As early as 1981, Fujita et al.  recognized that patients with obstructive sleep apnea (OSA) oft en have multiple levels of obstruction. The tongue base and hypopharynx have been found to be the major sites of obstruction in up to 50% of patients . Although uvulopalatopharyngoplasty (UPPP) remains the cornerstone of surgical therapy for OSA, failure to address additional sites of obstruction can signifi cantly limit the eff ectiveness of surgical intervention. In their series, Sher et. al.  demonstrated cure rates with UPPP alone of only 40% in nonselected patients and 5-10% in patients with type II/III airway collapse. Riley et. al.  concluded that the tongue base was the cause of persistent obstruction in patients who failed UPPP. Many techniques have been developed to address obstruction in the hypopharynx and tongue base and include midline glossectomy, lingualplasty, radiofrequency tongue ablation, hyoid suspension, mandibular osteotomy with genioglossus advancement, and maxillary-mandibular advancement. Many of these treatments are associated with signifi cant morbidity, including mental nerve anesthesia, dental trauma, and the potential to change the facial appearance. Most recently, a minimally invasive tongue-base suture suspension procedure has been developed and has been shown in many series to be a safe and effective means of addressing obstruction at this level. This technique utilizes a submucosal suture that is anchored to the genial tubercle to prevent the tongue from occluding the pharynx when muscle activity is reduced during sleep. DeRowe et. al.  conducted a phase 1 study including 16 patients with a respiratory disturbance index (RDI) between 12.5 and 70 who underwent isolated tongue-base suspension. Data was collected retrospectively with preoperative and postoperative comparisons. Two patients required suture removal for complications and were excluded from the analysis. The RDI improved from 35+16.5 to 17+8 (a 51.4% reduction, p=0.001). Although a validated questionnaire was not used, the remaining 14 patients all noted improvement in snoring. Thomas et. al.  examined 17 patients with severe OSA and Fujita type II collapse in a prospectively enrolled, randomized crossover trial examining genioglossus advancement and Repose (Infl u-ENT Medical, Concord, NH, USA) tongue suspension. Patients were over 21 years of age and exhibited moderate OSA with failure of conservative therapy. Retropalatal and retrolingual collapse was demonstrated by Müller maneuvers. Patients underwent UPPP with either genioglossus advancement or Repose tongue suspension. Nine patients underwent Repose tongue suspension with Epworth scores decreasing from 12.1+7.2 to 4.1+3.4 (p=0.007). The RDI improved from 35+16.5 to 17+8 (51.4% reduction) (p=0.001). Airway collapse as measured by Müller's maneuver improved by 64% at the palate and 83% at the tongue base (p=0.0006 and 0.0003, respectively). In four of nine patients, snoring questionnaire scores fell from 9.3+1.0 to 3.3+2.1 (p=0.02). Seven of the nine patients had postoperative sleep studies, and a surgical response was achieved in four of them (57%). In the tongue-advancement group, Epworth scores fell from 13.3+4.5 to 5.0+3.5 (p=0.002). Airway collapse improved by 31% at the palate and 75% at the tongue base (p=0.1 and 0.03, respectively). In four of eight patients, snoring questionnaire scores went from 9.3+1.0 to 5.0+0.6 (p=0.04). Four patients underwent postoperative polysomnography, two of whom achieved a surgical response (50%). It was concluded that Repose tongue suspension was slightly more eff ective in improving daytime somnolence and snoring. Woodson  investigated polysomnographic and subjective outcomes 2 months following Repose tongue suspension in 43 patients. The study included snorers with an apnea-hypopnea index (AHI) below 15 and OSA patients with AHI > 15 who demonstrated tongue-base obstruction on Müller's maneuver. Patients were excluded for AHI > 60, average desaturation less than 80%, and body mass index above 34. The RDI improved from 35.4+13.7 to 24.5+14.5 in the OSA group (p=0.009), however only a small number were defi nitively treated. There was signifi cant improvement in OSA symptoms but no signifi cant difference in snoring. Miller et. al.  performed a retrospective analysis of 19 patients who underwent UPPP with Repose tongue suspension. The RDI declined from 38.7+12.3 to 21.0+7.4 (46%) (p<0.05) with a surgical cure rate of 20%. Kühnel et. al.  performed a study of 28 male patients with sleep-disordered breathing. The RDI improved from 41 to 38 at 3 months and to 31 at 12 months aft er surgery. Epworth scores improved from 12 to 9 at 3 months and to 9 at 12 months aft er surgery. In nine cases, Epworth scores were worse after 1 year. Endoscopy fi ndings did not reveal a signifi cant diff erence between preoperative and postoperative data. Lateral cephalometric analysis was performed to evaluate changes of the posterior air airway space (PAS), defi ned as the distance between the tongue base and the posterior wall of the pharynx at the level of the line connecting the supramental point and gonion. The PAS increased from 10.6+3.5 to 12+3.8 (p=0.0056) for a diff erence of 2 mm. However, when patients in whom the uvula constituted the rostral boundary of the PAS were excluded, the difference was reduced to only 1.3 mm. It was concluded that a marked improvement in symptoms could be achieved in some patients who do not respond to conservative therapy.
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