Smile on sleep apnea
<p>For sleep apnea sufferers, the SMILE procedure is an alternative, minimally invasive surgical procedure that shrinks the tongue base without having to make a large incision through the tongue mucous membranes. Traditionally, to make the tongue base smaller, surgeons used to make a v-shaped incision in the back of the tongue and tie the two sides together. This procedure worked well for the most part, but it was bloody and painful—not a good thing for both the patient and the surgeon.</p> <p>Most people with obstructive sleep apnea have smaller jaws than normal, which means that the tongue takes up relatively too much space. You can either make the jaws bigger, or make the tongue smaller.</p> <p>In 2008, Dr. Eric Mair (the same surgeon that also introduced injection snoreplasty for snoring) described the SMILE procedure, which stands for Submucosal Minimally Invasive Lingual Excision. This procedure is performed under general anesthesia and can take about 20-30 minutes. The unique feature of this operation is that a special instrument called a Coblator is used to vaporize tissues at low temperature. This is the same instrument that I use routinely for tonsils and palate procedures. Because it doesn’t char and burn, patients report that pain is significantly less than the traditional electrocautery based procedures.</p> <p>A small stab incision is made on top of the tongue, and a narrow tunnel is made bluntly toward the muscle area to be removed. The Coblator wand is then placed through the tunnel, and a digital finger pulse oximeter on the opposite hand is placed through the mouth and used to feel the location of the tip of the wand inside the back area of the tongue. With the wand activated, the tip of the wand is passed up and down, literally melting the muscles in its’ path. Anywhere from 10 to 20% of the tongue muscle volume is removed.</p> <p>The Coblator seals blood vessels as it vaporizes tissues, but there will be some mild oozing, which usually improves with direct pressure for a few minutes or placement of a clotting aid.</p> <p>Care must be taken not to move too far to the sides, since nerves that go to the tongue and major blood vessels are in this general vicinity. Risks of injuring these important structures are minimal (less than 1-2%), but not insignificant. Bruising with temporary weakness or numbness can also occur, but usually goes away after a few weeks to months. Bleeding can also occur, but again, it’s no worse than with other surgical procedures in this general area.</p> <p>Typically, the SMILE procedure can be performed alone or along with other procedures such as a UPPP. Depending on the number of procedures performed, most people can go home the next morning (SMILE alone) or after 2-3 days (if other procedures are performed as well).</p> <p>There are other radiofrequency-based procedures, but the Coblator is different in that it literally removes tissues, and only one treatment is needed. These other devices mainly scar and tighten the muscles, with only minimal shrinkage of tissues, and more than one treatment is usually needed for good results.</p> <p>Because the SMILE procedure is a relatively new option for obstructive sleep apnea, we don’t have any long-term results. Preliminary studies show that it’s on par with many of the other similar tongue base procedures, with similar, low complication rates.</p> <p>The SMILE is not for everyone with sleep apnea. However, in carefully selected patients who have exhausted all non-surgical options and who have the right anatomy, the SMILE may be a good option. Patients who didn’t find success with a UPPP operation alone may also be a good candidate. Find an ENT surgeon that’s comfortable performing various other tongue base and palatal procedures, in addition to the SMILE procedure, so that the appropriate surgical procedure can be recommended for your unique, individual situation.</p>
