Base of Tongue Reduction (Base of Tongue Coblation) & Lingual Tonsillectomy for Obstructive Sleep Apnea (OSA)
Obstructive sleep apnea (OSA) is often a multi-level upper airway disorder in which anatomic factors in the nose, oral cavity, and throat collectively leads to obstruction during sleep. Nasal factors include deviated septum, turbinate hypertrophy, and adenoid hypertrophy. Oral cavity factors include large tongue, large tonsils, and uvular-palatal hypertrophy. Factors in the throat include large base of tongue and rarely, problems related to the voicebox.
Watch Video of Base of Tongue Coblation (Live Footage)
For several decades, there have been well established surgical procedures to address anatomical factors of the nose (septoplasty, turbinate reduction, adenoidectomy, etc) and oral cavity (UPPP, tonsillectomy, etc) that contribute to OSA. However, factors of the throat, particularly an enlarged base of tongue have been a difficult surgical problem to solve.
Where/What Exactly is the Base of Tongue?
The base of tongue is the back part of the tongue as it curves down into the throat (arrow in diagram). Lingual tonsils contribute to the size of this region as well (denoted by rough mucosa in the diagram right below where the arrow is pointing). In many patients suffering from OSA, this region is quite large and tends to collapse backward during sleep leading to obstruction. This may occur even in thin people. The only way to know if a patient has a large base of tongue is by fiberoptic laryngoscopy. It is impossible to tell if you have a large base of tongue by just looking in the mouth.
Furthermore, it may be necessary to perform a sedated endoscopy to ensure that the base of tongue is causing obstruction when asleep.
Another way to suspect a large base of tongue is when a patient has persistent OSA even if their nasal cavity and oral cavity is wide open. Often, these patients have persistent OSA in spite of having undergone a number of surgical procedures including septoplasty, tonsillectomy & adenoidectomy, turbinate reduction, and UPPP.
So How is Base of Tongue Reduction & Lingual Tonsillectomy Performed?
Base of tongue reduction (aka, Submucosal Minimally Invasive Lingual Excision or SMILE) is a method to reduce the overall size of this anatomic region. In the past, procedures were performed that attempted to resolve this problematic area in patients with OSA by indirectly moving and anchoring the tongue forward (hyoid advancement, genioglossal advancement, genio-hyoid advancement, mandibular advancement, etc). The tongue size itself was not addressed in any of these procedures. OR, aggressive base of tongue tissue is removed via midline partial glossectomy similar to the way tongue cancer is removed.
Non-invasive treatment that works for some people are mandibular advancement devices. There are also medical grade appliances that need to be fitted by a dentist. Such appliances work by moving the lower jaw forward and therefore the tongue forward opening up the airway. The most recent treatment developed to address this problemmatic area is the INSPIRE device which requires implanting a pacemaker-like device in the chest wall.
Base of tongue reduction and lingual tonsillectomy are two methods to actually directly address the size of this region rather than just shifting or manipulating the tongue position. In our practice, we use coblation to literally remove part of the base of tongue bulk (a submucosal partial glossectomy) without any external neck incisions.
The submucosal base of tongue reduction partial glossectomy is performed by making a 1cm incision in the center of the tongue and inserting the coblation wand (**EVac Plasma Wand) through this incision and into the muscular bulk of the base of tongue as shown on the picture. With activation, the base of tongue tissue bulk is liquified and suctioned out. This procedure is NOT equivalent to "tongue-channeling" or somnoplasty. A good analogy to compare this procedure to would be liposuction, but instead of fat, muscle and tissue stroma are removed instead. Although muscle is being removed with this procedure, swallowing and talking is no more affected than that experienced after tonsillectomy if the surgery is succesfully performed. Watch a YouTube video describing the procedure here. Because coblation is used, this procedure is also often called base of tongue coblation. The risks of submucosal base of tongue reduction, unfortunately, can be quite substantial however. Risks include permanent tongue paralysis, permanent trouble talking, permanent trouble swallowing, and potential need for even an emergency tracheostomy if excessive bleeding occurs causing a hematoma to form.
Lingual tonsillectomy is a slight modification of the Base of Tongue Reduction in that it is also performed by coblation but is performed external to the tongue. No incision is made. The procedure is performed by shaving the lingual tonsils slowly and carefully down to the tongue much like sanding down a piece of wood. Lingual tonsillectomy is also performed for bad breath resistant to other more conservative treatments as well as for reasons of chronic infections. This procedure is recommended if on endoscopy, the lingual tonsils are found to be very large. Please note that our office no longer offers lingual tonsillectomy. Watch a video of lingual tonsillectomy.
Rarely, if indicated, both lingual tonsillectomy and base of tongue reduction can be performed at the same time. Illustrated below are depictions of what is removed with base of tongue redution and lingual tonsillectomy.
Area in blue is removed with
Area in blue is removed in
What is the Recovery Like from Base of Tongue Reduction/Lingual Tonsillectomy?
Patients report that the pain is roughly 75% of that experienced after a regular tonsillectomy. Pain resolution, normal swallowing, and normal talking usually occurs after about 10 days. The procedure is performed under general anesthesia and typically takes about 15 minutes to perform. Due to the location of the surgery, patients spend one night in the hospital before being discharged home the next day.
Great! Am I a Candidate for Base of Tongue Reduction/Lingual Tonsillectomy?
Generally speaking, those with AHI scores on sleep study >15 along with confirmaton on sedated endoscopy of base of tongue collapse leading to airway obstruction are candidates. Other candidates include those patients who have persistent OSA in spite of having had other surgical procedures done. Please note that our office no longer offers lingual tonsillectomy.
If you are interested in base of tongue reduction, please contact our office for an appointment. PLEASE bring (if applicable) the following information to your appointment to expedite your visit:
- Sleep Study (Most Recent)
- CPAP Titration Sleep Study (Most Recent)
- Operative reports on previous surgical procedures performed in the past to address OSA
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Related Articles Readers Have Viewed
Evaluation of submucosal minimally invasive lingual excision technique for treatment of obstructive sleep apnea/hypopnea syndrome. Friedman M, Soans R, Gurpinar B, Lin HC, Joseph N. Otolaryngology-Head & Neck Surgery. 2008 Sept; 139(3):378-384. Link
Coblation Lingual Tonsillectomy. Maturo SC, Mair EA. Otolaryngology-Head & Neck Surgery. 2006 Sept;135(3):487-488. Link
Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction. Maturo SC, Mair EA. Ann Otol Rhinol Laryngol. 2006 Aug;115(8):624-30. Link
Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2003 Dec;129(6):611-21. Link
Persistent pediatric obstructive sleep apnea and lingual tonsillectomy. Otolaryngol Head Neck Surgery. 2009 July; 141(1): 81-85. Link
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