Is it the Tongue’s Fault? A Recent Study Says Yes, the Tongue Causes OSA

By Admin

A study published in 2019 emphasized the role of the tongue in obstructive sleep apnea (OSA), but unlike previous studies of its kind, the research focused specifically on how weight gain can increase the tongue’s fat content and lead to blockage. The title of the study, “Effect of Weight Loss on Upper Airway Anatomy and the Apnea Hypopnea Index: The Importance of Tongue Fat,” is an effective summary of the study’s findings, emphasizing weight loss as a treatment option for sleep apnea syndromes.. While there is still much to learn about other factors that contribute to OSA, and why only some people develop the disorder, this breakthrough discovery has helped to advance our knowledge of the specific mechanisms involved in apnea events and will likely lead to new treatment developments in the future.

The Role of the Tongue

While doctors and sleep specialists have known for some time that body weight and upper airway anatomy are related, studies have only recently observed a specific causal link between weight gain and the mechanisms of blockage. Recent studies have observed that tongue fat content often parallels high body mass index (BMI) values, as well as increased cardiometabolic risk and various abnormalities in the upper airway. But a strong link between tongue fat and apnea-hypopnea index (AHI) scores is a considerable step in the development of more precise, targeted treatment approaches. In the “Importance of Tongue Fat” study, led by a research team at the University of Pennsylvania Perelman School of Medicine, airway sizes, soft tissue, tongue fat, and abdominal fat volumes were all observed and quantified, but only the reductions in tongue fat showed strong correlations with reductions in the apnea hypopnea index (AHI). The researchers then used mediation analyses to indicate that tongue fat reduction was the primary mediator of the relationship. The apnea-hypopnea index, or AHI, is the predominant measure of sleep apnea severity, consisting of the number of apnea events (breathing pauses) and the number of hypopneas (periods of shallow breathing) occurring on average per hour. The results of the “Importance of Tongue Fat” study showed AHI correlations at high enough levels (rho=0.62, p<0.0001) to warrant further research on the role of the tongue in OSA development. Especially promising were the improvements of participants after 10-percent reductions in body weight over a six-month period. While some patients underwent weight-loss surgery to achieve the desired results, their AHI scores were consistent with those who maintained a diet and/or exercise regimen.

The Surgical Option

For some patients, weight loss or PAP therapy may not be enough to stop airway obstruction and restore healthy breathing patterns. In these cases, a surgical option may be considered for tongue reduction or other means of airflow improvement. A doctor or specialist in this area of medicine can assess a patient’s condition and explain the best option for his or her particular health needs. Surgical procedures can make the tongue firmer and less collapsible, or reduce tongue volume by removing tissue. As with any surgical procedure, special consideration should be made to the patient’s entire condition, including the existence of any related disease or disorder in addition to OSA. Surgery can involve several steps over a period of time, and PAP therapy may be required throughout the process. A successful surgery does not necessarily rule out CPAP. It is simply a part of a larger treatment plan that may be the best option for a particular syndrome.

Airway Blockage Image by Spiritia via Wikimedia Commons

Tongue Reduction Surgeries

Radiofrequency Volumetric Tissue Reduction (RFVTR) - A newer form of surgery, radiofrequency ablation, or radiofrequency volumetric tissue reduction (RFVTR), can be applied to the tongue to reduce and tighten the tissues through controlled cauterization. This method can be used to reduce the tongue or other problem tissues involved in blockage. Radiofrequency energy is delivered via probes that cause the tissue to scar over time. Rather than as an alternative to PAP therapy, this procedure is often used as a means to improve CPAP tolerance and adherence.

Base of Tongue Reduction - Along with Radiofrequency methods, there are other forms of “base of tongue reduction” that involve probes or transoral robots to insert energy into multiple points at the base of the tongue and remove tissue in a targeted manner. Surgical tongue-base reduction has become more effective as technological developments in the last decade allow for high levels of precision.

