Recent Advances in Otolaryngology: Head and Neck Surgery (Volume 3) Anil K Lalwani, Markus HF Pfister
INDEX
Page numbers followed by f refer to figure and t refer to table.
A
Acoustic neuroma 257, 258, 260, 264, 265
Acquired subglottic stenosis 102
Active middle ear implants 153, 174f
Additional treatment of dysphagia 361
Age-related hearing loss 325
Aggressive bacterial sinusitis 20
Allergic rhinitis 356
American
Academy of
Otolaryngology-Head and Neck Surgery Classification 258
Sleep Medicine 115
Geriatric Society 315
Medical Association 315
Society of Geriatric Otolaryngology 317
Amitriptyline 287
Amyotrophic lateral sclerosis 323
Anterior
and posterior
cartilage grafts 108
costal cartilage grafts 104
costal cartilage graft laryngotracheoplasty 106
epitympanic space 198f
ethmoid
air cells 16f
bulla 14, 16f
cell 13f
ethmoidal artery 10
graft 105
mallear ligament 196f
Anticonvulsants 286, 287
Apnex system 121
Arteriovenous malformation 76, 88
Articular surface of head of malleus 199f
Association of Directors of Geriatric Academic Programs 315
Audiological tests 260
Auditory
neuropathy spectrum disorder 125, 138
speech sound evaluation test 136
Autoimmune diseases 320, 321t
Automatic registration headset 374f
Autonomous nervous system 350t
Autosomal
dominant nonsyndromic hearing loss 338
recessive nonsyndromic hearing loss 338
Axial noncontrast computed tomography 14f, 15f
B
Basic fibroblast growth factor 84
Benign paroxysmal positional vertigo 327
Bevacizumab 88
Bilateral vestibular loss 273
Blepharospasm 350t
Blood-oxygen-level-dependent 296
Blue rubber bleb nevus syndrome 86f
Body
dysmorphic disorder 54
mass index 117
Bone
anchored hearing systems 139
conduction
hearing solution 150
implants 154
Botulinum toxin
in otorhinolaryngology 350
injections 355f
Bronchoscopy 103
C
Capillary malformation 76
Carotid artery 194f, 215f, 216f, 224f
Castration resistant prostate cancer 70
Central nervous system 282
Cerebrospinal fluid 10, 28, 30f, 222, 378
Cervical
slide tracheoplasty 108, 111
vestibular evoked myogenic potentials 274
Cervicofacial lymphatic malformations 85
Chemoradiotherapy 65
Chirurgia magna 281
Cholesteatoma 199, 215
sac 202f
Cholesterol granulomas 216
Chorda tympani 202f, 210f, 211f, 219f
Chronic
rhinosinusitis 45, 46
sinusitis survey 46, 47, 49
Cochlear implant 125, 150
internal receiver 135f
speech processor 132f
Cochleariform process 196f
Cognitive behavior therapy 293, 292
Compensation of vestibular loss 271
Composite tragal cartilage 212f
Comprehensive geriatric assessment 316
Computed tomography 9, 258
Computer
aided endoscopic surgery 372
assisted surgery 371
of paranasal sinuses and skull base 371
Concha bullosa 14, 16f
Cone-beam CT systems 10
Congenital hemangioma 75
Connective tissue 323
Continuous positive airway pressure 114
Contralateral routing of sound 139
Contrast enhanced axial magnetic resonance 259f, 261f, 263f
Conventional hearing aids 150
Corda tympani 199
Coronal
computed tomographic section of temporal bone 191f
noncontrast computed tomography 12f, 16f, 17f, 18f
Corpus hippocraticum 281
Cribriform plate 10
Cricotracheal resection 104, 108
Crista ampullaris of semicircular canal 272f
Current state of hypoglossal nerve stimulation 117
Cut edge of chorda tympani 197f
Cutaneous hemangiomas 82f
D
Dehiscence
of lamina papyracea 17
syndromes 277
Dehiscent facial nerve 216f
Dementia 321t, 322
Dermatologic acquired vascular tumors 75
Dichotic sentence identification test 325
Direct acoustic cochlear stimulator 156, 166, 300
Disorders of
external ear 318
semicircular canals 277
Dorsal cochlear nucleus 291
Drug induced sleep endoscopy 116
Dysphagia 320324, 328, 353, 361
