Tongue Base and Hypopharyngeal Surgery for Obstructive Sleep Apnea

Tongue base and hypopharyngeal obstruction are common sites of residual collapse in patients with OSA who are intolerant of CPAP or who have failed palatal surgery. This chapter describes four minimally invasive surgical approaches to the tongue base and hypopharynx, guided by drug-induced sleep endoscopy (DISE) using the VOTE classification framework. Coblation channeling ablation of the tongue (CCT) employs low-temperature plasma-mediated radiofrequency energy to create submucosal ablation channels within the tongue base, inducing fibrotic stiffening and volumetric reduction with minimal mucosal trauma. Endoscopic coblation-assisted tongue-base resection extends this principle under direct endoscopic visualization, enabling systematic debulking of lingual tonsillar hypertrophy and posterior tongue tissue while preserving critical neurovascular structures. Submucosal minimally invasive lingual excision (SMILE) achieves greater volumetric reduction through a small anterior midline incision, creating a submucosal tunnel within an anatomically defined safe corridor medial to the hypoglossal-lingual neurovascular bundle. Transoral robotic surgery (TORS) using the da Vinci Xi platform provides three-dimensional magnified visualization and wristed instrument articulation, enabling precise bilateral lingual tonsillectomy, tongue-base debulking, and partial epiglottidectomy in appropriately selected patients. Across all techniques, patient selection, anatomical phenotyping, and meticulous attention to neurovascular safety margins are essential. Complications including hemorrhage, airway edema, dysphagia, and taste disturbance are generally transient and manageable with structured perioperative protocols. These procedures are most effective as components of individualized, multilevel surgical strategies for OSA.