bluuebunny/crossref_metadata_2025 huggingface dataset:
Endoscopic Endonasal Approach to Meckel's Cave
Authors: Karkas Alexandre , Keller Jeffrey T. , Theodosopoulos Philip , Zimmer Lee A.
Published: August 2013

Objectives:

External approaches to Meckel's Cave (MC) and petrous carotid artery offer excellent exposure but are associated with neurological‐cosmetic‐functional morbidities. Our aim is to describe an endoscopic approach to MC while providing anatomical relationships, predictable morbidities, and clinical applications.

Methods:

Four cadaveric heads (8 sides) were dissected with 0° endoscopy through transnasal‐transmaxillary‐transsphenoid‐transpterygoid approach.

Results:

A large maxillary antrostomy was performed and the sphenopalatine artery identified; the posterior and superior walls of maxillary sinus were removed, the pterygopalatine fossa (PPF) exposed, and the internal maxillary artery and maxillary nerve (V2) entering foramen rotundum identified. Lateral to pterygoid buttress, medial attachments of lateral pterygoid muscle were dissected, and the mandibular nerve (V3) in the infratemporal fossa (ITF) entering foramen ovale was exposed. A large sphenoidotomy was performed and cavernous carotid artery located. The Vidian was followed retrogradely until identifying foramen lacerum and then petrous carotid artery. The ophthalmic nerve (V1) was identified in the superior orbital fissure and Gasserian ganglion (GG) in MC in the petrous apex. The GG was followed posteriorly to the retrogasserian root and porus trigeminus.

Conclusions:

The described endoscopic approach affords the same exposure as external approaches with less morbidity. Indications include lesions of MC, PPF, ITF with minimal intracranial extension and biopsy of suspected malignant tumors in these areas. Limitations of the technique are massive intracranial tumor extension and difficulties to control bleeding in a narrow space. Morbidity will be discussed based on anatomical dissection. Illustrative clinical cases with videos will be presented to support this approach.
Endoscopic Surgical Management of Dacryocele
Authors: Morante Juan C. C. , Venegas Monica M. H. , Morante Angel C. , Valdivia Victor , Cruzado‐Sanchez Deivy , Chang Jorge H.
Published: August 2013

Objectives:

1) Report our experience and surgical treatment of the unilateral giant dacryocele using the endoscopic technique. 2) Improve the lacrimal sac treatment with endonasal surgery, thus avoiding external dacryocystorhinostomy and its sequelae.

Methods:

We present the case of an adult patient with chronic dacryocystitis of 1 year of evolution, treated by endoscopic endonasal surgery (endoscopic dacryocystorhinostomy) in July 2012 at the Arzobispo Loayza National Hospital, Lima, Peru. The computed tomography described a giant mucocele of the right lacrimal sac. The technique was done entirely endoscopically, opening the lacrimal bone and the lacrimal sac with mucosal content and using a silicone probe. Nasal packing was placed for 3 days, and endoscopic control was carried out.

Results:

This patient was followed endoscopically each week, testing the permeability of the fistula, moving the probe, and checking the opening hole during the 6 months after surgery. There were no recurrences and no complications.

Conclusions:

Endoscopic dacryocystorhinostomy has become a very safe method to resolve lacrimal sac pathologies. It is a reliable and secure and has less sequelae than external dacryocystorhinostomies.
Eosinophilic Inflammation of Chronic Rhinosinusitis with Nasal Polyps Is Related to OX40 Ligand Expression
Authors: Garzaro Massimiliano , Boita Monica , Raimondo Luca , Riva Giuseppe , Cerutti Marta , Rolla Giovanni , Pecorari Giancarlo
Published: August 2013

Objectives:

Investigate whether OX40 Ligand is more expressed in sinus tissue from subjects with CRSwNP, compared to chronic rhinosinusitis without nasal polyps (CRSsNP) and whether OX40L expression is related to eosinophilic sinus infiltration.

