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3 Effect of Palate Surgery on TORS Results
TORS in a Multilevel Procedure
replaced by a modiﬁed expansion sphincter pharyngoplasty, inspired by the Pang
expansion sphincter pharyngoplasty technique . 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) .
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 . Meanwhile,
patients in Group A underwent UPPP procedure according to the Fairbanks technique , while patients in Group B underwent expansion sphincter pharyngoplasty (ESP) using a modiﬁcation of the Pang–Woodson technique . 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 .
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 .
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 .
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.  with some modiﬁcations . 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. ; (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) .
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 .
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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.
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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.
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9. Lin HS, Rowley JA, Badr MS, Folbe AJ, Yoo GH, Victor L, et al. Transoral robotic surgery for
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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
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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
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.
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) 
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.
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 . 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: email@example.com; firstname.lastname@example.org
A. Bahgat, M.D., M.Sc., E.B.E.
Department of Otorhinolaryngology—Head & Neck Surgery, Alexandria University,
© Springer International Publishing Switzerland 2016
C. Vicini et al. (eds.), TransOral Robotic Surgery for Obstructive Sleep Apnea,
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.  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 .
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 . Selective neural stimulation would
appear to offer advantages. For example, upper airway resistance can be decreased
by stimulating either the geniohyoid muscle  or the medial genioglossus . 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 . 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 .
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.