The effect of adenotonsillectomy on pulmonary hypertension in pediatric obstructive sleep apnea

Background

In a majority of OSA children with adenotonsillar hypertrophy, very mild symptoms or no symptoms at all are related to the cardiopulmonary system, but symptomless chronic changes may slowly occur in these children. Therefore, it is wise to monitor these patients by an easy, noninvasive cost-effective method; this can easily be done by monitoring mean pulmonary artery pressure (mPAP) of these children with Doppler echocardiography. Doppler echocardiography has been demonstrated to have a perfect correlation with cardiac catheterization. This study aims to determine the pulmonary arterial systolic pressure (PASP) in OSA children with hypertrophied tonsils and adenoid and to clarify whether adenotonsillectomy has any effect on pulmonary arterial pressure of these children.

Methods

Study was conducted on 50 children of both sexes aged from 4 to 15 years. Children complain of loud snoring and obstructive sleep apnea due to hypertrophied tonsils and adenoids. Children fit for general anesthesia and adenotonsillectomy. In all subjects, Doppler echocardiography was done before and after adenotonsillectomy.

Results

Comparison between preoperative PASP and after 2 months showed that normal PASP were found in 25 (50.0%) and 50 (100.0%) for preoperative and after 2 months respectively. There was statistically significant difference between preoperative PASP and after 2 months. However, there was no correlation between preoperative PASP and age, sex, or duration of symptoms.

Conclusion

From this study, we conclude that adenotonsillar hypertrophy causes higher PASP in OSA children, PASP is worse in neglected OSA cases with long duration of symptoms, and adenotonsillectomy is an effective therapeutic measure in such patients.

Head-Of-Bed Elevation (HOBE) for Improving Positional Obstructive Sleep Apnea (POSA): An Experimental Study

Purpose: Evaluate the effectiveness of the head-of-bed elevation position (HOBE) with a 30° elevation of the head and trunk, in improving obstruction of the upper airways in obstructive sleep apnea (OSA) patients. A prospective trial simultaneously performing drug-induced sleep endoscopy (DISE) and polysomnography (PSG) tests was performed. Methods: Forty-five patients were included in the prospective study protocol. All patients enrolled in the study and underwent the following evaluations: (1) a drug-induced sleep endoscopy, with an evaluation of obstructions and collapse of the upper airways at 0° and in a HOBE position, with head and trunk elevation of 30°; (2) an overnight PSG assessment in the hospital with head and trunk elevation from 0° to 30° during the night; (3) a questionnaire to evaluate the feedback of patients to sleeping with head-of-bed elevation. Results: Velum (V) and oropharynx lateral wall (O) collapses were reduced in the 30° up position. There were no statistical differences that emerged in the obstruction of the tongue base and epiglottis between the 0° position and the 30° up position (p > 0.05). The average AHI score changed from 23.8 ± 13.3 (0° supine position) to 17.7 ± 12.4 (HOBE position), with a statistical difference (p = 0.03); the same statistical difference emerged in the percentage of apneas that decreased from 55 ± 28.1 to 44 ± 25.8 (p = 0.05). Conclusions: By adopting the HOBE position with 30° elevation of the head and trunk, it is possible to obtain a reduction of upper airways collapses and an improvement of apnea/hypopnea events and nightly respiratory outcomes.

Predictive role of serum rheumatoid factor in different disease pattern of psoriasis and psoriatic arthritis

Background

Psoriasis is a multisystem inflammatory disorder with variable morphology, clinical pattern and multiple comorbidities. Interplay between genetic and environmental factors leading to an aberrant immune response in the skin may contribute to disease development. The assessment for risk factors, signs, and symptoms of potential comorbid diseases is an important component of patient management. The aim of this study is to determine rheumatoid factors (RF) positivity and its levels in psoriasis patients, and describe its relationship with the demographic and clinical characteristics, comorbidities, and disease patterns of psoriasis.

