ORIGINAL ARTICLE TRANSORAL ROBOTIC SURGERY OF THE TONGUE BASE IN OBSTRUCTIVE SLEEP APNEA-HYPOPNEA SYNDROME: ANATOMIC CONSIDERATIONS AND CLINICAL EXPERIENCE Claudio Vicini, MD, 1 Iacopo Dallan, MD, 2 Pietro Canzi, MD, 1 Sabrina Frassineti, MD, 1 Andrea Nacci, MD, 2 Veronica Seccia, MD, 2 Erica Panicucci, MD, 3 Maria Grazia La Pietra, PhD, 1 Filippo Montevecchi, MD, 1 Manfred Tschabitscher, MD 4 1 Department of Special Surgery, Ear, Nose, and Throat, and Oral Surgery Unit, Ospedale Morgagni Pierantoni, University of Pavia in Forlı `, Italy 2 Ear, Nose, and Throat Unit, Azienda ospedaliero-Universitaria Pisana, Pisa. E-mail: iacopodallan@tiscali.it 3 Department of Experimental Pathology, University of Pisa, Pisa, Italy 4 Department of Systematic Anatomy, University of Wien, Wien, Austria Accepted 22 October 2010 Published online 11 March 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21691 Abstract: Background. The purpose of our work was to describe, through cadaveric dissection, the anatomy of the tongue base with a robotic perspective and to demonstrate the feasibility of this approach in case of tongue base hypertrophy in Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). Methods. Forty-four patients with OSAHS underwent tongue base resection in the last 2 years. Twenty patients with a 10-month minimum follow-up were evaluated. The anatomic details of 3 tongue bases dissected from above are illustrated. Results. The cadaveric study shows that no constant land- marks are identifiable, with no significant neurovascular struc- tures present in the midline. Clinically, transoral robotic surgery (TORS) for the tongue base was feasible, with no major com- plications and satisfaction of the majority of patients. Mean apnea hypopnea index (AHI) improvement was 24.6  22.2 SD, mean Epworth Sleepiness Scale (ESS) improvement was 5.9  4.4 SD. Conclusion. Tongue base hypertrophy can be safely and effectively managed by TORS in OSAHS. Our midterm data are encouraging and worthy of further evaluation. V V C 2011 Wiley Periodicals, Inc. Head Neck 34: 15–22, 2012 Keywords: robotic surgery; tongue base; OSAHS; sleep apnea; transoral Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS) is a critical social problem which seriously affects patients’ quality of life (QOL); it is also known as an independent risk factor for hypertension, 1 myo- cardial infarction, 2 and stroke. 3 OSAHS, when related mainly to severe retrolingual obstruction, is a challenging task for the physician, especially from a surgical point of view; minimal inva- sive techniques are an option in mild cases but totally insufficient with massive bulky tissues. Minimally invasive robotic approach (transoral robotic surgery [TORS] performed with Intuitive da Vinci) has a prom- ising future in patients with tongue base hypertrophy OSAHS, as we demonstrated in our preliminary experi- ence, 4 but we believe that its clinical application should be performed with controlled studies; we think that tongue base management by means of TORS still remains a complex surgical task and needs a different anatomic orientation, even if resection of the tongue base for oncological purposes has already been reported previously. 5 Revision of data from the literature 4,6,7 seems to confirm the good tolerability of the procedure, and the complication rate is dependent on the specific proce- dure and not related to the use of the robotic techniques. Given the small amount of data available on this topic in the literature, we provide our personal ana- tomic and clinical experience, give a different ana- tomic perception of the tongue base, and discuss the results that confirm the tolerability and efficacy of this technology in patients with tongue base hyper- trophic OSAHS. MATERIALS AND METHODS Anatomic dissection was performed in 3 injected fresh cadaver heads to better elucidate the robotic perspec- tive of the tongue base anatomy. The dissection work was conducted at the Department of Anatomy of the Medical University of Wien by the same authors (I.D. and P.C.). Endoscopes with different angles (30  , 45  , and 70  ) were used to reproduce a superior to inferior perspective of the anatomy of the tongue base. Forty-four patients with OSAHS with severe hy- pertrophy of the tongue base were treated by means of Correspondence to: I. Dallan V V C 2011 Wiley Periodicals, Inc. Transoral Robotic Surgery in Obstructive Sleep Apnea-Hypopnea Syndrome HEAD & NECK—DOI 10.1002/hed January 2012 15