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3 Effect of Palate Surgery on TORS Results

3 Effect of Palate Surgery on TORS Results

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TORS in a Multilevel Procedure


replaced by a modified expansion sphincter pharyngoplasty, inspired by the Pang

expansion sphincter pharyngoplasty technique [11]. For that reason, our group has

had the unique opportunity to compare the contribution of two different palate surgeries (UPPP and ESP) to the outcome of a multilevel, one-step procedure including

a TORS tongue base reduction (TBR) and supraglottoplasty (SGP) [12].


Expansion Sphincter Pharyngoplasty

Two groups of 12 severe OSAHS cases each were sorted according to the primary

selection criteria of statistically comparable preoperative AHI (AHI = 38 in both

groups). The two groups were also reasonably matched for sex, age, body mass

index (BMI), and volume of removed tongue base (TB) tissue. Both groups underwent multilevel surgery of the upper airway including nose surgery if required and

TORS TBR-SGP according to the Vicini–Montevecchi technique [6]. Meanwhile,

patients in Group A underwent UPPP procedure according to the Fairbanks technique [13], while patients in Group B underwent expansion sphincter pharyngoplasty (ESP) using a modification of the Pang–Woodson technique [11]. These

modifications include (1) blunt palate tunneling without mucosal incisions; (2) posterior pillar flap tip stay suture in order to prevent a possible tearing of the tip by the

pulling suture; and (3) systematic use of a second intermediate suturing of the flap

under direct visual control [12].

The purpose of the study was to show the superiority of ESP compared to the

traditional UPPP as a multilevel procedure. The most striking finding is a postoperative AHI of 9.9 ± 8.6 SD for the ESP group versus a postoperative AHI of 19.8 ± 14.1

SD for the UPPP group. Pre- and postoperative comparison, in terms of AHI,

reached statistical significance for both techniques. Comparison between UPPP and

ESP, in terms of AHI improvement, is at the limit of statistical significance [12].

The authors concluded that the palate component of multilevel procedure, ESP,

including conventional nose surgery and robotically assisted TB-SPG surgery,

seems to be superior to UPPP. Functional and objective superiority (as measured by

postoperative polysomnography) and better acceptance by the patient (less pain and

less late discomfort) seem to balance the longer surgical time, the higher technical

complexity, and the longer learning curve [12].


Barbed Reposition Pharyngoplasty

A systematic retrospective review of the literature, analysis of our cases, and a targeted

cadaver dissection study prompted us to modify our approach to the lateral pharyngeal wall switching from ESP to relocation pharyngoplasty (RP) according to Li

et al. [14] with some modifications [15]. The new technique includes the following:

(1) a “barbed” suture, which refers to the use of knotless, bidirectional, and


A. Bahgat et al.

re-absorbable sutures introduced for similar purposes by Mantovani et al. [16]; (2)

“reposition pharyngoplasty” which displaces the posterior pillar (palatopharyngeal

muscle) in an anterior-lateral position to enlarge the oropharyngeal inlet as well as

the retro-palatal space; (3) suspension of the posterior pillar to the pterygomandibular raphe; and (4) weakening of the inferior aspect of the palatopharyngeal

muscle by means of a partial horizontal transection. The multiple sustaining suture

loops of barbed reposition pharyngoplasty (BRP) proved to be more stable than the

single pulling tip suture of ESP, with minimal risk of tearing the muscle fibers and

losing the suspension force.

In a preliminary study of ten adult male patients undergoing multilevel surgery

including BRP (mean age 53.4 ± 12.4, mean BMI 28.5 ± 3.6), the preoperative AHI

was reduced from 43.65 ± 26.83 to 13.57 ± 15.41 (P = 0.007), and the preoperative

ESS was reduced from 11.6 ± 4.8 to 4.3 ± 2 (P < 0.01) [15].

The most important advantage of this palatal technique is the stability of the new

expanded retro-palatal space, which was confirmed 6 months postoperatively by

in-office fiber-optic examination. In addition, this technique is easily taught, and

operative time is short, decreasing over the course of the study to as short as 20 min.

Finally, pain as assessed by visual analog scale (VAS) and dysphagia as assessed by

MD-Anderson dysphagia questionnaire showed that this technique is well tolerated

by patients who undergo multilevel surgery including TORS—TBR and SGP [15].


1. Waite PD, Wooten V, Lachner J, Guyette RF. Maxillomandibular advancement surgery in 23

patients with obstructive sleep apnea syndrome. J Oral Maxillofac Surg. 1989;47(12):1256–

61. discussion 62.