Results

Rheumatoid factor was positive in psoriatic patients more than control,30% of patients had positive rheumatoid factor while only 10% of control had positive results. Rheumatoid factor level was 63.8 ± 186.7 IU/ml in psoriasis vs. 9.3 ± 12.3 in control. Thirty percent of psoriasis patients have positive rheumatoid factor vs. 10% of control. There was no significant statistical difference between psoriasis patients with or without arthritis as regard rheumatoid factor positivity and titer; rheumatoid factor was positive in 20% in psoriatic patients with arthritis vs. 26% in psoriatic patients without arthritis. In psoriatic patients, the status of rheumatoid factor did not relate to disease severity, onset, course, site of affection, presence of scalp, nail affection, and presence of dactylitis (p value>0.5).

Conclusion

Psoriasis was associated with higher seropositivity of RF compared to age-matched non-psoriatic healthy controls. Occurrence and level of rheumatoid factor were not associated with severity or clinical pattern of psoriasis.

Effectiveness of drug-induced sleep endoscopy in improving outcomes of barbed pharyngoplasty for obstructive sleep apnea surgery: a prospective randomized trial

PURPOSE

To observe the effectiveness of preoperative drug-induced sleep endoscopy in improving surgical results of patients undergoing single-level barbed pharyngoplasty surgery for OSA, using a prospective randomized model.

METHODS

A single-center randomized controlled trial with two prospective arms was carried out to compare functional results in patients treated with barbed reposition pharyngoplasty (BRP) surgery without a preoperative drug-induced sleep endoscopy (DISE) evaluation vs patients treated with BRP surgery performed after DISE evaluation of sites/patterns of collapse.

RESULTS

We compared 50 patients who underwent BRP without a preoperative DISE evaluation (Group A) and 42 patients (Group B) treated with BRP surgery but preoperatively selected by means of a preoperative DISE. In this second group of patients, after DISE evaluation, 70% of patients were selected for single-level BRP surgery because they showed an isolated velopharyngeal collapse at the DISE evaluation, without obstruction at other upper airway levels evaluated. Both groups of patients showed a statistically significant difference between preoperative and postoperative values of AHI, ODI, and LOS (p<0.05 in all cases). Comparing Group A and Group B patients, the therapeutic success rate was found to be 60% in patients treated without preoperative DISE evaluation and 83% in patients treated with preoperative DISE (p = 0.02).

CONCLUSION

DISE appears to improve the surgical results of single-level velopharyngeal surgery due to the possibility of excluding patients with obstruction of the base of the tongue, the hypopharynx, and the epiglottis/larynx.

Surgical, clinical, and functional outcomes of transoral robotic surgery used in sleep surgery for obstructive sleep apnea syndrome: A systematic review and meta-analysis

We investigated safety and efficacy of transoral robotic surgery (TORS) for base of tongue (BOT) reduction in obstructive sleep apnea syndrome (OSAS) patients. PubMed, Cochrane Library, and Scopus were searched. A meta-analysis was performed. Random effects models were used. Thirty-one cohorts met our criteria (1693 patients). The analysis was based mostly on retrospective studies. The summary estimate of the reduction of Apnea-Hypoxia Index (AHI) was 24.25 abnormal events per hour (95% CI: 21.69-26.81) and reduction of Epworth Sleepiness Scale (ESS) was 7.92 (95% CI: 6.50-9.34). The summary estimate of increase in lowest O₂ saturation was 6.04% (95% CI: 3.05-9.03). The success rate of TORS BOT reduction, either alone or combined with other procedures, was 69% (95% CI: 64-79). The majority of studies reported low level of evidence but suggested that TORS BOT reduction may be a safe procedure associated with improvement of AHI, ESS, and lowest O₂ saturation.

Postoperative amyloidosis of tongue base: Extremely rare complication after multilevel sleep surgery

Amyloidosis is to be considered in the differential diagnosis of postoperative edema of tongue base after its ablation. It might be triggered by surgical trauma. After establishment of diagnosis, cause of secondary amyloidosis should be excluded.

