Issue link: https://viewer.e-digitaledition.com/i/55875
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ + + ++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: MINIMALLY INVASIVE PROCEDURES +++ +++ TransOral By Aaron I. Brescia, MD T ONGUE BASE SURGERY has historically presented otolar- yngologic surgeons with many challenges. Its effectiveness has been limited by a confined opera- tive field that's 90 degrees from the entry point into throat, as well as lighting and visualization drawbacks of endoscopic instruments. However, in 2009, the U.S. Food and Drug Administration (FDA) approved for sleep apnea the use of transoral robotic surgery (TORS) to remove tumors of the mouth, voice box, tonsil, tongue and other parts of the throat. This minimally invasive technique, developed by University of Pennsylvania School of Medicine's Department of Otorhinolaryngology — Head and Neck Surgery, provides surgeons with exceptional dexterity and accuracy, as well as superior imaging with three- dimensional depth perception. TORS has significantly improved the treat- ment of certain types of head and neck cancer and more recently, thanks to another FDA approval, has expanded treatment options for obstructive sleep apnea (OSA). OSA affects millions of adults and, when left untreated, contributes to lost productivity, sleep deprivation, weight gain and many other related conditions. Non-surgical treatment, which usually focuses on the use of a continuous positive airway pressure (CPAP) device, should always be employed first. However, the CPAP compliance rate is only about 50 to 60 percent, leaving a large population with OSA untreated. Many cannot and will not wear the CPAP mask, often because of discomfort associated with high levels of constant prescribed air pressure. That is the point at which surgical interventions are indicated. Unfortunately, adult OSA is nor- mally very complex and, traditionally, we've seen only marginal success with surgery, mainly because not all levels of obstruction are addressed. Causative factors vary from patient to patient and center on three anatomical areas: the nose, the soft palate and tonsils, and the base of the tongue — the most difficult to manage. Procedures commonly used to treat the first two areas include septoplasty, uvulopalato- pharyngoplasty (UPPP) and the Pillar Procedure. They are effective perhaps 50% of the time. For the tongue, on the other hand, techniques like tongue advancement and tongue base reduc- tion, though not new, have always been very difficult. What TORS provides is unprecedented access to the base of the tongue. In recent years, when the advan- tages of robot-assisted surgery have been highlighted — as in the case of gynecological surgery — there is much discussion about smaller incisions, reduced pain and faster recovery. With TORS, the benef its revolve 32 | Cleveland-Akron-Canton MD NEWS n MDNEWS.COM n MARCH-APRIL 2012 ROBOTIC SURGERY (TORS) around accessibility, meaningful and unparalleled tissue volume reduction and, certainly, fewer potential com- plications. The ensuing healing and scarring process, which tightens the back of the tongue, is not significantly different from traditional surgery. It's early to say what level of success TORS will achieve overall in reducing OSA symptoms in qualified patients, as statistically relevant numbers do not yet exist. And, for some, adjustment of the tongue base robotically is only the first step. A palate or nose procedure may still be required. During patient consultation, it's important for a physician to set indi- vidual patient goals and never promise a cure. Often, an excellent goal with TORS is to reduce CPAP air pressure requirements. Making the CPAP more tolerable — such as reducing the pres- sure from 20 to 10 — can lead to higher rates of patient compliance. Dr. Aaron Brescia is board-certified in otolaryngology — head and neck surgery and a member of the American Academy of Otolaryngology Head and Neck Surgery. He is a partner at Ohio Head and Neck Surgeons in Canton, and a staff member at Mercy Medical Center. Recently Dr. Brescia completed training at the University of Pennsylvania School of Medicine's Department of Otorhinolaryngology — Head and Neck. He is currently the only surgeon in Stark County performing TORS. ■