Midline Glossectomy and Lingualplasty - Glossectomy is a general term for tongue reduction methods, but midline glossectomy, or submucosal lingualplasty, refers more specifically to the tissues at the back of the tongue and along its midline. Often performed using electrocautery or laser, this procedure reduces the recovery time and limits any risks to other tissues in the area. These technologies involve a more complete removal of tongue tissue than tongue-base procedures or ablation techniques.

Genioglossus Advancement - Also referred to as Genial Tubercle Advancement (GTA), this surgery moves the base of the tongue forward, focusing on the muscles that attach the tongue to the base of the mouth. During a genioglossus advancement procedure, the attachment for the tongue (genial tubercle) is pulled forward along with connected tissue and bone.

Hyoid Suspension - The hyoid refers to the U-shaped bone in the front of your neck, and hyoid suspension is the surgical advancement of the hyoid bone and its muscle attachments to the tongue and airway. The hyoid is attached to the “Adam’s Apple” of the throat or suspended from the mandible. This procedure increases the airway in order to improve and stabilize the area.

Other Methods

Hypoglossal Nerve Stimulation - HNS, also referred to as neuromodulation, involves an electrode that is attached to the main (hypoglossal) nerve that controls the tongue muscles. A type of pacemaker is used to stimulate the tongue muscle while you are sleeping to prevent collapse of the tongue and other tissues. While this is an invasive procedure, some patients may prefer it to surgeries that reduce or change their anatomy.

Mandibular Repositioning Device (MRD) - These oral devices push the tongue and jaw forward to make the airway larger and improves airflow. Pioneering CPAP device company ResMed produces MRDs, and is currently undergoing a five-year multicentre study to design adjustable options that retain the mandible in a protruded position, rather than pushing it forward. This would require less pressure on the joints and tissues involved. Oral devices are usually reserved for those patients who are unable to use PAP therapy or undergo surgery as more thorough treatment options. Oral devices such as MRDs have a positive record of success rates, though not as consistent or dependable as CPAP or surgery.

Weight Loss Surgery

While a highly intensive procedure, bariatric surgery can promote weight loss and may improve sleep apnea in people who with adiposity issues. But these procedures are rarely recommended for the treatment of sleep apnea alone. More often, weight loss surgery is recommended due to other, more severe health risks. There are many types of weight loss surgery involving various types of gastric bypass or gut reduction techniques, and each type has its own potential risks and benefits. Most doctors will recommend that patients utilize other weight loss strategies before considering bariatric surgery, and more often than not, use of PAP therapy will continue following surgery.

Lifestyle Changes Can Save You

More and more doctors are prescribing lifestyle changes as part of holistic approach to treating sleep apnea and related health problems. Whether or not it is the tongue causing the problem of sleep apnea events, CPAP can open the airway without surgery, and lifestyle changes can address the issue with a long-term, goal-oriented focus. But in addition to these measures, you can also utilize oral exercises to strengthen your airway muscles and reduce fat content over time. When practiced for 20 to 30 minutes a day, these very simple exercises have been found to reduce the severity of sleep apnea symptoms, including snoring or choking up during sleep:

Push the tip of your tongue against the roof of your mouth and slide the tongue backward (10-20 repetitions)
Force the underside of your tongue downward against the floor of your mouth while keeping the tip of your tongue forward and in contact with your teeth (10-20 repetitions)
Force your tongue upward against the roof of your mouth (10-20 repetitions)

The “Importance of Tongue Fat” study could lead to new strategies in the prevention and treatment of both OSA and snoring, but the foundations of PAP therapy and weight control remain the starting points for any new sleep apnea patient. In hindsight of the study, the research team from the University of Pennsylvania Perelman School of Medicine now plan to determine which exercises and low-fat diets are particularly good at slimming down the tongue. Since not all weight gain leads to an OSA diagnosis, it still remains a mystery whether genetic or environmental influences play a significant role in the development of the disorder, but what this study makes clear is the indisputable link between weight gain, sleep apnea, and that precious organ we rely upon for talking, tasting, and breathing.