Obstructive sleep apnea (OSA) is characterized by repeated episodes of obstructive apnea and hypopnea during sleep. Clinically significant OSA has been reported to affect 14% of middle-aged adults in the United States and 49% in Europe, contributing to increased cardiovascular risk and mortality [1]. Continuous positive airway pressure (CPAP) remains the gold standard and first-line treatment for OSA patients. However, challenges with patient compliance often lead to treatment failure [2]. For patients who fail CPAP treatment, multidimensional surgery, including soft tissue and skeletal interventions, provides an alternative [3].

OSA is a multifactorial disease that commonly affects the velopharynx, oropharyngeal lateral wall, tongue, and epiglottis [3]. Treatment for velopharyngeal obstruction, the most common type of obstruction, typically yields good results for OSA patients [3]. In contrast, tongue collapse is more difficult to identify and treat, leading to inconsistent outcomes [4]. Surgical management of tongue obstruction involves reducing the volume and suspending the tongue base, but such procedures carry a high risk of complications [4,5], including adverse respiratory events from an enlarged hypopharyngeal space and risks associated with mandible osteotomy, such as hematoma, infection, and injury to the lower teeth.

To address these concerns, we developed minimally invasive advancements in tongue suspension suture techniques, designed to stabilize the tongue base. This technique is safe, efficient, and time-saving.

A 28-year-old female patient presented to our otorhinolaryngology clinic with snoring and sleep apnea. Her tonsil size was II/II and her body mass index (BMI) was 30.94 kg/m². Polysomnography revealed an apnea-hypopnea index of 69.9 and a lowest O₂ saturation of 84%. The Epworth Sleepiness Scale score was 3. Although CPAP treatment was initially recommended, the patient declined due to difficulty keeping the mask on her face. Consequently, we planned surgical intervention. A nasopharyngeal endoscopy revealed narrowing of the uvula and tonsils, suggesting partial obstruction at the uvular, tonsillar, and tongue levels (Fig. 4) [7]. We performed a uvulopalatopharyngoplasty and tongue base traction using the advancements in tongue suspension suture techniques. The patient reported subjective improvements in sleep and quality of life at both the 1- and 3-month postoperative follow-up visits, with no adverse events.

Tongue surgery poses a significant challenge in patients with OSA and tongue obstruction. This study introduces a novel technique—advancements in tongue suspension suture techniques—aimed at addressing tongue obstruction in OSA patients. The results showed improvements in daytime sleepiness and minimal swallowing-related morbidities.

Various surgical options exist for OSA patients with tongue obstruction, including hypertrophic lingual tonsil resection, radiofrequency, coblation for tongue volume reduction and genioglossus advancement. However, the success rate ranges widely from 40%-70% [8].

Additionally, mandible osteotomy of these procedures vary, and mandible osteotomy can carry risks such as infection and injury to the lower teeth. A minimally invasive tongue base suspension technique is therefore essential.

A tongue base surgery kit [9] has previously been introduced, with a specially designed screw to stabilize the suture over the inner lower gum. Additionally, Medtronic acquired the Repose system (Repose Surgical Kit, CKA Air Vance; Medtronic, Inc.), with which the suspension suture is inserted through a submental incision. However, these techniques have involved the bone. Therefore, inspired by rejuvenation surgery, we developed the advancements in tongue suspension suture techniques, with which the tongue is suspended using a PDO thread with a unique spur directed to the opposite side of a cone. Moreover, the PDO spur contracts in the soft tissue, including the genioglossus muscle. When tightened, the suture supports the anterior hypopharyngeal airway and tongue base, preventing obstruction. In our study, tightness of the suspension was determined by digitally feeling tightness at the tongue base, where an indentation could be felt. Overcorrection was avoided to prevent tissue strangulation, pain, and swelling [6]. Consequently, the volume of the tongue decreases over time.

This novel technique has several advantages. First, given that there is no external scar, our technique has superior cosmetic outcomes, which is becoming increasingly important when comparing new techniques with the conventional tongue base surgery. Second, the tongue suspension suture technique does not require ties or screws. With the Repose system, a screw is pierced into the mandible, which increases the potential for infection and foreign body sensation, both of which can be avoided with our technique. Third, our technique is minimally invasive, while previous interventions for treating patients who have OSA with tongue obstruction have involved excisions. Therefore, severe complications such as hematoma, dysphagia, odynophagia, dysarthria, edema, lingual atrophy, hypoesthesia of the tongue, reduced flexibility, and airway obstruction can be avoided postoperatively. In our study, none of the patients had major perioperative complications, nor alterations in taste, or speech in the follow-up after one month. Fourth, our advancements in tongue suspension suture techniques can be combined with the classical uvulopalatopharyngoplasty. Vicente [10] noted that the best response to tongue base surgery with uvulopalatopharyngoplasty was obtained in patients with a BMI <35 kg/m2. And we did combined approach both uvulopalatopharyngoplasty and tongue suspension. The method of combining tongue suspension to stabilize the tongue and volume reduction to widen the hypopharyngeal space together for a synergetic effect could be an alternative treatment option [9]. Fifth, this procedure requires a short time to perform since no bone needs to be tied due to the presence of the cone, and only 3-4 seconds are needed to place the cone. Sixth, the direction of contraction can easily be changed owing to the cone, allowing for more flexibility during surgery. Moreover, no special skills are required; any ENT doctor can easily perform this surgery and it can be collocated with other OSA surgeries.

However, one potential concern is that our PDO thread is an absorbent material, and we do not know how much pulled tissue remains after absorption. And also fibrosis around the suture may theoretically reduce a loss of tension, the actual effects of suture migration or suture breakage are unknown [11]. Our patient exhibited marked improvement in symptoms on short-term follow-up; however, long-term follow-up is necessary to confirm our surgical results.

In conclusion, our advancements in tongue suspension suture techniques provide a promising option for improving tongue base obstruction in OSA patients. Based on our findings, this technique is safe, efficient, and simple to perform.