Treating OSA? Don’t Forget the Tongue

The FTP is a simple, noninvasive way of gathering information about the structure of the palate and the tongue and where obstruction is occurring. With this anatomy-based staging system patients simply open their mouth and the otolaryngologist looks inside.

The positions range from Friedman Tongue Position 1, which is indicative of almost no problems in the tongue base, to Tongue Position 4, where there are severe problems at the tongue base, Dr. Friedman said.

FTP findings are used in conjunction with findings from sleep studies. Both results are needed to determine where the obstruction is and how severe it is, he said. Otolaryngologists need to take three factors into account before they treat OSA: the anatomy, severity, and symptoms.

Treatment Options for Tongue-Based Obstruction

The procedure used depends on the structural problems, Dr. Friedman said. There are five levels of treatment; doctors should start with the least invasive (such as continuous positive airway pressure [CPAP], oral appliances, and even encouraging weight loss), and then progress to more aggressive options, if needed. But physicians should warn patients at the start that they may need more than one procedure.

Even mild cases of OSA need multilevel, minimally invasive techniques. A recent study published by Dr. Friedman and colleagues looked at 135 OSA patients with mild disease. All patients had three-level treatment that included nasal surgery, palatal stiffening by Pillar implant technique, and radiofrequency (RF) volume reduction of the tongue base. Outcomes showed significant improvement in apnea with minimal morbidity, though some may need secondary treatment later on.

Dr. Friedman noted that RF of the tongue base is a safe and well-tolerated treatment, but is not widely used because it is often not covered by insurance companies.

Secondary levels of treatment for more severe disease include RF, and the newer approach of coblation of the tongue base. Coblation shows promise for a greater amount of tissue reduction with lower morbidity because the probe is placed beneath the surface of the tongue, where it disrupts tissue that can then be removed with suction. Research is ongoing with this approach, but I think it will play an important role in tongue-based treatment, Dr. Friedman said.

The third level of treatment is for people whose tongue is not oversized, but falls back and causes obstruction when the patient is supine. A way to treat this is with genioglossus advancement, something Dr. Friedman likens to a muscle sling. In his opinion, this procedure tends to provide only minor improvements for patients. But, for this particular problem, it has comparable results to RF and provides an option.