Transoral Endoscopic Coblation Tongue Base Surgery in Obstructive Sleep Apnea: Resection versus Ablation

BACKGROUND

A new transoral tongue base surgical procedure for the treatment of snoring and obstructive sleep apnea (OSA) is described. It is named "Robo-Cob" technique because it is similar to transoral robotic surgery (TORS) but it is performed by means of coblation technology in order to resect the tongue base in countries where TORS is not an available option for such benign conditions.

METHODS

In this prospective, randomized, controlled trial, the new Robo-Cob technique was carried out in 25 adult OSA patients with confirmed tongue base hypertrophy at preoperative drug-induced sedation endoscopy. The results of this procedure were compared with the coblation endoscopic lingual lightening (CELL) technique used to ablate (or minimally resect) the central part of the tongue base, in another 25 adult OSA patients with similar characteristics (age, sex, preoperative body mass index and Apnea-Hypopnea Index, AHI). The base of tongue surgery was part of multilevel surgery including also septoturbinoplasty and barbed reposition pharyngoplasty (with/without tonsillectomy).

RESULTS

In this study, the Robo-Cob technique is proved to be feasible and effective in all cases either alone or when combined with other procedures in multilevel surgical settings. No/minimal intraoperative or postoperative complications were observed. Postoperative pain as measured by visual analog scale ranged from 3 to 7. No tracheostomy was done in any patient. Objective clinical improvement was confirmed by a level 3 polygraphy performed 6 months after surgery. There was significant difference in operative time at the level of the tongue base between Robo-Cob and CELL techniques, with shorter times observed within the Robo-Cob group. Moreover, the Robo-Cob technique provided tongue base tissue specimens that allowed measurement of the volume that ranged from 5 to 17 cm3 (mean 11.64 ± 3.49 cm3). It was found that resection of at least 10 cm3 of tongue base tissue was associated with better outcomes in terms of postoperative AHI reduction.

CONCLUSION

In this study, the added values of using coblation for resection and not ablation appear to be the short surgical time, the low postoperative tissue edema, and the possibility of providing tissue specimens to measure resected volumes.

Challenges faced by young otolaryngologists-head & neck surgeons around the world

OBJECTIVES

To document work-related stressors and to identify coping strategies employed by young board-certified otolaryngologists-head & neck surgeons (OTL-HNS) around the world. The second objective is to evaluate demographic and professional characteristics associated with a higher level of work-related stress.

METHODS

A survey was sent to all OTL-HNS under 45 years old from the 2017 IFOS meeting. This survey was conducted by the YO-IFOS group (Young Otolaryngologists of the International Federation of Otolaryngological Societies). Data were collected for a period of 1 month. Demographic characteristics and information concerning challenges encountered by OTL-HNS during the early years of their career were collected.

RESULTS

Among the 2787 attendees, 928 responded to the survey (response rate=33.3%). The three most frequent challenges faced by OTL-HNS in the early years of their career were related to administrative workload (45%), high patient quota (42%) and desire to achieve adequate work-life balance (42%). Practices used by OTL-HNS to cope with stress were physical activity (37%), recreational activities (35%) and self-organization (32%). Higher levels of stress were frequently found in participants who possessed five to ten years of experience (P=0.007) and who were employed by an academic institution (P=0.020). On the other hand, lower levels of stress were often encountered in participants who had 5 years or less of experience (P=0.002).

CONCLUSION

This study provides insight on characteristics that are associated with various levels of stress. Moreover, it demonstrates the work-related stressors and the resilience techniques employed by OTL-HNS in early years of their career. Stress will always be present during the surgeon's career. Therefore, knowing how to recognize it and how to deal with it is key. More resources should be made available for OTL-HNS needing aid. Because surgeons must be in control of their stress if they want to provide high quality health care.