Dysphonia 318
Dystonic laryngeal movements 352
E
Elastic deformation of clip prostheses 247
Electroencephalogram 290
Electromagnetic
localization system 374
tracking system 375f
Encephalocele 34f, 35f
Endolymphatic
duct 272f
sac 272f
tumors 278
Endoscopic
ear surgery 187
open cavity management of cholesteatoma 202
repair of cerebrospinal fluid leaks 23
transcanal management of
cholesteatoma 200f
limited cholesteatoma 200
Epidermal growth factor receptor 62, 63f, 6567
Epworth sleepiness scale 117
score 3
Eroded
carotid artery canal 216f
middle turn of cochlea 216f
Esophageal squamous cell carcinoma 70
Ethmoid sinus 377f
Eustachian tube 193f, 196f, 198f, 220f, 221f
disorders 318
Expansion surgery 105
Expiratory muscle strength training 323t, 324
Extensive
pneumatization of sphenoid sinus 18
sinonasal polyposis 378
Extracorporeal membrane oxygenation 109
F
Facial
movement disorders 350, 351
pain 358
recess 191
Fatigue severity scale 117
Fibrosarcoma 89
Fibrous layer of tympanic membrane 215f
Fine structure processing 126
Flash lamp pulsed dye laser 85
Flavonoids and terpenoids 286
Flexible
bronchoscopy 103
laryngoscopy 103
Floating mass transducer 156
Foramen rotundum 15
Fovea ethmoidalis 16f
Frontal cell 15
Functional
endoscopic
evaluation of swallowing 320
sinus 9
outcomes of sleep questionnaire 117
Fungal sinusitis 20
Furosemide 288
G
Gamma knife radiosurgery 257, 258, 259, 260
technique for acoustic neuromas 258
Gamma-aminobutyric acid 285
Gardner-Robertson classification 258
Gastrointestinal tract 86f
Genetics
and vascular malformations 88
in otolaryngology 332
Geniculate ganglion 221f, 224f, 225f, 227f, 229f, 230f
Geriatric
otolaryngology 313, 317
standard balance deficit test 274
Ginkgo biloba 286
Glasgow benefit inventory 46
Glioma 89
Glomeruloid hemangioma 74
Goose neck 239
G-protein-coupled receptors 63
Great petrosal nerve 221, 227f, 230f
Guillain-Barré syndrome 321t
Gustatory sweating 350, 353, 356
H
Haller cells 15
Handle of malleus 197f, 208f
Head and neck
cancer 341
paragangliomas 345
squamous cell carcinoma 6567
Hearing loss 318t
rehabilitation 150
Hemangiopericytoma 89
Hemifacial spasm 350
Hereditary
hearing impairment 332, 333
hemorrhagic telangiectasia 86f
High-flow parotid hemangioma 79f
Horizontal segment of facial nerve 197f
Human papilloma virus 61, 344
Huntington's disease 321t
Hyperbaric oxygen therapy 288
Hyperlacrimation 350t
Hypersalivation 350t
Hypofractionated stereotactic radiotherapy 265
Hypoglossal nerve stimulation 114
Hypotympanic air cell 194f
I
Imipramine 287
Implant coupling 244
Implantable hearing aids 149
Incudomallear joint 198f
Incudostapedial joint 193f, 198f, 204f, 205f, 208f, 209f
Infantile hemangiomas 75
Infant-toddler meaningful auditory integration scale 136
Inferior part of tympanomeatal flap 213f
Injection technique 356f
Intensity modulated radiation therapy 65
Internal auditory canal 230f
Intracranial pressure 25, 28, 29, 30f
Intracutaneous botulinum toxin injections 353f
Intrathecal fluorescein 31
Intrathoracic slide tracheoplasty 109
Intratympanic
corticosteroids 284
injection of gentamicin 276
steroid 284
Intravenous vincristine 85
Ipsilateral competing message 325
J
Janus-activated kinase 68
Jugular bulb 193f
K
Kaposiform hemangioendothelioma 75
Kasabach-Merritt syndrome 75
L
Labyrinthectomy 276
Labyrinthine fistula 278
Labyrinthitis 278
Lacrimal gland applications 362
Lamina papyracea 10
Laryngeal dystonia 352
Laryngotracheoplasty 102
Lasabach-Merritt syndrome 75
Laser
assisted uvulopalatoplasty 114
therapy 88
Lateral
incudomallear ligament 194f
mallear ligament 194f
semicircular canal 196f, 199f, 211, 219f221f, 224f, 225f, 227f, 230f, 272f
