Robotic-assisted Base of Tongue Resection for Adult Sleep Apnea

A 52-year-old female presented for an evaluation for sleep apnea surgery.  She complained of choking sensation at night.  She had an AHI of 6.7 events per hour, a oxygen saturation nadir of 71%, and BMI of 30.6.  She and a prior history of adenotonsillectomy as a child.  Flexible examination in the office revealed grade 4 lingual tonsil hypertrophy.  She was deemed a candidate for lingual tonsillectomy and was taken to the operating for robotic lingual tonsillectomy.  The technique for adult lingual tonsillectomy is shown in step-by-step fashion with tips for good results both operatively and functionally learned from robotic surgery for cancer of the unknown primary origin.

Contributors: Jessica Moskovitz, MD, Leila J. Mady, MD, PhD, MPH, Umamaheswar Duvvuri, MD, PhD

Robotic-assisted Base of Tongue Resection for Adult Sleep Apnea
Sleep apnea unresponsive to CPAP with lingual tonsil hypertrophy based on flexible fiberoptic endoscopic grade1,2
Absolute Contraindications: successful use of CPAP, need for concurrent UPPP,3 bleeding disorder Relative Contraindications: multi-level obstruction that may benefit first from turbinopasty, septoplasty or UPPP first, anticoagulant therapy
The patient is orally or nasally intubated per surgeon preference. The head of the bed is rotated 90-180 degrees from anesthesia depending on the configuration of the room. Protective eye goggles are placed over the patient’s eyes. The mouth gag is positioned so that the blade so that the circumvallate papillae can be seen on both sides. The robot is docked. (See video for intraoperative setup schema, Intuitive Surgical, ©2017.) The 30-degree endoscope is positioned centrally, while the spatula tip Bovie should be ipsilateral to the hemi-tongue base being removed and the Maryland forceps on the contralateral side. (See video. Intuitive Surgical, ©2017.)
The history should examine the patient’s weight, efforts at weight loss, duration of CPAP use and compliance and review of symptoms (e.g. snoring, daytime headache, daytime sleepiness) significant for untreated sleep apnea (e.g. witnessed apnea, refractory hypertension) and history of tonsillectomy other sleep apnea surgery.4,5 We also suggest that an Epworth sleepiness scale should also be measured preoperatively. Preoperative examination including assessment of patient weight, BMI, blood pressure, rhinoscopy for turbinate hypertrophy and septal deviation, oral cavity examination for tonsillar hypertrophy and or long uvula, Mallampati classification, neck circumference, hyomental distance.4 Flexible fiberoptic examination should also be performed to grade the level of obstruction when awake.1,2 Lateral radiographs have also been used.1 A sleep study should be performed with CPAP in place. DISE should also be performed to assess the levels of obstruction and severity with muscle relaxation during sedation.
Exposure should be done with care and attempt to view the circumvallate papilla and both anterior tonsillar pillars in one view (see video). A T-shape incision through the mucosa and superficial layer of the lymphoid tissue at the circumvallate papilla and straight down the midline is drawn. The specimen will be removed as a right and left hemi-tongue base. Once the incision is made, the specimen is retracted for counter tension using the Maryland forceps. Dissection proceeds in the fascial plane that exists between the lingual tonsil tissue and the intrinsic musculature of the base of tongue (see video). Care is taken not to resect the intrinsic musculature as this increases the risk of hemorrhage (4%).6 This has been demonstrated in lingual tonsillectomy performed for cancer of the unknown primary origin. The dissection proceeds out to the lateral glossoepigottic folds and all the way to the depth of vallecula. Care is taken not remove the mucosa of the epiglottis in order to avoid epiglottic edema. The specimens should be labeled and sent to pathology separately as is done in adult tonsillectomy. While the incidence of unknown primary HPV-associated oropharyngeal cancer is rare, one would not want to miss this as an incidental finding and treatment would require knowledge of laterally.
Advantages: Better visualization of the vallecula and epiglottis, the ability to have an assistant (not possible with transoral laser resection), improved ability to visualization and control hemorrhage.2 Disadvantages: requirement of robotic credentialing, use of the robotic system and the need for specialized operating room staff, increased cost, increased length of stay2,7,8
Major: Severe or life-threatening bleeding with airway compromise and asphyxiation; oropharyngeal stenosis3 Minor: Bleeding requiring return to OR (4%), (cup rate) tongue numbness, lingual edema, temporary dysphagia2,6
1. Sung MW, Lee WH, Wee JH, Lee CH, Kim E, Kim JW. Factors associated with hypertrophy of the lingual tonsils in adults with sleep-disordered breathing. JAMA Otolaryngol Head Neck Surg. 2013;139(6):598-603. 2. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Transoral robotic lingual tonsillectomy in adults: preliminary results. Acta Otolaryngol. 2015;135(1):64-69. 3. Muderris T, Sevil E, Bercin S, Gul F, Kiris M. Oropharyngeal stenosis after transoral robotic lingual tonsillectomy. J Craniofac Surg. 2015;26(3):853-855. 4. Nuckton TJ, Glidden DV, Browner WS, Claman DM. Physical examination: Mallampati score as an independent predictor of obstructive sleep apnea. Sleep. 2006;29(7):903-908. 5. Murat Enoz JL. Recurrent Obstructive Sleep Apnea due to Compensatory Hypertrophy of Lingual Tonsils following UPPP. 2007; http://ispub.com/IJORL/7/2/10903#. 6. Geltzeiler M, Doerfler S, Turner M, et al. Transoral robotic surgery for management of cervical unknown primary squamous cell carcinoma: Updates on efficacy, surgical technique and margin status. Oral Oncol. 2017;66:9-13. 7. Vauterin T, Garas G, Arora A. Transoral Robotic Surgery for Obstructive Sleep Apnoea-Hypopnoea Syndrome. ORL J Otorhinolaryngol Relat Spec. 2018:1-14. 8. Hamaker A. Few Outcome Differences, Higher Costs for DISE and TORS to Treat OSA. ENT Today. 2016(January 2016).

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