Prospective multicentre study on barbed reposition pharyngoplasty standing alone or as a part of multilevel surgery for sleep apnoea

OBJECTIVES

The aim of this study was to demonstrate in a prospective multicentre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnoea/hypopnea syndrome (OSAHS) patients.

DESIGN

Prospective study.

SETTING

Multicentre study.

PARTICIPANTS

Patients suffering from obstructive sleep apnoea.

MAIN OUTCOMES MEASURES

Values of postoperative apnoea-hypopnea index (AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS).

RESULTS

111 Barbed Reposition Pharyngoplasty procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analysed in 15 different centres. The average hospitalisation period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average body mass index at the time of the procedure was 27.9 ± 3.2, and the majority of the patients were men (83%). The mean preoperative and postoperative apnoea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (P < .001). The mean preoperative and postoperative ESS score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (P < .001). The mean preoperative and postoperative ODI were 29.6 ± 20.7 and 12.7 ± 10.8, respectively (P < .001).

CONCLUSIONS

Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity.

Barbed reposition pharyngoplasty (BRP) for OSAHS: a feasibility, safety, efficacy and teachability pilot study. "We are on the giant's shoulders"

A new palatal procedure for snoring/obstructive sleep apnea (OSA) is described. The procedure was named as barbed reposition pharyngoplasty (BRP). The technique is described step by step. The new surgical technique was carried out in ten adult OSA patients with mean age of 53.4 ± 12.4 years (average 30-70) with confirmed retropalatal obstruction. In this pilot study; we assessed the feasibility by calculating the number of cases that failed to be operated and converted to other palatal technique during the same surgical setting, safety was assessed by evaluating both intra-operative and post-operative complications, teachability measured by the learning curve of our team members (the time of surgical procedure). In this study, the technique is proved to be feasible in all cases. There were no significant intra-operative or post-operative complications. Objective clinical improvement was confirmed by polysomnography 6 months post-operative with significant decrease in mean AHI from 43.65 ± 26.83 to 13.57 ± 15.41 (P = 0.007), daytime sleepiness assessed by Epworth Sleepiness Scale from 11.6 ± 4.86 to 4.3 ± 2 (P < 0.01), ODI from 44.7 ± 27.3 to 12.9 ± 16.3 (P = 0.004). Operative time decreased over the course of the study with an initial steep ascent in technical skill acquisition followed by more gradual improvement, and a steady decrease in operative time to as short as 20 min. Our preliminary results suggest that BRP technique is feasible, safe and effective in management of OSA patients. Moreover, it is easy to learn even for not experienced surgeons, less time consuming and with no significant complications.

Combined transoral robotic tongue base surgery and palate surgery in obstructive sleep apnea-hypopnea syndrome: expansion sphincter pharyngoplasty versus uvulopalatopharyngoplasty

BACKGROUND

Transoral robotic surgery (TORS) for obstructive sleep apnea-hypopnea syndrome is a relatively young technique principally devised for managing apneas in the tongue base (TB) area and supraglottic larynx. This procedure is included in the so-called "multilevel surgery" often including a palatal and nasal surgery.

METHODS

We carried out a retrospective analysis in order to understand in detail the relative impact on apneas of the 2 different procedures carried out in the palate area (expansion sphincter pharyngoplasty and uvulopalatopharyngoplasty). We evaluated 2 groups, each of 12 cases, which were sorted according to the primary selection criteria of statistically comparable preoperative apnea-hypopnea index (AHI), sex, age, body mass index (BMI), and volume of removed TB tissue.

RESULTS

Postoperative AHI registered was of 9.9 ± 8.6 SD for the expansion sphincter pharyngoplasty group and 19.8 ± 14.1 SD for the uvulopalatopharyngoplasty group.

CONCLUSION

As the palate component of our multilevel procedure, expansion sphincter pharyngoplasty, including conventional nose surgery and robotic surgery, seems to be superior to uvulopalatopharyngoplasty.