vestibulospinal tract 273f
Leukemia 89
Lidocaine 285
Lingual resistance exercises 323t
Lower esophageal sphincter 362
Lumbar drainage 30f
Lymphatic malformation 76, 88
M
Magnetic
and electrical brain stimulation 297
resonance
angiography 78f
imaging 9, 19, 28, 257, 345, 372
Magnetoencephalography 298
Maintenance of hearing aids 152
Mammalian target of rapamycin 70
Management of
cerebrospinal fluid 23
cholesteatoma 207f
vascular malformations 87
Margins of meningoencephalocele 33f
Mastoiditis 278
Maxillomandibular advancement 115
McNeill dysphagia therapy program 323t
Medial
longitudinal fasciculus 273f
vestibulospinal tract 273f
Meniere's disease 276, 285, 286, 326
Microlaryngoscopy 103
Microstructure of middle ear transducer 161f
Microvenular hemangioma 75
Middle
cranial fossa 220f, 221f, 224f, 225f, 227f, 229f, 230f
ear implant 150, 159, 162f
turbinate flap 37
Mobile posturography 274
Monoclonal antibody 67
Multichannel cochlear implants 125
Multiple sclerosis 323
Muscle weakness 317t
Music therapy 304, 305
Myofibroma 89
N
Nasal
health survey 51
septum 50
Nasoseptal flap 36
Neuroblastoma 89
Neurological diseases 321t
Noninvoluting congenital hemangioma 76, 76f
Non-small cell lung cancer 70
Nonsuppurative otitis media 318t
O
Obstructive sleep apnea 1, 114, 116
Oculopharyngeal muscular dystrophy 345
Onodi cells 16
Open endoscopic management of cholesteatoma 199
Operating room setup 189f
Optic nerve 10
Optical tracking system 375, 376f
Organ of Corti 288
Ossicular chain reconstruction 178
Osteophytes 321t
Otorhinolaryngology 350
P
Pancreatic neuroendocrine tumor 70
Paraganglioma 345
Parkinson's disease 321t
Parotid gland 359, 361
Pediatric cricotracheal resection 102
Percutaneous endoscopic gastrostomy 323
Pericranial flap 37
Petrous apex 188, 211, 216f
PHACES syndrome 80f
Pittsburgh sleep quality index 117
Plastic deformation of crimp prostheses 246
Polymerase chain reaction 334
Polysomnography 114
Positive airway pressure 1
Postauricular mastoidectomy 190f
Posterior
aspect of tensor fold 197f
costal cartilage
graft 104
laryngotracheoplasty 107f
fossa 80f
graft 106
pillar 193f
semicircular canal 224f
wall of maxillary sinuses 14f
Presbycusis 324
Presbystatis 327
Pressure-release valve 30
Primary nasal symptoms 49
Problemata physica 281
Progression-free survival 64
Pterygopalatine fossa 14, 15f, 21f
Pyogenic granuloma 75
Pyramidal eminence 193f, 194, 224
Q
Quality of life
after rhinoplasty 50, 52
after septoplasty 50
R
Radiosurgery
for larger tumors 264
technique 258
Rapid eye movement 116
Rapidly involuting congenital hemangioma 76f
Real-time functional magnetic resonance imaging 296f
Recurrent benign paroxysmal positional vertigo 277
Removal of
bone; facial recess 192f
cholesteatoma 199, 216f
stenotic segment 109f
Resection
of meningocele or encephalocele 33
surgery 108
Retrotympanum 192
Revision sinus surgery 378
Rhabdomyosarcoma 89
Rheumatoid arthritis 321t
Rhinorrhea 378
Rhinosinusitis
disability index 47
outcome measure 46
quality-of-life survey 47
Rosetti infant-toddler language scale 137
S
Sagittal noncontrast computed tomography 13f, 17f
Salivary glands 359361
Sarcoidosis 321t
Schwann cells 278
Scleroderma 321t
Sclerotherapy 88
Secondary rhinogenous symptoms 49
Semicircular canals 271
Sensorineural hearing loss 125, 159f
Septoplasty 50
Shape memory alloy prostheses 248
Sialorrhea 354
Single-sided deafness 139
Sinonasal
cerebrospinal fluid 25f, 27f
outcome test 4649
Sinus
subtympanicus 194f
tympani 193f
Sleep apnea quality of life index 117
Slide tracheoplasty 104
Sound therapy 289
Spasmodic dysphonia 350t
Sphenoethmoidal recess 13
Sphenoid
