Introduction

First-line surgical treatment of obstructive sleep apnea (OSA) in both pediatric and adult patients is adenotonsillectomy and has often been uvulopalatopharyngoplasty in adults. When initial medical or surgical treatment of OSA fails to successfully treat the condition, adjunct surgical treatment may be warranted. Lingual tonsillectomy and tongue-base reduction are two of these surgical techniques that can lead to improved outcomes in patients with OSA.

In the pediatric population, adenotonsillectomy seems to be very successful initially. Months to years later, some of these initial successes present with recurrent symptoms. In these cases, lingual tonsillar hypertrophy may be the cause. In obese patients, the risk of lingual hypertrophy of the tonsil appears to be higher after adenotonsillectomy.

Lingual tonsillectomy alone can be very effective in relieving upper airway obstruction when the lingual tonsils are noted to be large and obstructive during drug-induced sleep endoscopy (DISE) or other methods of upper airway assessment. When lingual tonsils are small or absent, but there is still significant tongue-base collapse leading to upper airway obstruction, tongue-base reduction surgery may be beneficial ( Fig. 55.1 ).

Endoscopic view demonstrating hypertrophic lingual tonsil tissue.

Various methods of video-assisted lingual tonsillectomy have been described. One such method is via suspension laryngoscopy with the use of the coblation device. This has proven to be a reliable technique that can be performed without needing any assistants for retraction.

Both procedures aim to improve the retroglossal airway during sleep, which may improve OSA symptoms. Even if OSA is not resolved, these procedures can potentially improve compliance with continuous positive airway pressure (CPAP), leading to reduced pressure settings on CPAP devices.

Key Operative Learning Points: Endoscopic Lingual Tonsillectomy

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  Preoperative airway assessment with DISE is advocated for proper patient selection. Some centers employ CINE MRI when sleep endoscopy is not available.

  
  
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  Lingual tonsillectomy is best considered in patients who have previously had adenotonsillectomy.

  
  
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  While nasal intubation may aid in surgical ease, it is not necessary. The procedure can be performed with oral intubation to facilitate concurrent nasal surgery.

  
  
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  The vallecula should be unobstructed and completely free of lingual tonsil tissue at the completion of the surgery.

  
  
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  The lateral lingual tissue may be more superficially removed to reduce the risk of significant peri- or postoperative bleeding.

  
  
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  This procedure can be performed in both pediatric and adult patients by using the appropriate pediatric and adult-sized laryngoscopes.

Preoperative Period

A comprehensive medical history remains the cornerstone of the preoperative evaluation. Once it has been determined that a patient is intolerant or unable to achieve adequate benefit with standard medical treatments, surgical options should be considered. Physical examination, upper airway endoscopy, and imaging techniques should be used to describe the anatomy of the upper airway and tailor a comprehensive surgical treatment plan. The key to success with these techniques is patient selection, and significant time should be spent with the patient preoperatively to be certain that chances for success are optimized.

Patients considered for second-line surgical treatment should be evaluated for other medical conditions that could lead to sleep disorders. In pediatric patients, CPAP is often not tolerated and, when used long term, it may lead to craniofacial abnormalities. In this population, lingual tonsillectomy may be considered without a trial of CPAP. In adults, surgery would be considered for patients who fail or are intolerant of CPAP or other medical and dental treatments.