2. Fujita S. Obstructive sleep apnea syndrome: pathophysiology, upper airway evaluation and

surgical treatment. Ear Nose Throat J. 1993;72(1):67–72. 5–6.

3. Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea syndrome: a review of 306

consecutively treated surgical patients. Otolaryngol Head Neck Surg. 1993;108(2):117–25.

4. Thaler ER, Rassekh CH, Lee JM, Weinstein GS, O'Malley Jr BW. Outcomes for multilevel

surgery for sleep apnea: obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty. Laryngoscope. 2016;126(1):266–9.

5. Kezirian EJ. Nonresponders to pharyngeal surgery for obstructive sleep apnea: insights from

drug-induced sleep endoscopy. Laryngoscope. 2011;121(6):1320–6.

6. Vicini C, Dallan I, Canzi P, Frassineti S, Nacci A, Seccia V, et al. Transoral robotic surgery of

the tongue base in obstructive sleep apnea-hypopnea syndrome: anatomic considerations and

clinical experience. Head Neck. 2012;34(1):15–22.

7. Vicini C, Dallan I, Canzi P, Frassineti S, La Pietra MG, Montevecchi F. Transoral robotic

tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: a preliminary report.

ORL J Otorhinolaryngol Relat Spec. 2010;72(1):22–7.

8. Friedman M, Hamilton C, Samuelson CG, Kelley K, Taylor D, Pearson-Chauhan K, et al.

Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 2012;146(5):854–62.

9. Lin HS, Rowley JA, Badr MS, Folbe AJ, Yoo GH, Victor L, et al. Transoral robotic surgery for

treatment of obstructive sleep apnea-hypopnea syndrome. Laryngoscope. 2013;123(7):



TORS in a Multilevel Procedure


10. Vicini C, Montevecchi F, Campanini A, Dallan I, Hoff PT, Spector ME, et al. Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an

emerging surgical technology in a targeted application for benign disease. ORL

J Otorhinolaryngol Relat Spec. 2014;76(2):63–9.

11. Pang KP, Woodson BT. Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007;137(1):110–4.

12. Vicini C, Montevecchi F, Pang K, Bahgat A, Dallan I, Frassineti S, et al. Combined transoral

robotic tongue base surgery and palate surgery in obstructive sleep apnea-hypopnea syndrome:

expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty. Head Neck.


13. Fairbanks DN. Operative techniques of uvulopalatopharyngoplasty. Ear Nose Throat

J. 1999;78(11):846–50.

14. Li HY, Lee LA. Relocation pharyngoplasty for obstructive sleep apnea. Laryngoscope.


15. Vicini C, Hendawy E, Campanini A, Eesa M, Bahgat A, AlGhamdi S, Montevecchi F, et al.

Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study. “We are on the giant’s shoulders”. Eur Arch Otorhinolaryngol.


16. Mantovani M, Minetti A, Torretta S, Pincherle A, Tassone G, Pignataro L. The “Barbed Roman

Blinds” technique: a step forward. Acta Otorhinolaryngol Ital. 2013;33(2):128.

Chapter 10

Alternative Procedures

Mohamed Eesa, Ahmed Bahgat, and Ehsan Hendawy



TORS was devised as a robotically assisted transoral version of Chabolle’s operation

(open transcervical Tongue Base Reduction and Hyo-Epiglottoplasty, TBRHE) [1]

for moderate to severe obstructive sleep apnea hypopnea syndrome (OSAHS). This

chapter gives an overview of the alternative procedures that can be used to address

tongue base obstruction in OSAHS patients.


Historical Background

The ideal surgical approach for the tongue base should provide both excellent exposure and visualization in order to perform a safe and adequate resection of obstructing tissue. The procedure should minimize collateral damage to surroundings

structures in order to maintain the critical role of the tongue base in determining the

patient’s quality of life.

Base of tongue (BOT) resection for the treatment of OSAHS is not a new concept. In 1991, Fujita et al. first reported on the use of carbon dioxide laser for midline glossectomy in 12 patients who did not respond to UPPP [2]. Many modifications

of this technique have been published to improve the response rate; however, surgical management of the tongue base by a microscopic-laser-assisted approach is