meningoencephalocele 33f
sinus 10, 13f, 377f
Spherical recess 224f, 230f
Spindle cell hemangioendothelioma 75
Spontaneous CSF leaks 25
Squamous cell carcinoma 61, 341
Standard balance deficit test 274
Stapes
capitulum 159f, 160f
footplate 216f
Staphylococcus aureus 103
Stenosis of Stensen duct 361
Stereotactic
fractionated radiotherapy 266
radiation therapy 264
Stroke 320, 321t
Sturge-Weber syndrome 87f
Styloid
eminence 194f
prominence 193f
Submandibular gland 361
Superior part of tympanomeatal flap 213f
Surgical
exposition of endolymphatic sac 276
treatment of vestibular disorders 276
Swallowing exercises 323
Systemic lupus erythematosis 321t
T
Targetoid hemangioma 75
Temporal bone fractures 278
Temporoparietal fascial flap 37
Tendon of tensor tympani 199f
Tensor tympani
canal 220f
muscle 220f, 221f
tendon 197f, 198f
Thalidomide 88
Three-dimensional computed tomography angiography 379
Tinnitus
retraining therapy 291
therapy 281
Total implantable cochlear amplifier 166, 167f
Tracheal resection 104, 108
Tracheostomy 321t
Transcanal
endoscopic anatomy of tympanic cavity 191
management of limited cholesteatoma 200
Transcranial
direct current stimulation 299
magnetic stimulation 297
Transcutaneous electric nerve stimulation 300
Transducer loading assistant 172
Transoral robotic surgery 1
Traumatic CSF leaks 24
Treatment of
acute tinnitus 283
chronic tinnitus 286
hemangiomas 85
Meniere's disease 285
tinnitus 283
Trigeminal distribution facial capillary malformation 87
Trimipramine 287
Tullio's phenomenon 277
Tympanic membrane 206f, 208f, 213f, 214f
Tympanomeatal flap 212f
Typical
hemangioma 77f
infantile hemangioma 76
Tyrosine kinase inhibitor 62, 63f
U
Upper esophageal sphincter 361
Uvulopalatopharyngoplasty 114
V
Vascular
endothelial growth factor 64, 67, 84
malformations 85
strip 215f
tumors 74
Vasomotor rhinitis 356
Venous malformation 76, 88
Ventriculoperitoneal shunt 29, 30
Vertical segment of facial nerve 192f
Vertiginous syndromes 318
Vestibular
causes of balance disorders 326
disorders 318
irritation 278
rehabilitation 271
schwannoma 257, 278
Vestibulospinal pathway 273f
Vidian canal 15
Visual analogue scales 51
Visual reinforcement audiometry 136
W
Wegener's granulomatosis 20
Z
Zenker's diverticulum 321, 363
×
Chapter Notes

Save Clear


Transoral Robotic Surgery for Obstructive Sleep ApneaChapter 1

Hardik K Doshi,
Rahmatullah Rahmati
 
INTRODUCTION
Obstructive sleep apnea (OSA) is characterized by repetitive airway collapse resulting in oxygen desaturation and sleep interruption. OSA is associated with cardiopulmonary morbidity and mortality, neurocognitive impairment, and reduced quality of life. Positive airway pressure (PAP) remains the gold standard treatment for moderate-to-severe OSA.1 In patients who are not compliant or tolerant of PAP, a variety of surgical interventions exist. Surgical options for OSA aim to increase or stabilize the size of the airway via repositioning or removing the bony and/or soft tissue architecture at various subsites most prone to collapse during respiration.2 Evidence supports the role for multilevel surgery to address these areas of collapse along the upper aerodigestive tract.1 With the innovation of various medical devices, an increasing number of interventions have become available in the field of sleep surgery. Most notably, the da Vinci surgical robot by Intuitive Surgical, which was FDA approved for use in the extirpation of head and neck neoplasms, has been investigated for its potential application in treating OSA. This chapter will review the literature describing the feasibility and outcomes of transoral robotic surgery (TORS) for OSA.