Methods:

In 2011, 20 patients with CRS (11 CRSwNP, 9 CRSsNP) were recruited for FESS, and 7 subjects who underwent cosmetic rhinoplasty and served as control group, were consecutively enrolled. Messenger RNA expression for thymic stromal lymphopoietin (TSLP), TSLP Receptor, OX40L was analyzed by real time PCR in sinus biopsies of all patients. Immunoreactivity score (IRS) for OX40L and eosinophil count by Wright‐Giemsa staining were obtained in sinus biopsies of the same patients.

Results:

The mRNA expression of OX40L was higher in CRSwNP (2.4 ± 0.26) compared to CRSsNP (1.38 ± 0.19, p<0.05) and controls (0.49 ± 0.14), P < 0.001. The mRNA expression of TSLP and TSLPR was significantly higher in CRSwNP compared to controls (2.5 ± 0.32 vs 0.98 ± 0.17, P < 0.01 and 1.42 ± 0.31 vs 0.25 ± 0.07, P < 0.001, respectively) but not significantly higher compared to CRSsNP. IRS for OX40L was significantly higher in CRSwNP as compared to CRSsNP (P < 0.05) and controls (P <0.001), and there was a significant correlation between the OX40L IRS, as well the number of OX40L positive cells, and the number of eosinophils in sinus biopsies (r=0.69; p<0.0001 and r=0.52, p=0.007 respectively).

Conclusions:

TSLP/OX40L axis is upregulated in CRSwNP and it is related to the intensity of eosinophilic inflammation. Whether these costimulatory molecules present new therapeutic targets require further investigation.
Is High Blood Sugar a Risk Factor for Paranasal Sinus Fungus Ball?
Authors: Chusakul Supinda
Published: August 2013

Objectives:

1) Examine the risk factors for having paranasal sinus fungus ball with high blood sugar. 2) Describe the clinical features of the patients’ diagnoses as paranasal sinus fungus ball (SFB).

Methods:

A tertiary care hospital based match case‐control study was conducted from December 2007 to December 2011. The matching criteria were age and gender. Fifty cases with chronic rhinosinusitis with SFB were identified from medical records, and 45 chronic rhinosinusitis without SFB served as controls. The cases and controls were placed into 3 groups depending on fasting blood sugar (FBS) levels (normal: FBS less than 100 mg/DL; impaired: FBS (100‐125 mg/DL); and diabetics: FBS>125 mg/DL). Patients with FBS >100 mg/DL were determined as high blood sugar. Demographic data, clinical symptoms, and findings on imaging were records. The main outcome measure was matched odd ratio and 95% confidence interval of high blood sugar associated with paranasal sinus fungus ball.

Results:

Patients with high FBS had an odds ratio of 1.15 (95% confidence interval, 0.6‐2.19) when compared with patients with normal FBS. Seventy percent of chronic rhinosinusitis with SFB are female, and 94% of SFB are older than 40 years old. The most common presentation is nasal discharge/post‐nasal drip (33/50 cases). The maxillary sinus is the most commonly involved sinus (46%), followed by the sphenoid sinus (30%).

Conclusions:

This study has not found that having high fasting blood sugar is linked with a higher risk of getting fungus ball of paranasal sinuses.
Nasal Nitric Oxide Change after Functional Endoscopic Sinus Surgery
Authors: Fu Chia‐Hsiang , Lee Ta‐Jen , Huang Chi‐Che , Chang Po‐Hung , Chen Yi‐Wei
Published: August 2013

Objectives:

Evaluate the symptom scores and nasal nitric oxide (nNO) in patients with chronic rhinosinusitis (CRS) after functional endoscopic sinus surgery (FESS).

Methods:

Through a non‐invasive method, we prospectively collected pre‐ and post‐operative nNO 3 months after FESS. Basic demographic data of patients, underlying diseases, image / endoscopy scores, allergy tests, rhinometries, and pre‐ and post‐operative symptom scores (SNOT‐22 and RQLQ) were recorded and analyzed.