M. Eesa, M.D., M.Sc., E.B.E. (*) • E. Hendawy, M.D., M.Sc., E.B.E.

Department of Otolaryngology and Head-Neck Surgery, University of Zagazig,

Zagazig 44519, Sharkia, Egypt

e-mail: dr.eesaorl@gmail.com; ehsanhendawy@gmail.com

A. Bahgat, M.D., M.Sc., E.B.E.

Department of Otorhinolaryngology—Head & Neck Surgery, Alexandria University,

Alexandria, Egypt

© Springer International Publishing Switzerland 2016

C. Vicini et al. (eds.), TransOral Robotic Surgery for Obstructive Sleep Apnea,

DOI 10.1007/978-3-319-34040-1_10



M. Eesa et al.

challenging from a technical point and requires extensive training. Furthermore,

using this technique, manipulation of tongue base tissues causes complex geometric

distortions in the architecture of the region, thus impairing the surgeon’s orientation

and increasing the risk of complications. Insufficient visualization of crucial neurovascular structures restricts resection to the midline of the tongue, ignoring the lateral tongue base. In addition, the postoperative functional and pain profiles for laser

resection are very problematic. These are the reasons why laser resections were

abandoned in many parts of the world.

Open approaches through the neck can be performed to improve access, but have

significant associated morbidity. Historically, Chabolle was the first to propose a

tongue base resection through a transcervical suprahyoid approach. Later, Vicini

et al. [3] modified this technique to include a transcervical infra-hyoid submucosal

tongue base reduction with the addition of thyro-hyoidopexy to improve its effectiveness and reduce complications. Although the open approach is effective, the

procedures remained confined to a very limited number of centers due to both the

technical difficulties and associated morbidity.

In recent times, reasonable success has been achieved through the use of radiofrequency base-of-tongue reduction (RFBOT) through either a transoral or transcervical ultrasound-guided approach; however, radiofrequency surgery can only be

successful in cases of moderate tongue base hypertrophy [4].

Submucosal minimally invasive lingual excision (SMILE), and Coblation® assisted

lingual tonsillectomy with or without endoscopic assistance have been described to

address large tongue base obstruction in children with obstructive macroglossia and has

been found to be promising. However, these procedures are limited by poor visualization

and access to the BOT region. Moreover, SMILE is believed to be more invasive and has

resulted in increased morbidity as compared to RFBOT; the most significant potential

complication of SMILE is damage to the lingual artery or the hypoglossal nerve.


TORS Versus Chabolle’s Operation

A retrospective comparative study was carried out in our center to compare TORS

versus transcervical tongue base reduction (according to Chabolle); two matched

groups of OSAHS patients were sorted according to the primary selection criteria of

statistically comparable preoperative AHI. The two groups were also reasonably

matched for sex, age, body mass index (BMI), and palate surgery (UPPP).

Tracheostomy was done in all patients.

Postoperative AHI registered (after at least 6 months) showed no statistically

significant difference (p = 0.14) between TORS (14.21 ± 10.46) and Chabolle procedure (21.67 ± 19.38). The same result was obtained in ESS; 7.75 ± 3.52 for Chabolle

procedure, and 6.91 ± 4.22 for TORS (p = 0.5).

In conclusion, TORS can achieve the same effect as the Chabolle operation both

subjectively (ESS) and objectively (AHI) with significantly less operative time

(182.5 ± 51.72 min for Chabolle and 150.35 ± 36.59 min for TORS), less invasiveness

(no cervical incision), less postoperative hospital stay (19.92 ± 8.19 days for

10 Alternative Procedures


Chabolle and 7.68 ± 1.91 days for TORS), and an earlier resumption of oral feeding

(11.83 ± 7.94 days for Chabolle and 1.13 ± 0.34 days for TORS). The total cost

between TORS and Chabolle was statistically insignificant (5494.98 € for Chabolle

and 5572.78 € for TORS) (p > 0.05) due to less operative time and less postoperative

hospital stay for TORS patients.


TORS Versus Maxillomandibular Advancement


A retrospective comparative study was carried out in our center to compare TORS

versus MMA (unpublished data); two matched groups of OSAHS patients were

sorted according to the primary selection criteria of statistically comparable preoperative AHI. The two groups were also reasonably matched for sex, age, and body

mass index (BMI); tracheostomy was performed in all patients.

Postoperative AHI registered (after at least 6 months) showed a statistically significant difference (p = 0.02) between TORS (14.21 ± 10.46) and MMA (8.16 ± 6.98).

However, there was no statistically significant difference in postoperative ESS;

7.68 ± 1.34 for MMA and 6.91 ± 4.22 for TORS (p = 0.5).

There was a significant difference in favor of TORS in total operative time

(357.6 ± 41.48 min for MMA and 150.35 ± 36.59 min for TORS), start of oral feeding (16 ± 1.32 days for MMA and 1.13 ± 0.34 days for TORS), and total cost

(10,702.08 € for MMA including cost of titanium plates and screws used in fixation,

and 5572.78 € for TORS).