 
TRANSORAL ROBOTIC SURGERY—BACKGROUND AND TECHNIQUE
First established as an efficacious method of resecting oropharyngeal cancers, the application of the surgical robot in the management of OSA has been investigated more recently.24 With the tongue base recognized as a major site of obstruction in OSA, various procedures such as genioglossus advancement, partial midline glossectomy, hyoid myotomy, and Repose stay sutures currently exist to address the region.5 However, these surgeries are potentially limited by the need for external incisions, inadequate exposure, nonarticulated instrumentation, and overall technical difficulty. In an effort 2to add to the surgical armamentarium for managing OSA, Vicini et al. in 2010 investigated the tolerability and effectiveness of transoral robotic tongue base resection.4
Through the use of the EndoWrist articulated instruments and three-dimensional high-definition cameras (0° and 30°), TORS offers an additional level of precision to excise the soft tissue of the upper aerodigestive tract that would otherwise require a complex open approach.
As with any surgery, patients should be carefully selected for transoral robotic surgical intervention. For access purposes, any anatomical limitations such as retrognathia, micrognathia, trismus, or the inability to hyperextend the neck should be examined. Candidates for TORS ideally have primary obstruction at the tongue base, though interventions at the supraglottis and soft palate via the robot have also been described. 69
Though it is safest to limit the tissue resection to the superficial layer of lingual lymphoid tissue, most tongue base cases require dissection into the tongue base musculature. Deeper dissection and the absence of dependable landmarks can lead to exposure of the lingual artery and its dorsal branches and injury to the hypoglossal and lingual nerves.7 Thus, familiarity with the anatomy of the underlying neurovascular bundle is paramount. Based on cadaveric and angiographic studies, the distance between the foramen cecum and hypoglossal/lingual neurovascular bundle is approximately 1.7 cm. Therefore, tongue base resection performed within approximately 1.5 cm of the foramen cecum is reported to be safe.10 Any additional tissue removal would require vigilance under sufficiently high magnification. Alternatively, some surgeons have used Doppler ultrasound to directly trace the path of bilateral lingual arteries to provide anatomical boundaries for resection.9
Various techniques for tongue base resection have been described in the literature. Resection is generally performed in a piecemeal or en bloc fashion. Preoperative sleep endoscopy may be used to delineate the lateral extent of resection.2,5 Vicini et al. utilize a piecemeal resection starting in the midline and then carefully extending the resection laterally.4 Friedman et al. describe removing a triangular wedge of the tongue base musculature after parallel cuts are made in the circumvallate papillae/foramen cecum region of the tongue base.9 Lee et al. performed a piecemeal lingual tonsillectomy and only a small amount of the underlyin g musculature.5 Figure 1.1 illustrates before and after changes to base of tongue region after robotic resection for hypertrophic lingual tonsils.
