Friedman M et al. Otolaryngology-Head and Neck Surgery 2008;139:378-384

I have included this study in part to introduce a new and interesting surgical technique for treating sleep apnea where the tongue is playing a major role (called SMILE) and to demonstrate the safety of standard techniques addressing the base of tongue called Radiofrequency Tongue Base Reduction.  Other studies show a complication rate of 2 to 3% using standard radiofrequency techniques.  This shows similar results.

My take:

This is a very interesting approach for severe cases with a large base of tongue and has many theoretical advantages.  At this point, the complication rate is too high for me to recommend except perhaps in rare circumstance.  I am confident (especially considering the primary author) this technique and the device will be refined and the complication rates will improve and I will keep watching what Dr. Friedman and his group is doing in Chicago.  For now, I am more comfortable with the standard radiofrequency techniques accepting the fact that there may be the need for more than one procedure. 

Summary:

This article, published by one of the best known surgeons of sleep medicine, discusses a new way to treat base of tongue in sleep apnea.  The base of tongue has always been the most difficult site to address with soft tissue techniques (without splitting the jaw). 

This study compares two techniques with 48 patients in each group.  In the first technique, a radiofrequency probe was inserted into 10 sites in the base of tongue.  The probe used was Somnoplasty which is slightly different than the Coblation probes used in my clinic.  This technique has been used for years to reduce the base of tongue. 

The second technique is called SMILE (submucosal minimally invasive lingual excision) uses a much larger probe and results in more tongue tissue being removed.  The blood flow to the tongue (lingual arteries) was first identified and marked using ultrasound.  Local anesthetic was than injected and a small incision was placed in the midline of the tongue.  A coblation wand was introduced through the incision and advanced into the base of tongue.  Tissue was removed using an ablation setting and staying within 1cm of midline and away from the lingual arteries.  The incision was than left open to drain. 

The new technique was developed because of the limited improvement that can be obtained through standard radiofrequency reduction of the base of tongue.  The goal was to allow more removal of tissue without increasing complications. 

Results:

When looking at the sleep studies and symptoms, there was no significant difference between groups.  When looking for ‘surgical success’ (which was defined as a 50% reduction in AHI and a final AHI less than 20), the SMILE procedure was better. 

The SMILE procedure showed a 65% success rate versus a 42% success using radiofrequency techniques.  The difference was even greater if patients with severe sleep apnea and a large tongue (Friedman Tongue Position Score greater than 3). 

Complications:

Pain

The radiofrequency group needed narcotic pain medications for an average of 2.4 days and required an average of 2.9 days to resume normal diet.

The SMILE group needed narcotic pain medications for an average of 3.6 days and required an average of 4.9 days to resume normal diet.

Bleeding

In the standard radiofrequency group there was no significant bleeding. 

In the SMILE group there was 2 cases (4%) with bleeding that could not be controlled with pressure.  One case required the initial incision be enlarged and standard bipolar cautery used under direct vision to cauterize a vessel.  The second case required an incision in the neck to identify the lingual artery to control bleeding.

Hypoglossal Nerve Injury (the nerve that makes your tongue move)

One patient (2%) in the radiofrequency group had a nerve paralysis that resolved within one month.

Four patients (8%) in the SMILE group had a nerve paralysis.  Three resolved within 2 months, one was permanent. 

There were no cases of bilateral nerve paralysis in either group.

Airway Complications

There were no significant airway problems in either group.

Edema (Swelling)

None of the radiofrequency patients had significant swelling.

Six patients (12%) in the SMILE group had swelling that interfered with tongue motion, swallowing, or speech.  These were treated with steroids and resolved within 3 days although patients had to remain in hospital for this time.