Results:

Twenty‐eight patients completed post‐operative evaluation, including 12 CRS without nasal polyps (CRSsNP) and 16 CRS with nasal polyps (CRSwNP). Pre‐operative nNO had no difference between two groups in our patients (P = 0.187). Other demographic and pre‐operative data had no difference between these two groups except Lund‐Mackey CT score (P < 0.001) and Lund‐Kennedy endoscopy score (P = 0.031). We found disease severity strongly correlated with nNO only in nonallergic patients (P = 0.006 and <0.001 for CT score and endoscopy score, respectively). However, subjective symptoms did not correlate well with nNO. As to post‐op nNO, the significant elevation was only detected in the CRSwNP group (P = 0.005). Several factors were found to correlate with post‐operative nNO change, but all in nonallergic patients, including the existence of nasal polyps, Lund‐Mackey score, asthma, and pre‐operative nNO level.

Conclusions:

Collection of nNO is a quick, non‐invasive method for evaluating sinus status. We may expect the nNO change after FESS is performed, especially in nonallergic patients, as another reference for outcome prediction before sinus surgery scheduled.
New Landmark for the Endoscopic Endonasal Transsphenoidal Approach of Pituitary Surgery
Authors: Cho Jin‐Hee , Kim Young‐Ha , Yu Byung Jae , Kim Ju Eun
Published: August 2013

Objectives:

Clarify the anatomical correlations of the sphenoid sinus with surrounding structures in the normal Korean population, and identify surgical landmarks for safe sellar floor dissection in the anterior skull base by endoscopy and microscopy.

Methods:

We reviewed the 196 brain magnetic resonance imaging (MRI) findings showing a normal appearance and measured the distances between anatomical landmarks.

Results:

The mean distances from the base of the columella to the anterior wall of the sphenoid sinus, and the sellar floor were 69.71±4.25 mm and 86.26±4.57 mm, respectively, in the over 15 age group and showed the smallest degree of variation among the measurements. The mean angles between the floor of the nasal cavity and the straight line connecting the base of the columella and the sellar floor were 29.45°±3.25° and 24.75°±4.00° in the over 15 and under 15 age groups, respectively. The mean values of both distances and angles increased with age until 15 years, after which no further increases were evident. There were no significant differences in the measurements between males and females or among subjects with different degrees of pneumatization in the over 15 age group.

Conclusions:

The distances from the base of the columella to the sellar floor and the anterior wall of the sphenoid sinus, which were consistent among individuals, could be used as a surgical indicator to investigate the sellar floor in endoscopic or microscopic transsphenoidal approaches.
Outpatient Treatment of Post Endoscopic Sinus Surgery Adhesions: How We Do It
Authors: Lee Yi‐Jie , Lo Stephen , Yeak Samuel
Published: August 2013

Objectives:

The formation of intra‐nasal adhesions following endoscopic sinus surgery (ESS) is a well‐known cause of surgical failure. These arise from raw wound edges resulting in progressive nasal obstruction and leading to closure of recess openings. Many publications discuss various intra‐operative nasal packing or hemostatic agents with regard to post‐operative hemostasis and wound healing but not affecting adhesion formation. The difficulty lies with maintaining airway patency post‐operatively, as adhesion recurrence rate is high.

Methods:

A retrospective study on all patients operated by the authors who had ESS for chronic sinusitis or nasal polyposis between January 2011 and December 2011 revealed 16 nasal cavities that developed post‐operative intra‐nasal adhesions. Adhesiolysis was performed under local anesthesia in the outpatient department. Gelfoam was placed over the raw edges as a hemostatic aid and to avoid reformation of adhesions. This was repeated weekly until the edges healed.

Results:

All patients (100%) were treated successfully with no adhesion recurrence after 6 months. The longest outpatient treatment was for 8 weeks with the mean at 5 weeks.

