Taste Disturbance Following Tongue Base Resection for OSA

Transcription

1 The Laryngoscope VC 2015 The American Laryngological, Rhinological and Otological Society, Inc. Taste Disturbance Following Tongue Base Resection for OSA Hsin-Ching Lin, MD, FACS; Michelle S. Hwang, BS; Chang-Chuan Liao, MD; Michael Friedman, MD, FACS Objectives/Hypothesis: To investigate taste disturbance (TD) following endoscopic coblator open tongue base resection (Eco-TBR) for the treatment of obstructive sleep apnea (OSA) hypopnea syndrome. Study Design: A retrospective study in a tertiary academic medical center. Methods: Eighty patients with OSA who failed continuous positive airway pressure therapy and underwent Eco-TBR for the tongue base obstruction were enrolled in this study. Taste changes and complications were examined before and after surgery. The standard three-drop-method gustatory function test was used to study taste status preoperatively and at 7 days, 1 month, and 3 months postoperatively. Results: Six female and 74 male patients with OSA (mean age, 42.6 years; mean apnea hypopnea index, 48.9/hour) had a minimum follow-up of 3 months and complete data available for analysis. One patient had postoperative oral bleeding. No long-term obvious dysphagia was encountered. Twelve patients had obvious TD in the four basic tastes (sweet, sour, salty, and bitter). At 3 months postoperative time, eight patients still had changes in taste sensation; however, the TD severity decreased and did not impact the patients regular social life. The percentage of taste changes by time after Eco-TBR was between 13.8% and 17.5%. Conclusion: This study shows Eco-TBR may contribute to postoperative TD. The surgeons should clearly inform the OSA patient about the possibility of TDs after tongue base resection. Key Words: Sleep apnea, obstructive sleep apnea/hypopnea syndrome, snoring, taste, tongue base surgery. Level of Evidence: 4. Laryngoscope, 126: , 2016 From the Department of Otolaryngology (H-C.L., C-C.L.), The Sleep Center (H-C.L.), Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan; the Department of Otolaryngology Advanced Center for Specialty Care, Advocate Illinois Masonic Medical Center (M.S.H., M.F.); and the Department of Otolaryngology Head and Neck Surgery, Division of Sleep Surgery, Rush University Medical Center (M.F.), Chicago, Illinois, U.S.A. Editor s Note: This Manuscript was accepted for publication July 27, Presented in part as an oral presentation at the 2014 Annual Meeting of the American Academy of Otolaryngology Head and Neck Surgery Foundation and OTO Expo, Orlando, Florida, September 21 24, This study was sponsored in its entirety by the principal investigator (H-C.L.). M.F. received a research grant from ImThera Medical, Inc., San Diego, CA. The authors have no other funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Hsin-Ching Lin, MD, Department of Otolaryngology, Sleep Center, Kaohsiung Chang Gung Memorial Hospital, 123, Ta-Pei Rd., Niao-Sung District, Kaohsiung City, 833, Taiwan. enthclin@aol.com DOI: /lary INTRODUCTION Looking back on the advancements of obstructive sleep apnea (OSA) surgery, tongue base surgery has always been a challenge. Traditionally, hypopharyngeal/ tongue base procedures for OSA are usually aggressive and more technically challenging. In 2010, Kezirian et al. 1 reported on the types of surgeries performed for OSA in four U.S. states. They found that only 18.6% of the enrolled 35,263 OSA surgeries involved hypopharyngeal surgery. Traditional tongue base surgeries such as midline laser glossectomy, tongue base suspension, genioglossus advancement, and hyoid suspension are effective only to a certain degree. These traditional procedures are intrusive and often associated with complications, including edema, infection, bleeding, lingual paralysis, and persistent odynophagia. 2 6 With the use of coblation technology, which provides relatively low temperature and thermal injury to the target lesion and surrounding tissues, an alternative approach called submucosal minimally invasive lingual excision (SMILE) with coblator was developed in an effort to maximize tongue base reduction using a minimally invasive technique. 7 In our prior study, 8 we compared the efficacy, morbidity, and complications of the SMILE technique to radiofrequency reduction of the tongue base in adults with OSA. Although the effects of SMILE have been promising, the SMILE technique is still difficult for the majority of ear, nose, and throat surgeons. To minimize the risk of trauma and edema and to reduce morbidity, Woodson initially used coblation technique for open tongue base resection with the assistance of direct laryngoscope. 9 We further utilized the endoscopic coblator open tongue base resection (Eco-TBR) to treat hypopharyngeal collapse in severe OSA patients. Our results demonstrated that transoral Eco-TBR combined with modified uvulopalatopharyngoplasty resulted in short term morbidity; however, there were no serious complications. We reached reasonable surgical outcomes and proved the safety of this procedure. 10 Our experience has been encouraging overall, and this procedure 1009