Sphenoid sinus mucocele

The authors present their experience of managing an interesting case of a 65-year-old woman who presented to their clinic with 1-month history of persistent deep-seated headache. The patient sought medical advice in neurology and ophthalmology clinics before being referred to the ear, nose and throat clinic. CT imaging revealed isolated opacification and expansion of both sphenoid sinuses with bony continuity along the periphery of the sinuses features consistent with mucocele. MRI was needed to fully evaluate the extension of the lesion. The lesion was diagnosed as bilateral sphenoid sinuses mucoceles. Transnasal endoscopic drainage of the sphenoid mucoceles leads to gradual improvement of the symptoms. We discuss the clinical presentation, diagnosis and treatment of this case as well as a review of the literature.

Acute tuberculous abscess of the thyroid gland

The authors are presenting our experience of managing an interesting case of a 28-year-old woman who presented to our clinic with a midline neck swelling of 1-month duration. There was a rapid increase in the degree of swelling associated with erythema, pain and fever 7 days before seeking medical help. Plain and contrast-enhanced CT scans of the neck were done. Diagnosis of acute suppurative abscess was made and the patient underwent emergency incision and drainage. Histopathological examination of the abscess wall showed epitheloid and Langhans' giant cells. The findings were suggestive of tuberculosis. Subsequently, a positive culture for Mycobacterium tuberculosis was obtained on Lowenstein-Jenson medium. The patient was started on antituberculous chemotherapy for 6 months. On a 6-month clinical follow-up, the patient was asymptomatic and euthyroid. We discuss the clinical presentation, diagnosis and treatment of this case as well as a review of the literature.

Eagle's syndrome, a rare cause of neck pain

Eagle's syndrome (ES) sometimes called styloid or stylohyoid syndrome is defined as the symptomatic elongation of the styloid process or mineralisation of the stylohyoid ligament. The symptoms related to this condition can be confused with those attributed to a wide variety of facial neuralgias. We report a 34-year-old male patient who presented with a recurrent neck pain and dysphagia. He was diagnosed to have an elongated styloid process. An intraoral transtonsillar shortening of the styloid process was done. We discuss the clinical presentation, diagnosis and treatment of ES as well as a review of the literature.

Oropharyngeal teratoma, a rare cause of airway obstruction in neonates

Oropharyngeal teratomas are extremely rare congenital tumours, and because of their location in the upper airway they represent one of the most unusual causes of airway obstruction during the neonatal period. We report a 2-month-old girl who presented with repeated vomiting, failure to thrive and recurrent bouts of stridor and cyanosis since birth. On examination there was a mass originating from the oropharynx. The mass was excised under general anaesthesia by CO(2) laser. Histopathological examination revealed a teratoma of the oropharynx. We discuss the clinical presentation, diagnosis and treatment of this case as well as a review of the literature.

Adaptive Output Feedback Voltage-Based Control of Magnetically-Saturated Induction Motors

The problem of controlling the induction motor -model with magnetic saturation is considered. An adaptive controller is developed under the assumption of measurable stator currents and speed only with unknown rotor resistance and load torque. All the unknown parameters are assumed constant or slowly varying and are estimated online by the controller. Simulation results are provided for illustration.

Chondrosarcoma of the nasal septum

Chondrosarcoma of the nasal septum is a rare malignancy. When it occurs, early diagnosis is difficult because patients generally present with common, non-specific sinonasal complaints. This is the report of a 62-year-old woman who presented with a 1-month history of nasal obstruction, headache and anosmia. Nasal endoscopy showed a nasal mass obstructing both nasal cavities not separable from the septum. A wedge biopsy of the nasal mass was taken. Histopathology was suggestive of chondrosarcoma. The tumour was removed by an endoscopic approach. The clinical presentation, diagnosis and treatment of this case as well as a review of the literature are discussed.