Conclusions:

Adhesions are well known complications following ESS reducing surgical efficacy. Repeated surgeries for adhesiolysis are usually unsuccessful, as recurrences are common. This is the first study describing the use of Gelfoam for treatment of post‐operative intra‐nasal adhesion formation with 100% success rate and no recurrences. This can be easily performed under local anesthesia in the outpatient setting. This avoids unnecessary inpatient admissions or the risk of general anesthesia, providing safer and better quality care for patients.
Preapproval of Sinus Computed Tomography for Evaluation of Chronic Rhinosinusitis Does Not Save Healthcare Costs
Authors: Sedaghat Ahmad R. , Gray Stacey T. , Kieff David A.
Published: August 2013

Objectives:

Evaluate cost effectiveness of required pre‐approval for computed tomography (CT) of the sinuses for chronic rhinosinusitis (CRS) evaluation by weighing the associated cost of pre‐approval against savings from rejected claims. Study design: Retrospective analysis of prospectively collected data. Setting: An academic otolaryngology practice.

Methods:

Over a 6‐month period, all sinus CT scans ordered and requiring pre‐approval by a third‐party payer were tabulated. Characteristics of the pre‐approval process that were recorded and analyzed included time spent by office administrative staff, need for peer‐to peer review, and time spent by the ordering physician.

Results:

All 111 sinus CT scans ordered required pre‐approval based on insurer requirements—38 performed by computer, 71 by telephone, and 2 required both–costing an average of 8.1 minutes per scan by administrative staff (range: 2.0 – 20.0 minutes). 13 pre‐approvals required peer‐to‐peer telephone interaction by the ordering physician, using an average of 7.7 minutes (range 5 – 12 minutes). In no case was the insurance company “peer” an otolaryngologist. Moreover, no sinus CT scan pre‐approval was ultimately rejected by the third party payer.

Conclusions:

Pre‐approval for sinus CTs ordered by otolaryngologists neither saves costs for third‐party payers nor leads to appropriate rejection of scan requests because sinus CT for the evaluation of CRS is well‐established and the standard of care. However, pre‐approval in this context comes at the expense of practice administrative and physicians’ time. Pre‐approval for sinus CT scans ordered by an otolaryngologist for evaluation of CRS is an unnecessary and costly requirement.
Prevalence of Respiratory Viruses in Chronic Rhinosinusitis and Its Influence on the Mucosa
Authors: Anselmo Lima Wilma T. , Paula Flavia E. , Lima Jesse , Modena Jose L. Proença , Arruda Eurico , Valera Fabiana , Tamashiro Edwin
Published: August 2013

Objectives:

Find a correlation between the presence of respiratory viruses and the pathogenesis of chronic rhinosinusitis (CRS).

Methods:

Prospective cross‐sectional study. Genomes of respiratory viruses in patients were analyzed by real‐time polymerase chain reaction (PCR) in samples of nasal washes and nasal tissue samples obtained from both CRS with polyps (CRSwNP) and without nasal polyps (CRSsNP). Histological analysis was also performed to quantify eosinophils, neutrophils, and lymphocytes.

Results:

A total of 132 patients were evaluated, 31 controls, 31 patients with CRSsNP, and 70 patients with CRSwNP. Considering all samples together, human metapneumovirus (HMPV) and human rhinovirus (HRV) were the most frequently detected virus genomes found in CRS patients, present in respectively 19 of 70 and 16 of 70 of patients with CRSwNP, as opposed to 5 of 31 of HMPV and 4 of 31 of HRV in those with CRSsNP. In CRSsNP the virus presence was associated with a lower count of lymphocytes and neutrophils, but not to eosinophils count. In CRSwNP group, the virus presence was associated to a higher count of lymphocytes and neutrophils and to a lower count of eosinophils. Regarding rhinovirus presence, no cell count was associated with its presence in CRSwNP, and in CRSsNP the rhinovirus presence was associated only with a lower count of lymphocytes.

Conclusions:

The high detection of respiratory viruses in these patients highlights the need for further studies detailing possible roles that these ubiquitous respiratory agents may have in the pathogenesis of CRS.
Removal of a BB from the Nasofrontal Outflow Tract Using a Urologic Basket
Authors: Shipchandler Taha Z. , Taraska Allison K.
Published: August 2013

Objectives:

1) Describe a novel approach to BB removal from the nasofrontal outflow tract. 2) Present pre‐, intra‐, and post‐operative photographs and imaging to illustrate surgical technique. 3) Review other techniques described for similar foreign bodies.

