The use of transoral robotic surgery (TORS) in ENT is rather controversial, but the use of robotic surgery for obstructive sleep apneoa (OSA), makes it doubly so. Previous studies on TORS in OSA have been performed with other types of surgery which has not enabled us to understand the individual benefit of this type of treatment. This is the first study to only use TORS as an intervention and the authors have attempted to be as objective as possible in measuring the outcomes. Importantly the follow-up period was at least a year with pre- and postoperative polysomnography, but quality of life, voice and swallowing patient reported outcome measures (PROMS), were also included. Patients were selected based on drug induced sedation endoscopy (DISE), otherwise known as sleep nasendoscopy. Surgery included midline tongue base laser resection and / or epiglottic wedge resection for those who were found to have a trap door epiglottic collapse. Out of the 14 patients who entered the trial three patients declined to undergo a postoperative polysomnography as “they reported feeling significantly better”. It is a pity these patients could not be convinced to complete the study but even so the results were extremely good in this difficult to manage subpopulation. Of the 11 remaining patients, 63.6% had a successful surgery using the literature standard definition, but the authors also used even more strict criteria to quantify success (such as no longer needing CPAP and effectively curing the patient with an Apneoa / Hypopnea index of less than 5). Interestingly there was one patient who was actually worse after the surgery, but there was no individual data for weight gain or possible reasons for this failure. There were no significant complications or alterations of voice or swallowing functions. This is an important study which clearly defines the significant benefits of this surgery, but it also highlights the importance of DISE in selecting patients. This in itself may partly explain the exceptionally good results in this study. I understand that the authors are continuing to investigate and gain experience with this surgery, and hopefully more data will be made available in the future.

Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment.
Arora A, Chaidas K, Garas G, et al.
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Vik Veer

Royal National Throat, Nose & Ear Hospital and Queens Hospital, Romford, UK.

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