 
TRANSORAL ROBOTIC SLEEP SURGERY LITERATURE REVIEW
The first article to report on the use of transoral robotic tongue base resection in OSA was published by Vicini et al. in 2010. This retrospective study followed 10 patients for a minimum of 3 months who demonstrated an Epworth sleepiness scale (ESS) score > 11, apnea–hypopnea index (AHI) > 20, nonacceptance or dropout from continuous PAP use, and clinical tongue base hypertrophy with adequate tongue base exposure.3
zoom view
Fig. 1.1: Schematic of narrowed retrolingual space due to lingual tonsil hypertrophy before and after robotic resection.
All patients prior to intervention underwent a tracheostomy procedure; however, no serious airway or bleeding complications were reported. Furthermore, no cases required an open conversion or need for revision surgery to address the tongue base. The blood loss and operating time were equal to or less than an open or endoscopic laser resection, while the TORS procedure allowed for multiplanar visualization of the tissue. All patients were decannulated between the 5th or 13th day and all patients had satisfactory swallowing after 2 weeks resulting in no significant reduction in postoperative BMI scores. Measuring preoperative and postoperative indices, AHI and ESS scores reached statistically significant changes (Table 1.1).
Vicini et al. followed the preliminary paper with a follow-up the subsequent year with 10 additional (20 total) patients along with anatomic analysis of the tongue base in 3 cadaveric heads. A similar inclusion criterion was utilized; however, patients were followed out for a minimum time of 410 months. In order to better differentiate between subjective improvement in OSA symptoms and objective improvement, patients were deemed surgically cured if posttreatment AHI and ESS scores were < 10. In turn, 70% of the cohort was found to be cured based on their AHI, and 90% based on their ESS. Overall, 60% (12/20) were found to be cured of both. Additionally, it was found that setting up and operating time improved with experience. Once again, measuring preoperative and postoperative indices including AHI, ESS, and additionally lowest oxygen saturation, these levels reached statistically significant improvement (Table 1.1).
In an effort to address other subsites problematic in OSA, Vicini et al. used a cadaver model to develop a technique of geniohyoidpexy to complete the basic TOR tongue base with supraglottoplasty surgery to improve outcomes to match those described by Chabolle et al. where a hyoid epiglottoplasty is utilized with an open tongue base approach.6,11
Table 1.1   Literature comparison
AHI
ESS
Lowest O2 saturation
Complications requiring OR intervention
Minor complications
Vicini et al (2010)
Preoperative
38.3 ± 23.5
12.4 ± 3.5
Postoperative
20.6 ± 17.3
6.9 ± 2.8
0/10
Minor bleeding (30%), severe pharyngeal edema (10%)
Vicini et al (2010)
Preoperative
36.3 ± 21.1
12.6 ± 4.4
77.7 ± 9.7
Postoperative
16.4 ± 15.2
7.7 ± 3.3
81.9 ± 7.3
0/20
Minor bleeding (15%), severe pharyngeal edema (5%), subcutaneous emphysema (10%)
Friedman et al.
Preoperative (Robot)
54.6 ± 21.8
14.4 ± 4.5
78.5 ± 7.4
Postoperative (Robot)
18.6 ± 9.1
5.4 ± 3.1
86.5 ± 6.3
0/27
Dysphagia (# of patients not reported)
Preoperative (SMILE)
53.7± 29.3
14.8 ± 4.0
79.7 ± 11.9
5
Postoperative (SMILE)
26.6 ± 23.9
6.7 ± 4.7
84.8 ± 9.0
0/22
Dysphagia (# of patients not reported)
Preoperative (RFBOT)
54.7 ± 26.6
16.6 ± 2.8
80.8 ± 7.8
Postoperative (RFBOT)
34.6 ± 22.5
10.8 ± 3.5
84.3 ± 7.5
0/24
Dysphagia (# of patients not reported)
Lee et al.
Preoperative
55.6 ± 26.0
13.4 ± 6.1
75.8 ± 9.6
Postoperative
24.1 ± 19.6
5.9 ± 4.7
81.7 ± 8.2
1*/24 (4.2%)
Transient dysphagia (20.85%), transient dysgeusia (12.5%), transient globus (8.3%)
Lin et al.