Methods:

Case report of patient receiving treatment in November 2012. The patient presented with a history of BB trauma to the forehead eight months prior. Imaging revealed a BB lodged in the right nasofrontal outflow tract. Symptoms reported since the trauma included headache and facial pain.

Results:

This case resulted in successful removal of the BB using a Lynch incision approach and retrieval of the BB with a urologic basket device. The incision was made through the scar that resulted from the initial trauma. The frontal sinus was entered using a standard otologic drill. The BB was noted to be lodged in the nasofrontal outflow tract. A urologic basket was used to grasp the BB and remove it from the tract. This resulted in removal with minimal tissue trauma. The patient reported improvement in symptoms following the procedure.

Conclusions:

There are several case reports in the literature involving endoscopic or external approaches to foreign body removal within the frontal sinus. In these cases standard instruments such as hemostats were used for retrieval. The location within the nasofrontal outflow tract is unique and emphasizes the importance of removal with minimal tissue trauma to prevent stenosis. This case illustrates an opportunity to use seemingly unrelated surgical equipment to accomplish impacted foreign body removal with minimal trauma to surrounding tissues.
Sinonasal Mucosal Melanoma: 20‐Year Experience at a Tertiary Referral Center
Authors: Vorasubin Nopawan , Peng Kevin , Sanaiha Yas , Suh Jeffrey D. , Wang Marilene
Published: August 2013

Objectives:

Sinonasal melanoma (SNM) is a rare cancer with extremely poor prognosis. Detecting melanoma on frozen section has historically been considered to be unreliable. A review of cases of SNM treated at a tertiary referral center was conducted with emphasis on investigating the correlation between detecting melanoma on frozen section and permanent analysis.

Methods:

An institutional review board (IRB)‐approved search of the pathology database for cases of primary SNM treated between 1991‐2011 was performed. The medical charts were then reviewed.

Results:

Fourteen cases of SNM were identified. Eleven arose from the nasal cavity, 2 arose from the maxillary sinus, and 1 from bilateral ethmoids. At average follow‐up period of 22 mos (2‐85 mos), 13 patients were alive. Five cases were free of disease (NED), 6 had recurrent disease (RD), and 3 had unknown disease status. Patients with NED presented at an average age 67 years (47‐82 years). On pathological analysis, average melanoma size was 5.2cm (2‐9cm), all had clear margins, 2 had perineural invasion (PNI), and 1 had lymphovascular invasion (LVI). Four received adjuvant radiation (XRT). Of the RD patients, average age was 63.7 years. On pathologic analysis, average size of the tumor was 2.3cm (0.5‐3.5cm); margin status was positive in 2, clear in 2, and not evaluated in 2 cases. Ten cases had evaluation of intraoperative frozen sections. When compared with final pathology, FS correlated with permanent section 100% cases. One had LVI with PNI, and 5 cases received XRT.

Conclusions:

Based on this series, intraoperative frozen section analysis of SNM correlates well with final pathology.
Integrative Analysis Identifies Genes Disrupted by DNA Methylation in Oral Cancer Progression
Authors: Towle Rebecca , Poh Catherine F. , Garnis Cathie
Published: August 2013

Objectives:

1) Identify genes deregulated through altered DNA methylation in oral cancer. 2) Gain a better understanding of pathways involved in OSCC progression.

Methods:

Multiple biopsies were obtained from an oral cancer (OC) field exhibiting hyperplasia, dysplasia, and carcinoma in situ (CIS)/squamous cell carcinoma (SCC) from ten patients. DNA and RNA from microdissected tissue samples were extracted. Methylation levels were obtained using the Illumina Infinium HumanMethylation27K microarray, and gene expression levels were assessed using the Agilent Human Gene Expression 4x44k microarray. Significant genes were identified using a Wilcoxon signed rank test. Data from both platforms were integrated and candidate genes identified.