2 has become our surgical treatment of choice for OSA patients. The value of a surgical procedure must take into consideration any possible complications and side effects. The tongue is essential for tasting. Taste or gustatory dysfunctions are implicated in loss of appetite, unintended weight loss, and malnutrition. Tasting difficulties can induce psychological distress and compromise social activities and quality of life. 11 The purpose of the study was to investigate taste disturbances (TDs) following transoral Eco-TBR. MATERIALS AND METHODS This is a retrospective study of a prospective group of patients. Institutional review board approval was obtained from the Chang Gung Medical Foundation Institutional Review Board to review the clinical data. Gustatory Function Test A standard three-drop-method gustatory test examination was performed in this study. 15,16 The four basic tastes (sweet, sour, salty, and bitter) were used to identify the possibility of taste loss. The concentrations and contents of test solutions were as follows: sweet, 0.4 g/ml sucrose; sour, g/ml citric acid; salty, 0.25 g/ml sodium chloride; and bitter, g/ml quinine-hydrochloride. The taste solutions were prepared immediately at the beginning of this assessment. The process of identifying a taste sensation involved three separate trials of administering three drops of test solutions on the middle of the tongue using a 10-lL pipette. Test solutions were conducted randomly in these trials. One trial was for the administration of the real taste solution, whereas two trials were for the administration of a placebo (distilled water). Each subject kept the mouth open for 15 seconds, tasted, and then swallowed the solution. They were then asked to describe the nature(s) of the taste. Distilled water was used to rinse the oral cavity after each test. The time required for completion of this test was approximately 10 minutes. Subjects Charts of 80 patients with OSA at the Sleep Center of the Kaohsiung Chang Gung Memorial Hospital, Taiwan, who diagnosed with a full-night polysomnography, failed or refused continuous positive airway pressure (CPAP) therapy or oral appliance, and then underwent surgical treatment of modified uvulopalatopharyngoplasty combined with transoral Eco-TBR were reviewed. All surgeries were performed by the first author (H-C.L.) under general anesthesia. The surgical techniques used are as our previous literature. 10,12 More specifically, the Eco-TBR was performed with Coblator II Surgical System (EVac 70 Xtra Plasma Wand; Arthocare Corp, Sunnydale, CA) with the assistance of transoral 70-degree rigid sinus endoscope. The malleable coblator wand was gently bent according to the depth of the tongue base obstruction. The retention suture with 4-0 silk with taper needle was settled down 1.5-cm anterior to the circumvallate papillae to increase the operation space of the obstructed tongue base region. Under the endoscopic guidance, the tongue base was ablated from approximately the foramen cecum to the tip of the epiglottis. The lateral border is ablated to no closer than 0.5 cm of the lateral oropharyngeal wall. The ablated depth was estimated 1.5 cm to 2 cm. After complete hemostasis with coblator, the ablated area was left open without any suture. Inclusion criteria for the present study included: 1. Age 20 years old 2. Significant symptoms of habitual snoring and/or excessive daytime somnolence 3. No previous upper airway surgical treatment for OSA 4. Failure or refusal of conservative treatments, such as oral appliances or CPAP 5. Level and severity of upper airway obstructions identified by Mueller s maneuver on endoscopy and Propofol-induced sleep endoscope 6. Surgical techniques based on findings of the examination of Friedman s OSA staging system 13,14 and the airway endoscopy We excluded patients with obvious gustatory dysfunction preoperatively, previous tongue surgery, middle ear surgery, sinonasal surgery, head injury, or a history of severe upper respiratory tract infection during the period of this study. Data Collection Patients received a thorough interview and a GFT before surgery and at week 1, month 1, and month 3 after surgery. The subjective symptoms of ageusia, hypogeusia, hypergeusia, dysgeusia, and phantogeusia were recorded. During the followup, if the patient had any noticeable TD, they were asked to report the severity of the change compared with the preoperative status. Complications occurring within the immediate postoperative period and during the following period were also recorded. RESULTS This population consisted of six females