As we trace the advancements of obstructive sleep apnea (OSA) surgery, it is important to realize that tongue base surgery has remained a challenge. Traditional hypopharyngeal/tongue base procedures for OSA are usually aggressive, time consuming, and technically advanced. Some previously reported cases even needed temporary postoperative tracheotomy. Kezirian et al. reported on the types of surgeries performed for OSA in four US states. They found that only 18.6% of the enrolled 35,263 OSA surgeries involved hypopharyngeal surgery.

Tracheotomy was the first surgical treatment for OSA. It can shunt the entire upper airway and is effective; however, the majority of the patients and physicians do not accept it as a permanent treatment for OSA. Traditional tongue base surgeries such as midline laser glossectomy, transcervical tongue base reduction with hyoepiglottoplasty, tongue base suspension, genioglossus advancement, and hyoid suspension are effective to a certain degree. These traditional procedures are invasive and often associated with complications, including edema, infection, bleeding, lingual paralysis, and persistent odynophagia.

The use of Coblation technology (plasma-mediated radiofrequency), which provides relatively low temperature (40°–70°C) and minimal thermal injury to the target lesion and surrounding tissues, is an alternative approach to treatment of the tongue. A procedure called submucosal minimally invasive lingual excision (SMILE) with Coblator was developed in an effort to maximize tongue base reduction using a minimally invasive technique. Maturo and Mair initially presented the anatomic dissection of fresh cadavers and a representative case series of children who underwent SMILE under intraoral ultrasonic and endoscopic guidance. In our prior study, we compared the efficacy, morbidity, and complications of the SMILE technique to radiofrequency reduction of the tongue base in adults with OSA. Although the effects of SMILE have shown promise, the SMILE technique is still difficult for the majority of ear, nose, and throat surgeons. SMILE also resulted in relatively high morbidity, such as damage to the lingual artery and hypoglossal nerve and significant postoperative edema. To minimize the risk of trauma and edema and to reduce morbidity, Woodson used Coblation technique for open tongue base resection under the assistance of direct laryngoscope. However, the operation view was still limited for the target lesion via the direct laryngoscope.

We further utilized the transoral endoscopic Coblator open tongue base resection (Eco-TBR) to treat hypopharyngeal collapse in OSA patients. Our results demonstrated that transoral Eco-TBR resulted in short-term morbidity; however, there were no serious long-term complications. We reached reasonable surgical outcomes and proved the safety of this procedure.