Preoperative
43.9 ± 41.1
13.7 ± 5.2
83.3 ± 5.5
Postoperative
17.6 ± 16.2
6.4 ± 4.5
84.0 ± 6.4
1**/12 (8.3%)
Transient dysgeusia (25%)
Note: Bold and italicized are statistically significant.
1* Bleeding POD7; 1** Oropharyngeal scarring requiring lysis.
(AHI: Apnea-hypopnea index; ESS: Epworth sleepiness scale).
A dissection method within the sagittal avascular plane inside an ideal triangle between the mandible, hyoid bone body, and the lingual frenulum is outlined. Ultimately, the hyoid is tied under slight tension to the mandible with the procedure taking roughly < 20 minutes in total. Additionally, to elucidate the improvement in treatment of OSA when used in conjunction with TORS, Vicini et al. also investigated the modified Pang expansion sphincter pharyngoplasty (nonrobotic) to the uvulopharyngoplasty (nonrobotic) procedure.12 Though the Pang expansion sphincter pharyngoplasty required more time to perform (average of 39 minutes), it was found to be superior in post-procedure AHI and ESS to the classic uvulopharyngoplasty when used in conjunction with TORS. It is thought that that the expansion sphincter pharyngoplasty creates a greater angle between the lateral wall and palate.86
Friedman et al. inv estigated the feasibility of performing a Z-palatoplasty with a robotically assisted partial glossectomy without tracheotomy to those who underwent a Z-palatoplasty with tongue base reduction via radio frequency (radio frequency base-of-tongue reduction [RFBOT] or coblation (submucosal minimally invasive lingual excision [SMILE].) Twenty seven TORS patients were compared with 24 RFBOT patients and 22 SMILE patients. As with Vicini et al. rate of cure was defined as AHI < 20 and reduction in AHI ≥ 50%. Like the reports by Vicini et al. no incidence of significant bleeding or airway complications were reported (Table 1.1). It was found that only the robot group had a statistically significant improvement in minimum oxygen saturation, while all groups had a statistical significant decrease in AHI and ESS (though a greater percentage in absolute decrease was seen within the robot group for both AHI and ESS) (Table 1.1). Interestingly, no direct correlation was found between the weight of lingual tissue removed and the degree of improvement in minimum oxygen saturation, or ESS. TORS required longer length of stay in the hospital (1.6 ± 0.7) and return to normal diet (19.3 ± 8.4 days). The percentage of surgical cure was higher in the robot group (66.7%) versus the coblation (45.5%) and radio frequency (20.8%), though statistically significant compared with only the radio frequency group.
In similar fashion of investigating TORS with a concomitant palate surgery, Lee et al. investigate transoral robotic lingual tonsillectomy with the classic uvulopharyngoplasty. Traditional surgery involving uvulopalatopharyngoplasty alone has not reliably led to normalization of the AHI for patients with moderate-to-severe OSA. Lee et al. offered those patients who underwent drug-induced sleep endoscopy and were found to have significant obstruction at the level of the retroglossal region the option of an uvulopharyngoplasty and transoral robot lingual tonsillectomy. These patients, selected prospectively, were matched against historical controls. In alignment with reports by Vicini and Friedman, surgical success was defined as a 50% reduction of preop AHI and postop AHI of < 20, while surgical response was defined as a reduction from the preoperative AHI of at least 50%. AHI, ESS, and lowest oxygen saturation levels were all found to be statistically significant postoperatively with 13 patients meeting the criteria for surgical response and 9 meeting the criteria for surgical cure (Table 1.1). Unlike data published by Vicini and Friedman, one patient did experience a postoperative bleed (postoperative day 7) that required a visit to the operating room for cauterization (Table 1.1). Minor complications included dysphagia, dysgeusia, and transient globus—all of which resolved by 3 months.
