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.

Several different techniques for midline glossectomy have been described in the literature. 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.

More recently, excisional approaches utilizing a plasma wand device under endoscopic visualization to obtain significant volumetric tongue base reduction has been described, including a submucosal minimally invasive lingual excision (SMILE) procedure in adult and pediatric patients (Maturo 2006) and more open approaches (Robinson 2003, Woodson 2007). Recently, a study of 48 patients utilizing the SMILE approach (Friedman 2008), showed a 65% success rate.  No large studies of the open approaches have been reported, but would be expected to have similar results.

References

1. Fujita S, Woodson BT, Clark JL, Wittig R. Laser midline glossectomy as a treatment for obstructive sleep apnea. Laryngoscope 101(8):805-9, 1991.
2. 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.
3. 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.
4. 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.
5. Mickelson SA, Rosenthal L. Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome. Laryngoscope 107(5):614-9, 1997.
6. 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.
7. 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.
8. 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.
9. 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.
10. 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.

Adopted: May 4, 2011

Guidelines are not a substitute for the experience and judgment of a physician and are developed to enhance the physicians' ability to practice evidence-based medicine.

Important Notice

The American Academy of Otolaryngology-Head and Neck Surgery, Inc. and Foundation (AAO-HNS/F) Policy Statements are guidelines only. In no sense do they represent a standard of care. The applicability of an indicator for a procedure, and/or of the process or outcome criteria, must be determined by the responsible physician in light of all the circumstances presented by the individual patient. Adherence to these guidelines will not ensure successful treatment in every situation. The AAO-HNS emphasizes that these policies 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.