and 74 males with a mean age of 42.6 years. The means of Epworth Sleepiness Scale, body mass index (kg/m 2 ), and apnea hypopnea index (/hr.) were 10.5, 27.1 and 48.9, respectively. There were no perioperative complications or cases of immediate postoperative airway obstruction in this study. One patient had delayed bleeding from an opened tongue base wound 7 days postoperatively and was rehospitalized for conservative treatment. None of the other patients had abscess formation in the tongue base or active bleeding that required surgical intervention. No cases of hypoglossal nerve injury, permanent severe velopharyngeal insufficiency, or dysphagia were encountered in this study. The gustatory changes of these enrolled patients after OSA surgery by time are shown in Figures 1 and 2. The percentage of TD at 1 week, 1 month, and 3 months was 17.5% (14 patients), 13.8% (11 patients), and 15.0% (12 patients), respectively. Sixty-nine patients were followed up to 6 months postoperatively, and nine of these patients (13.04%) had detected with TD at that time. One patient developed delay-onset TD on salty disturbance after 3 months. Additionally, two patients experienced delay-onset changes on all tastes 3 months after surgery. We found that if all kinds of TD occurred, the recovery status may be unfavorable. Extended follow-up found that one patient returned to normal taste 1 year after surgery. The patients reported that there was no 1010

3 Fig. 1. The percentage of taste changes by time after surgery (n 5 80). There were 69 patients who had extended follow-up for more than 6 months. POM1 5 postoperative month 1; POM3 5 postoperative month 3; POM6 5 postoperative month 6; POW 1 5 postoperative week 1. serious impact of taste change after Eco-TBR on their daily social activities. DISCUSSION There have been several reports on gustatory dysfunction following otolaryngological surgery (e.g., palatal surgery, tonsillectomy, microlaryngoscopy, and otologic surgery) To the best of our knowledge, there has been only one study that reported the change of gustatory function in tongue base surgery for OSA. Eun et al. 20 studied 25 OSA patients who underwent uvulopalatopharyngoplasty with radiofrequency tongue base reduction (RF-TBR). They demonstrated that gustatory function remained unchanged after RF-TBR in their short-term follow-up of 4 weeks. However, the disadvantage of this minimally invasive tongue base procedure, radiofrequency, is that it frequently needs to be repeated due to limited tissue volume reduction. In the present Fig. 2. Individual taste disturbance by time. No impact on sour and bitter was noticed. Eco-TBR 5 endoscopic coblator open tongue base resection; POM1 5 postoperative month 1; POM3 5 postoperative month 3; POM6 5 postoperative month 6; POW 1 5 postoperative week 1. study, we performed the more aggressive tongue base resection with coblator. Our previous study demonstrated that Eco-TBR for the treatment of OSA patient was safe and promising. 8,10 The clinical assessment of gustatory function with psychophysical and objective testing is still in its infancy. There is no gold standard test for gustatory function. Among various gustatory function tests (the three-drop method, taste strips, electrogustometry, and spatial taste test), the three-drop method using four main flavors (sweet, salty, sour, and bitter) has been widely used to examine basic tastes due to its clinical convenience and good test retest reliability. 16 In this study, we applied the three-drop method to examine the taste changes at week 1, month 1, and month 3 after surgery. We noted that Eco-TBR may induce the likelihood of TD postoperatively, the incidence of TD was 13% to 17% in our follow-up period. The causes of gustatory dysfunction after Eco-TBR for OSA may include direct injury to taste buds, damage to taste sensory nerve branches, excessive excision of taste receptors on the tongue base, postinflammatory process during wound healing, or mechanical pressure to the tongue base by the suspension suture. Because the majority of OSA patients had multilevel airway obstruction, the reasonable treatment should be a multilevel approach. Eco-TBR was usually applied to the patients with moderate/severe OSA; thus, the patients also had the oropharyngeal obstruction. We performed the Z-palatopharyngoplasty (ZPPP) for palatal collapse in this study. Previous literature documented that the incidence of postoperative gustatory dysfunction after tonsillectomy or palatopharyngeal surgery was 4.6% to 10%. 16,17,19 It could be caused by direct or indirect injury to the lingual branch of the glossopharyngeal nerve, compression of the tongue with a retractor during operation, post-inflammatory process during wound healing, postoperative pain with consecutive nutritional changes, or psychological constitution of the patient. 