With OSA generally resulting from obstruction at various subsites throughout the upper airway, much of the literature compares various outcomes (i.e. AHI, ESS, and minimum oxygen saturations) after performing multilevel surgery. Therefore, reports describing base of tongue resection 7concomitantly with other upper airway procedures make interpretation of the efficacy of base of tongue reduction alone difficult to assess. Lin et al. in a retrospective analysis examined 27 patients who underwent TORS for base of tongue reduction only, though the majority has previously undergone a combination of other airway procedures including a uvulopalatopharyngoplasty/Z-palatoplasty, coblation-assisted lingual tonsillectomy, hyoid advancement, and tracheostomy. Similar to the criteria outlined by Vicini, Friedman, and Lee, surgical response was defined as a 50% reduction in AHI and final AHI < 20 postoperatively. Both AHI and ESS demonstrated statistical significance with 50% of the patients achieving surgical cure comparable with the results produced by others who underwent concomitant multilevel airway surgery to treat OSA (Table 1.1). However, unlike other reported papers, one patient (8%) demonstrated oropharyngeal scarring causing dysphagia that required scar tissue lysis (Table 1.1). With the possibility of oropharyngeal scarring from tongue base resection and concomitant palatal surgery, the authors recommended considering a two-stage approach with the TORS-assisted base of tongue re section occurring prior to a second-stage palate surgery.
 
CONCLUSION
The application of the robot, in order to provide improved access, enhanced visualization and precision has been demonstrated to be feasible and tolerable in patients with OSA. The studies thus far reveal improved AHI, ESS, and O2 saturations with robotic sleep surgery. With additional studies and appropriate patient selection, TORS may become a powerful tool in the armamentarium of the otolaryngologist to effectively treat airway obstruction at the base of tongue and possible adjacent sites of airway collapse.
REFERENCES
  1. Caples SM, Rowley, JA, Prinsell, JR, et al. Surgical modifications of the upper airway for obstructive sleep apnea in adults: a systematic review and meta-analysis. Sleep. 2010;33 (10): 1369–407.
  1. Lin HS, Rowley, JA, Badr, MS, et al. Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome. Laryngoscope. 2013;123:1811–6.
  1. O’Malley BW Jr, Weinstein, GS, Synder, W, et al. Transoral robotic surgery (TORS) for base of tongue neoplasms. Laryngoscope. 2006;116:1465–1472.
  1. Vicini C, Dallan, I, Canzi, P, et al. Transoral robotic tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: a preliminary report. ORL J Otorhinolaryngol Relat Spec. 2010;72:22–7.
  1. Lee Jm, Weinstein GS, O’Malley Jr. BW, et al. Transoral robot-assisted lingual tonsillectomy and uvulopalatopharyngoplasty for obstructive sleep apnea. Ann Otol Rhinol Laryngol. 2012;121 (10): 635–9.8
  1. Vicini C, Montevecchi, F, Dallan, I, et al. Transoral robotic geniohyoidpexy as an additional step of transoral robotic tongue base reduction and supraglottoplasty: feasibility in a Cadaver model. Otorhinolaryngol Relat Spec. 2011;73(3):147–50.
  1. Vicini C, Dallan, I, Canzi, P, 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.
  1. Vicini C, Montevecchi, F, Pang, K, et al. Combined transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea-hypopnea syndrome: expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty. Head Neck. 2013;00:1–7.
  1. Friedman M, Hamilton, C, Samuelson, CG, et al. Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. Otolaryngol Head Neck Surg. 2012;146:854–62.
  1. Lauretano AM, Li, KK, Caradonna, DS, Khosta, RK, Fried, MP. Anatomic location of the tongue base neurovascular bundle. Laryngoscope. 1997;107:1057–9.
  1. Chabolle F, Wagner, I, Blumen, MB, et al. Tongue base reduction with hyoepigottoplasty a treatment for severe obstructive sleep apnea. Laryngoscope. 1999;109:1273–80.
  1. Pang KP, Woodson, BT. Expansion sphincter pharyngoplasty: a new technique for the treatment of obstructive sleep apnea. Otolaryngol Head Neck Surg. 2007;30:110–4.