Results:

We identify numerous genes that exhibit both aberrant methylation and matched altered gene expression. In oral dysplasias we identify PEG10 and SOX17 as being frequently deregulated. These genes have roles in the TGFbeta and WNT signal transduction pathways, respectively, and crosstalk between these two pathways has been observed previously in tumorigenesis. In the CIS/SCC biopsies, we observe 67 genes hypermethylated and 113 hypomethylated in at least 30% of cases with matched altered gene expression.

Conclusions:

This is the first report integrating profiles of DNA methylation and gene expression data for different histological stages of OC. Given the frequency of methylation and expression correlating with one another, we demonstrate that methylation is one of the critical mechanisms in OC progression.
Toxic Shock Syndrome following Septoplasty: Report of 2 Cases and Literature Review
Authors: Gurunathan Ramesh K. , McCadden Luke , Nadig Shrinath
Published: August 2013

Objectives:

Toxic shock syndrome (TSS) is a rare but potentially life‐threatening multisystem disease. Reported incidence after nasal surgery is 16.5 per 100,000 operations. We report 2 such cases from Northern Ireland occurred over last 8 years (2006 and 2012). Diagnostic criteria, pathogenesis, and management of TSS are discussed.

Methods:

Case 1: A 19‐year‐old man developed sudden severe facial swelling, fever, diffuse erythroderma, tachycardia, and hypotension 16 hours after routine septoplasty and cautery to inferior turbinates. He had sialastic internal nasal splints and calcium alginate packing. Initially anaphylaxis to latex or diclofenac was suspected but disproved by lab investigations. He had surgical tracheotomy to protect airway from progressive facial cellulitis. Nasal swab confirmed grown staphylococcus aureus (TSST‐1 producing‐strain), and he recovered slowly with antibiotics. Case 2: A 24 year‐ old man developed a mild form of TSS 36 hours post‐surgery after routine septopasty and Merocel packing, with nausea, hypotension, tachycardia, fever, and erythroderma. TSS was promptly suspected. The patient moved to intensive care for supportive care of refractory hypotension, and he made a slow recovery with antibiotics. Nasal swab had grown staphylococcus aureus. (TSST‐1 strain).

Results:

TSS cases following nasal surgery have been associated with nasal packing, mucosal barrier violation, and prior colonization of toxic‐shock‐syndrome‐toxin‐1 (TSST‐1) strain as well as low antitoxin antibody levels. Hence TSS requires nasal carriage of a toxigenic strain of staphylococcus aureus by a susceptible patient. Topical or systemic antibiotics did not have a demonstrable protective effect.

Conclusions:

Early recognition and prompt intervention minimize the morbidity and mortality associated with this disease.
Indications and Safety of Up‐to‐Date Lingual Tonsillectomy
Authors: Siupsinskiene Nora
Published: August 2013

Objectives:

To describe the main indications for lingual tonsillectomy (LT) and to analyze the safety and post‐operative morbidity of LT with laryngoscopic approach.

Methods:

In this prospective observational study, 70 consecutive adult patients (31 males and 39 females) with hypertrophic lingual tonsils proven by fibronasolaryngoscopy during April 2009 to December 2012 operated at a university hospital were selected. LT was performed under general anesthesia and direct micropharyngoscopy with laryngeal microinstruments and electrocoagulator. Indications for operation, procedure time, intraoperative blood loss, post‐operative pain measured using 100‐mm visual analogue scale (0– no pain, 100– extreme pain), complications (post‐operative bleeding, edema of epiglottis and infection), and length of stay in the hospital were assessed.

Results:

Dysphagia in relation to laryngopharyngeal reflux (55.7% of cases) and sleep‐disordered breathing (38.6% of cases) were the main indications for LT. Mean procedure time was 41.1+/‐ 10.2 min. with an average intraoperative blood loss of 21.9+/‐ 11.1 ml. Post‐operative pain score for the first two days was mild and ranged from 0 to 51 points (mean 27.8+/‐ 9.8 points). There was no post‐operative bleeding. Three patients (4.3%) had slight edema of epiglottis. Mean discharge time was 2.4 days. Post‐operative pain was positively moderately related to procedure time, amount of intraoperative blood loss, and degree of lingual tonsil hypertrophy (p<0.01).

