1 INTRODUCTION

2 PATIENT SELECTION

Patients diagnosed with obstructive sleep apnea in whom the preoperative evaluation confirms or suggests tongue base collapse as the cause of the hypopharyngeal obstruction are candidates for RF. Patients need to be in stable medical condition, understand that the procedure may be a multiple stage process, and appreciate the potential complications. Patients with preoperative complaints of dysphagia or dysarthria should undergo a modified barium swallow and/or a speech therapy evaluation prior to considering these therapeutic options, so as not to exacerbate these complaints post treatment. Those patients with underlying diabetes mellitus should be counseled regarding the increased risk of tongue abscess formation.

Two treatment approaches exist: (1) performing RF alone; (2) performing RF with other base of tongue procedures, such as genioglossus advancement, hyoid suspension or repose procedure.

3 OUTLINE OF PROCEDURE: TONGUE BASE RADIOFREQUENCY

The technique can be performed as an outpatient or as an inpatient. Depending on the severity of the patient’s sleep-disordered breathing, post-treatment airway monitoring and/or protection with nasal continuous positive airway pressure (CPAP) or a tracheotomy may be considered.

First, the oral cavity is prepped by the patient gargling with approximately 30 ml of 0.12% oral chlorhexidine (Peridex). Oral or parenteral cephalexin is administered prior to placing the electrode. If under local anesthesia, the tongue may be sprayed with 20% benzocaine as a topical anesthetic. In addition, a local anesthetic as a gel (2% lidocaine) may be placed on a sterile cotton tipped applicator at the tongue injection sites. A 25-gauge needle injects 5.0 ml of local anesthesia such as 0.25% bupivacaine (Marcaine) with 1:200,000 epinephrine into each site. A different sterile needle is used at each site of injection. Lingual nerve blocks may be used, but are not necessary. The author does not inject saline into the treatment area. There is an increased risk of infection with each additional injection at the lesion site by bringing potential superficial tongue debris and bacteria into the area to be ablated.

Currently, a dual 22-gauge RF needle electrode with a10 mm active length and a 10 mm protective sheath in a custom-fabricated device allows placement of the electrode under the superficial tongue musculature in the area selected for treatment. Potential sites of treatment include the midline and paramedian dorsal base of tongue areas and the anterior ventral tongue areas (Figs 40.1 and 40.2). Treatment sites should be spaced a minimum of 1.5 cm apart if a single needle probe is used or at least 2.5 cm using the dual needle probe device (Fig. 40.3). Continual pressure on the electrode and visualization that the insulation sheath is not retracting out of the tongue tissue reduce the risk of superficial tissue injury. Using the most current Gyrus radio frequency generator machines and a dual probe at 85°C, 600 joules (J) of rapid energy radiofrequency is delivered to two base of tongue sites with a total of 1200 J delivered. Treatment sessions may be repeated every 4–6 weeks.

Fig. 40.1 Tongue cross-sectional view. Note that the probe should be seated firmly against the dorsal tongue tissue to prevent withdrawal of the probe and injury to the superficial tissue. Also, the hypoglossal neurovascular bundle is located approximately 2.0–2.5 cm deep from the dorsum and should be safe from injury if the probe is placed no more lateral than the paramedian position.

Fig. 40.2 Tongue dorsum view. Note the position of the probe is at the midline or paramedian position of the dorsal tongue. The probe can be placed at the base of tongue, middle tongue area or ventral surface of the tongue to achieve tongue reduction.

Fig. 40.3 Tongue radiofrequency handpiece – double or dual probe. Each probe has a 1 cm distal active tip and a 1 cm proximal insulated component.

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