Tongue Suspension

Tongue Suspension

When behavioral, dietary, and non-invasive techniques fail, surgery plays a vital role in the treatment of obstructive sleep apnea, despite the fact that it may not completely eliminate or cure the syndrome. Ultimately the treating physician has the responsibility to council patients on the risks, benefits and limitations of surgery. A focused physical examination is of paramount importance to determine the site or sites of obstruction. 

OSAHS has been established as being the result of multilevel obstruction in the majority of patients. Identification of levels of obstruction can be accomplished in a variety of ways depending on surgeon preference. Clinical staging with Friedman tongue position, cephalometrics and sleep endoscopy have been proven useful in identifying hypopharyngeal obstruction alone or in combination with palatal obstruction. Hypopharyngeal obstruction due to posterior displacement of the tongue during sleep can occur with or without macroglossia. The importance of tongue position is obvious given that snoring and obstructive symptoms do not occur while awake. A logical extension of this problem is that cure rates should be improved by preventing posterior tongue displacement.

Currently two tongue suspension systems are approved for use in the United States. These are Medtronic’s Airvance®(formerly Repose®) system and Siesta Medicals’s EncoreTM system. The Airvance is a minimally invasive procedure that involves stabilizing the tongue base using a triangular suture configuration anchored to a titanium screw embedded in the mandibular cortex and was first approved for use in the United States in 1998. The Encore is a similar procedure but creates a suture loop within the tongue without having to create penetrations through the mucosal surface of the tongue.

In a 2006 systematic review, Kezirian and Goldberg examined 6 papers on the treatment of hypopharyngeal obstruction with tongue-base suspension (5 papers EBM level-4, 1 paper EBM level-2). Each individual study reported significant improvements in apnea hypopnea index (AHI) and daytime somnolence; however, cure rates were 20-57% with overall success in 22/77 cases (35%). All patients evaluated had moderate to severe OSAHS. In 4 of the studies (totaling 49 patients), patients underwent multi-level surgery involving a palatal reconstruction. In two of the studies (totaling 28 patients), tongue suspension was performed as a standalone procedure. Since that time, a number of studies have evaluated the use of tongue suspension in conjunction with uvulopalatopharyngoplasty (1,2,3,4,5,6,7) with 116 patients studied and an improved average cure rate of 71% (range of 50-81%) in contrast to the classical UPPP success rate of 40% reported by Sher8. In two prospective studies(4,8) including one Randomized Control Trial, tongue suspension was found to be similarly effective as radiofrequency baseof- tongue reduction for the treatment of hypopharyngeal obstruction, either alone or in conjunction with UPPP. All of the studies which reported statistical significance showed a consistent and statistically significant improvement in the AHI as well as the Epworth Sleep Score (ESS). Taken as a whole, standalone tongue suspension improves the AHI an average of 38% and tongue suspension as part of a multi-level intervention improves the AHI an average of 62%.

The durability of this technique should also be considered. The potential for migration of the anchoring suture within the lingual tissue over time is a concern shared by many otolaryngologists. For standalone tongue suspension, Kuhnel et al. demonstrated only a modest drop in success from 32% at 3 months to 30% at 1 year. Although only in 8 patients, Sezen et al. reported a 75% success rate at 1 year. In a 2009 study by Fibbi et al. with 12 tongue suspension patients, success with tongue suspension alone in patients with mild OSAHS was reported as 67% at six months; however, this subsequently dropped to 42% success at two years (7). In combination with UPPP, three studies with longer term follow up totaling 88 patients demonstrated an overall surgical success rate of 75% (2,3,5). Vicente et al. observed an excellent success rate of 78% at three years. Morbid obesity was found to be the single greatest predictor of poor treatment outcome in these patients (3).

Unconvincing results seen in some early studies may have been due in part to inappropriate patient selection. Vicente et al. and Fernandez et al. both reported diminished success in obese patients (3,8).

Overall post-operative complication rates associated with tongue suspension have been reported in the range of 12.5-18%8,9.Complications may include suture breakage, bleeding, floor-of-mouth edema, infection (more commonly sialadenitis or very rarely mandibular-osteomyelitis) and hypoglossal nerve injury (rare). Senders and Strong reported transient velopharyngeal dysfunction in 25% of patients undergoing tongue suspension and limited anterior excursion in 10-15% (10). Kühnel et al. described disproportionate pain relative to wound-size and suture extrusion in 3/28 cases (5). In recent years, the surgical access site for tongue suspension has switched from the floor of mouth to a submental incision. With this change, complications of floor of mouth edema and suture extrusion can be expected to be reduced. The procedure has been demonstrated to be completely reversible via the explant of the tongue suspension suture and bone anchor.

RECOMMENDATIONS

Tongue based suspension is effective and not considered investigational when considered as part of a comprehensive approach in the medical and surgical management of symptomatic adult patients with mild OSAHS and adult patients with moderate and severe OSAHS who have evidence of tongue base or associated hypopharyngeal obstruction. Results appear to diminish in obese patients and this technique should receive a weaker recommendation for these patients. 

Adopted 12/8/2012

REFERENCES

  1. Omur M, Ozturan D, Elez F, Unver C, Derman S. Tongue base suspension combined with UPPP in severe OSA patients. Otolaryngol Head Neck Surg. 2005; 133: 218-223. 
  2. Vicente E, Marín JM, Carrizo S, Naya MJ. Tongue-base suspension in conjunction with uvulopalatopharyngoplasty for treatment of severe obstructive sleep apnea: long-term follow-up results. Laryngoscope. 2006; 116: 1223-1227. 
  3. 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; 140: 917-923. 
  4. Sezen OS, Aydin E, Eraslan G, Haytoglu S, Coskuner T, Unver S. Modified tongue base suspension for multilevel or single level obstructions in sleep apnea: Clinical and radiologic results. AurisNasus Larynx. 2011; 38:487–494. 
  5. Kühnel TS, Schurr C, Wagner B, Geisler P. Morphological changes of the posterior airway space after tongue base suspension. Laryngoscope. 2005; 115: 475-480. 
  6. Sezen OS, Aydin E, Eraslan G, Haytoglu S, Coskuner T, Unver S. Modified tongue base suspension for multilevel or single level obstructions in sleep apnea: Clinical and radiologic results. AurisNasus Larynx. 2011; 38:487–494. 
  7. Fibbi A, Ameli F, Brocchetti F, Mignosi S, Cabano ME, Semino L. Tongue base suspension and radiofrequency volume reduction: a comparison between 2 techniques for the treatment of sleep-disordered breathing. American Journal of Otolaryngology – Head and Neck Medicine and Surgery.2009; 30: 401-406. 
  8. Sher AE, Schechtman KB, Piccirillo JF.The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep. 1996; 19(2): 156-177. 
  9. Woodson BT. A tongue suspension suture for obstructive sleep apnea and snorers. Otolaryngol Head Neck Surg. 2001; 124: 297-303. Senders CW, Strong EB.The surgical treatment of obstructive sleep apnea.Clinical Reviews in Allergy & Immunology.2003; 25: 213-220. 
  10. Senders CW, Strong EB.The surgical treatment of obstructive sleep apnea. Clinical Reviews in Allergy & Immunology.2003; 25: 213-220. 

Important Disclaimer Notice

Position statements are approved by the American Academy of Otolaryngology—--Head and Neck Surgery, Inc. 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.