21,22 However, Badia et al. reported that there was no significant change in the patients perception of smell and taste or in their objective measurement following a uvulopalatoplasty. 23 Furthermore, some patients had tonsillectomy as part of the ZPPP procedure. Injury to taste via cranial nerve IX has been reported with tonsillectomy and must be considered a possible factor that can contribute to TD. To eliminate the impact of TD from the modified palatopharyngeal surgeries, we performed GFT as the following process: One trial was for the administration of the real taste solution, whereas two trials were for the administration of a placebo (distilled water). Subjects were asked to keep their mouths open for 15 seconds, taste, and then swallow the solution. However, this potential cofactor on TD in the study should still be considered. Further study on the issues of TD with only Eco-TBR to clarify the concern is warranted. Gustatory dysfunctions are classified as quantitative or qualitative disorders. Quantitative taste dysfunctions include ageusia, hypogeusia, and hypergeusia, whereas qualitative dysfunctions are dysgeusia and 1011

4 phantogeusia. In this study, patients with TD reported symptoms of ageusia and hypogeusia. The patients with TD after Eco-TBR in this study gradually recovered their taste function over time and self-reported that the taste changes did not have the obvious impact on their daily life. However, quality of life was not quantitatively or qualitatively assessed in this study. After the conclusion of this study, in our unpublished data we did have two patients who had an impact of TD on their professional work as chefs, although they reported no impact on their daily life. Taste dysfunction sometimes reflects the subjective complaints as reported by patients, and the relevant disorders potentially leading to medicolegal issues are the subjectively perceived complaints. 24,25 The results of this study did show a concrete rate of occurrence for taste change after Eco-TBR and should be useful for further considerations regarding preoperative informed consent on OSA tongue base surgery. Furthermore, if zinc supplementation, 26 a traditional medical therapy for taste disorders, could improve the TD condition in this group of patients, it should be investigated. The limitations of the study include its retrospective nature, and the results were based on the enrolled patient s self-controlled subjective reporting. The study also lacked a control group. Furthermore, the degree of tissue removal with Eco-TBR is a limitation to this technique. Because we estimated the amount to be removed based on anatomical landmark in this study, the planned ablated specimens of the tongue base with Eco-TBR cannot be accurately weighed for the severity of changes on gustatory functions after surgery. Imaging may be employed in the future to overcome this limitation. Another limitation is that the relationship between the time of tongue compression and suspension with a stay suture for Eco-TBR procedure might disturb the taste function, but this could not be well determined in this study. A variable duration and quantity of coblation energy was delivered and should be acknowledged as a possible potential confounder of gustatory changes on the patients. This study also had a short follow-up period and still relatively small number of subjects studied. Further studies with long-term follow-up and larger patient numbers would be required to adequately answer these questions. CONCLUSION This study shows Eco-TBR may induce the likelihood of TD postoperatively. Preoperatively, we must clearly inform the patient about the possibility of gustatory change after Eco-TBR. It appears that our data shows that there is a minor but substantial subset of patients that have persistent TD. The TD was resolved in only a few (approximately 20%) who manifested a TD 1 week postprocedure. Based on the relatively lower morbidity and reasonable surgical outcomes, Eco-TBR is still a feasible treatment for OSA if the patient could fully understand the OSA treatment plan and potential complications after surgery. Acknowledgments Author contributions are as follows: Hsin-Ching Lin, MD, FACS, provided study design, surgical procedures, data collection and analysis, writing of article, final approval, and accountability for all aspects of the work. Michelle S. Hwang, BS, provided data analysis, drafting and revision, final approval, and accountability for all aspects of the work. Chang-Chuan Liao, MD, provided data collection and analysis, drafting, final approval, and accountability for all aspects of the work. Michael Friedman, MD, FACS, provided data interpretation, drafting, final approval, accountability for all aspects of the work, and critical revision of the article for important intellectual content. The authors thank Drs. 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