It seems like surgical options for patients with obstructive sleep apnea who can’t tolerate CPAP oral appliances is growing rapidly. I haven’t attended my annual Otolaryngology – Head & Neck Surgery Academy meeting since 2013. This year at our meeting in Dallas, there were significantly more presentations and surgical options compared to years past. The two most prominent high-tech options were tongue nerve stimulation (pacemaker) and robotic surgery for the tongue.
Since it was a meeting for surgeons only, there were no CPAP companies, sleep testing or dental device companies on the convention floor.
Here’s a rundown of the 5 things I learned or was most impressed about:
1. Nasal valve and septal procedures.
There wasn’t a specific new technique to help you breathe better through your nose, but there was a number of courses that reviewed the state of the art in dealing to difficult noses. These courses covered a review of basic techniques to complicated reconstructive techniques. As you may know, I usually recommend proper nasal breathing before moving on to treat snoring, upper airway resistance syndrome or obstructive sleep apnea. This can also allow you to use CPAP or dental appliances much more effectively.
2. Tongue and hyoid suspension.
I first began doing tongue base and hyoid suspension early in my career about 15 years ago, but have shifted to other options like tongue reduction procedures. Advancements in suture placement techniques and more studies showing good results has made me start thinking about re-staring these options again.
3. Tongue nerve stimulation (Inspire and ImThera).
Inspire received FDA approval last year for their hypoglossal (tongue) nerve pacemaker technology. There’s been a limited number of implants to date but the preliminary results look promising. ImThera, which already has been approved by regulators in Europe, and is currently undergoing their definitive study for FDA clearance in the US. Note that this option only addresses the tongue. If you have other areas of obstruction (soft palate or nose), results may not be as good.
4. Robotic surgery (DaVinci and Medrobotics).
There are many different ways of seeing what you’re doing with tongue base surgery (direct, angled camera and robot) with proponents for all three options. There are also different ways to make cuts (knife, cautery, laser, radio frequency), with proponents for each option as well. Robotic surgery also addresses only the tongue as well (along with the epiglottis). It’s very new and promising technology, but we’ll have to see what the long-term studies show and if insurance will pay cover it routinely.
5. Midline partial glossectomy.
This wasn’t actually presented, but I met a lot of surgeons using this basic, low-tech technique who are reporting excellent results, usually similar to what’s published for the more high-tech procedures.
6. Palatal procedures.
The state of the art for soft palate procedures were described, from expansion sphincter pharyngoplasty (ESP), using barbed-sutures to pull on soft palate tissues to perform the ESP, and trans-palatal advancement.
7. Maxillo-mandibular advancement (MMA).
The MMA procedure, where both the upper and lower jaws are moved forward, was presented as another viable first or second line option for surgery. As expected, the results were much better than soft tissue procedures, but with longer recovery and various potential complications such as numbness. As expected, there were strong opinions about the pros and cons doing this as a first line surgical option.
My take-away from this conference was that ultimately, you can’t say which procedure is better, since most procedures typically address only one of multiple levels of obstruction. Also, most surgeons get really good at doing one or two procedures for each level of obstruction (nose, soft palate, tongue). Two surgeons may get equally good results using completely different operations. Every patient will have different needs at every level of obstruction, and every surgeon will have different options for treating each level.
If you’ve undergone any of the above mentioned procedures, what was your experience? Please enter your comments below.