0.77) and 45% reduction in long-term (>24 month) (OR 0.55, 95% C.I. 0.45-0.72) respiratory disturbance index (RDI) levels. (Farrar 2008, Level 3 evidence).

Randomized comparison of submucosal RFA with tongue suspension found significant improvements in OSA for both treatment groups with significantly less morbidity with submucosal ablation.(Fernandez-Julian 2009, Level 1 evidence).  Other studies have also demonstrated low morbidity with tongue base \ submucosal RFA.( Kezirian 2005, Level 4 evidence).

Controlled study of treatment schemes for RFA suggests additional improvement in outcomes with repeated treatments.(Steward 2004, Level 2 evidence)  However, more recent studies have demonstrated significant improvement with a single high energy treatment session with low morbidity.(Nelson 2007, Level 4 evidence).

Adopted 5/3/2010
Reaffirmed 12/8/2012

References:

1. Woodson BT, Steward DL, Weaver EM, Javaheri S., A randomized trial of temperature controlled radiofrequency, continuous positive airway pressure, and placebo for obstructive sleep apnea syndrome. Otol H&N Surg 128(6):848-61, 2003.
2. Steward DL, Weaver EM, Woodson BT. Multilevel temperature-controlled radiofrequency for obstructive sleep apnea: extended follow-up.  Otol H&N Surg 132(4):630-5, 2005.
3. Woodson BT, Nelson L, Mickelson SA, Huntley T, Sher A. A multi-institutional study of radiofrequency volumetric tissue reduction for OSAS.  Otol H&N Surg. 125(4):303-311, 2001.
4. Li KK, Powell NB, Riley RW, Guilleminault C. Temperature-controlled radiofrequency tongue base reduction for sleep-disordered breathing: Long-term outcomes.  Otol H&N Surg 127(3):230-4, 2002.
5. Friedman M, Ibrahim H, Lee g, Joseph NJ. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otol H&N Surg 129(6):611-21, 2003.
6. Kezirian EJ, Powell NB, Riley RW, Hester JE. Incidence of complications in radiofrequency treatment of the upper airway. Laryngoscope 115(7):1298-304, 2005.
7. Steward DL. Effectiveness of multilevel (tongue and palate) radiofrequency tissue ablation for patients with obstructive sleep apnea syndrome. Laryngoscope 114(12): 2073-84,2004.
8. Steward DL, Weaver EM, Woodson BT.  A comparison of radiofrequency treatment schemes for obstructive sleep apnea syndrome. Oto H&N Surg 130(5):579-85, 2004.
9. Stuck BA, Kopke J, Hormann K, Verse T, Eckert A, Bran G, Duber C, Maurer JT. Volumetric tissue reduction in radiofrequency surgery of the tongue base. Oto H&N Surg 132(1):132-5, 2005.
10. Fischer Y, Khan M, Mann WJ. Multilevel temperature-controlled radiofrequency therapy of soft palate, base of tongue, and tonsils in adults with obstructive sleep apnea. 113(10):1786-91, 2003.
11. Pazos G, Mair EA. Complications of radiofrequency ablation in the treatment of sleep-disordered breathing. Otol H&N Surg 125(5):462-6, 2001.
12. Robinson S, Lewis R, Norton A, McPeake S. Ultrasound-guided radiofrequency submucosal tongue-base excision for sleep apnoea: a preliminary report. Clin Otolaryngol 28(4):341-5, 2003.
13. Stuck BA, Kopke J, Maurer JT, Verse T, Eckert A, Bran G, Duber C, Hormann K, Lesion formation in radiofrequency surgery of the tongue base. Laryngoscope 113(9):1572-6, 2003.
14. Troell RJ, Radiofrequency techniques in the treatment of sleep disordered breathing, Otol Clin N Am 36:473-493, 2003.
15. Powell NB, Riley RW, Guilleminault C. Radiofrequency tongue base reduction in sleep-disordered breathing: A pilot study. Otol H&N Surg 120(5):656-64, 1999.
16. Riley RW, Powell NB, Li KK, Weaver EM, Guilleminault C.  An adjunctive method of radiofrequency volumetric tissue reduction of the tongue for OSAS.  Otol H&N Surg 129(1):37-42, 2003.
17. Ceylan K, Emir H, Kizilkaya Z, Tastan E, Yavanoglu A, Uzunkulaoglu H, Samim E, Felek SA. First-choice treatment in mild to moderate obstructive sleep apnea: single-stage, multilevel, temperature-controlled radiofrequency tissue volume reduction or nasal continuous positive airway pressure.  Arch Otolaryngol Head Neck Surg. 2009 Sep;135(9):915-9.
18. Fernández-Julián E, Muñoz N, Achiques MT, García-Pérez MA, Orts M, Marco J.  Randomized study comparing two tongue base surgeries for moderate to severe obstructive sleep apnea syndrome.  Otolaryngol Head Neck Surg. 2009 Jun;140(6):917-23
19. Eun YG, Kwon KH, Shin SY, Lee KH, Byun JY, Kim SW. Multilevel surgery in patients with rapid eye movement-related obstructive sleep apnea.  Otolaryngol Head Neck Surg. 2009 Apr;140(4):536-41.
20. Farrar J, Ryan J, Oliver E, Gillespie MB. Radiofrequency ablation for the treatment of obstructive sleep apnea: a meta-analysis.  Laryngoscope. 2008 Oct;118(10):1878-83.
21. Eun YG, Kim SW, Kwon KH, Byun JY, Lee KH. Single-session radiofrequency tongue base reduction combined with uvulopalatopharyngoplasty for obstructive sleep apnea syndrome.  Eur Arch Otorhinolaryngol. 2008 Dec;265(12):1495-500.
22. van den Broek E, Richard W, van Tinteren H, de Vries N. UPPP combined with radiofrequency thermotherapy of the tongue base for the treatment of obstructive sleep apnea syndrome.  Eur Arch Otorhinolaryngol. 2008 Nov;265(11):1361-5.
23. Nelson LM, Barrera JE. High energy single session radiofrequency tongue treatment in obstructive sleep apnea surgery.  Otolaryngol Head Neck Surg. 2007 Dec;137(6):883-8.
24. Friedman M, Lin HC, Gurpinar B, Joseph NJ. Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome.  Laryngoscope. 2007 Oct;117(10):1859-63.

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Position statements are approved by the American Academy of Otolaryngology—Head and Neck Surgery or Foundation (AAO-HNS/F) Boards of Directors and are typically generated from AAO-HNS/F committees. Once approved by the Academy or Foundation Board of Directors, they become official position statements and are added to the existing position statement library. In no sense do they represent a standard of care. The applicability of position statements, as guidance for a procedure, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these clinical position statements will not ensure successful treatment in every situation. As with all AAO-HNS/F guidance, this position statement should not be deemed inclusive of all proper treatment decisions or methods of care, nor exclusive of other treatment decisions or methods of care reasonably directed to obtaining the same results. Position statements are not intended to and should not be treated as legal, medical, or business advice.