Moreover, TORS was found to be BMI sensitive; when comparing two matched

groups with BMI greater than 30, results of MMA are superior to TORS for postoperative AHI (7.94 ± 6.68 for MMA and 18.74 ± 13.12 for TORS). But when comparing the groups with a BMI equal or less than 30, there is no significant difference in

postoperative AHI between TORS and MMA (8.63 ± 8.05 for Bi-max and

12.34 ± 10.29 for TORS).


TORS Versus Genioglossus Advancement ± Hyoid


Three groups of patients who underwent tongue base surgery, including TORS,

genioglossus advancement (GGA) with or without hyoid suspension (HS), and

hyoid suspension alone were evaluated (unpublished data). The three groups were

matched for AHI sex, age, BMI, and palate surgery.

Postoperative AHI registered (after at least 6 months) was 28.28 ± 23.72 for

GGA ± HS group, 21.04 ± 16.55 for the HS group and 14.13 ± 11.72 for the TORS

group. The difference in postoperative AHI was statistically significant between

TORS versus either GGA ± HS (p = 0.008) or hyoid suspension groups (p = 0.04) in

favor of TORS. However, the difference was not statistically significant between


M. Eesa et al.

GGA ± HS and the HS groups (p = 0.18). In conclusion, the AHI reduction in TORS

is better than GGA ± HS or HS alone (unpublished data).

Postoperative improvement of ESS showed the same results (9.5 ± 1.74 for

GGA ± HS group, 7.72 ± 2.33 for HS group and 6.33 ± 3.15 for the TORS group).

The difference in postoperative ESS was statistically significant between TORS

compared to either GGA ± HS (p = 0.001) or HS groups (p = 0.02) in favor of

TORS. In summary, ESS reduction in TORS is better than HS or GGA ± HS.

GGA ± HS has proven to be inferior to TORS in terms of both subjective and

objective functional outcomes.

Hyoid suspension as performed in our institution as thyro-hyoidopexy (THP)

moves the hyoid and, subsequently, the tongue base anteriorly. Its primary function

is to stent the lateral hypopharyngeal walls and prevent lateral collapse in moderate

OSAHS patients (AHI less than 30). THP should be avoided if the main pattern of

hypopharyngeal collapse, as seen by DISE, is anterior–posterior as is often observed

in severe OSAHS patients (AHI greater than 30), in which case TORS would be

recommended. Performing both THP and TORS as a single procedure may result in

the development of a pharyngo-cutaneous fistula and is therefore not advised. If

TORS BOT resection is unsuccessful and lateral hypopharyngeal collapse is present

on DISE, THP is currently under evaluation as a salvage procedure.


Hypoglossal Nerve Stimulation

Hypoglossal nerve stimulation (HGNS) returns tone to the sleeping tongue. A number of animal studies, conducted in multiple labs and reported over the past several

years, have demonstrated that hypoglossal nerve stimulation can produce consistent

improvements in the tone of the tongue [5]. Selective neural stimulation would

appear to offer advantages. For example, upper airway resistance can be decreased

by stimulating either the geniohyoid muscle [6] or the medial genioglossus [7]. In

addition, airway compliance can be increased by stimulation of the hyoglossus and

styloglossus muscles. This has been demonstrated in animals and in humans.

Early studies were conducted in patients where unilateral hypoglossal nerve

stimulators were implanted in eight patients [8]. No surgical complications were

reported. As reported by the authors, all of the patients derived significant clinical

benefit over a follow-up period of 6 months. The study demonstrated the feasibility

and therapeutic potential for hypoglossal nerve stimulation in obstructive sleep

apnea in man. More recent studies of neurostimulation devices for OSA have been

completed in larger populations with success.

A single-arm, open-label study has been completed in four sites in Australia using

the HGNS device manufactured by Apnex Medical®, Inc. Twenty-one subjects with

moderate to severe OSA were enrolled. The results showed significant improvement

(all p < 0.05) from baseline to 6 months in: AHI (43.1 ± 17.5 to 19.5 ± 16.7), ESS

(12.1 ± 4.7 to 8.1 ± 4.4). Two serious device-related adverse events occurred. In conclusion, the HGNS demonstrated favorable safety, efficacy, and compliance [9].

Another clinical study was completed by Inspire Medical Systems®, Inc. Patients

with moderate to severe OSA were implanted. The study was conducted in two parts.

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