Conclusions:

Lingual tonsillectomy using laryngoscopic approach is a safe method with minimal post‐operative morbidity and could be routinely used in clinical practice.
Obstructive Sleep Apnea and Its Comorbidities: A Study of 100 Patients
Authors: Pinto Jose A. , Mizoguchi Elcio I. , Ribeiro Renata C. , Martins Laila P. M. , Dias Seliram B. F. , Gomes Leonardo M.
Published: August 2013

Objectives:

Evaluate the main comorbidities associated with obstructive sleep apnea (OSA) and its prevalence in a group of patients diagnosed with OSA by polysomnography.

Methods:

Patients with symptoms suggestive of sleep disorder underwent full‐ night attended polysomnography. Retrospective study of 100 charts of patients previously diagnosed OSA in our service between October 2010 to January 2013. We classified the degree of apnea according to the values of the apnea hypopnea index (AHI) by polysomnography: mild (5 to 15 events/ hour), moderate (15 to 30 events/ hour), and severe (more than 30 events/ hour).

Results:

A total of 100 patients, 84 men and 16 women, mean age 50.05 years ranging from 19 to 75 years. The prevalence of comorbidities were: arterial hypertension (39%), obesity (34%), depression (19%), gastroesophageal reflux disease (18%), diabetes mellitus (15%), hypercholesterolemia (10%), and asthma (4%), and 33 patients had no comorbidities. The comorbidities occurred in 56.2% of patients diagnosed with mild OSA, 67.6% with moderate OSA, and 70% with severe OSA.

Conclusions:

Patients with OSA present a high prevalence of several comorbidities. Patients with moderate and severe OSA presented more comorbidities than patients with mild OSA.
The Prevalence and Topography of Multiple Level Obstruction in Cases of Obstructive Sleep Apnea
Authors: Hennawi DIiaa Mohamed El , Madian Yasser T. , Tabbakh Mohamed T. , Rashwan Mohamed S.
Published: August 2013

Objectives:

Determine the prevalence of multiple level obstruction and the frequency of their sites in cases of obstructive sleep apnea.

Methods:

The sample size of this descriptive cross sectional study was an inclusive sample including all patients presenting to the outpatient clinic of Suez Canal University Hospital, Ismaila Egypt complaining of snoring with or without obstructive sleep apnea (OSA) between January 1 and December 31. All patients were evaluated by Müller maneuver followed by polysomnography. Patients diagnosed with OSA were subjected to drug induced sleep endoscopy (DISE). Grades and patterns of obstruction were evaluated by NOHL classification.

Results:

Of thirty patients, nine (33%) showed multiple levels of obstructions. One had 25‐50% obstruction in the oropharynx, 50‐75 % obstruction in the hypopharynx, and a flappy epiglottis. Two had 50‐75% obstruction in the oropharynx, different degrees of obstructions in the oropharynx, and a flappy epiglottis. Six had 75‐100% of obstructions at both oropharynx and hypopharynx.

Conclusions:

From the above results management strategy of OSA should be reformed to improve the quality of management.
Prospective Analysis of Sleep Stages, Obstructive Sleep Apnea Status, and Head and Neck Anatomy
Authors: Dion Gregory R. , Chapa Emily , Dodge Ross , O'Connor Peter
Published: August 2013

Objectives:

1) Determine if time in each sleep stage correlates to presence and severity of obstructive sleep apnea (OSA). 2) Analyze anatomy from nasopharyngoscopy and an otolaryngology exam for correlation with sleep stages. 3) Compare Epworth sleepiness scale (ESS), Nasal Obstruction and Septoplasty Effectiveness (NOSE) survey, and the Calgary Sleep Apnea Quality of Life Index (SAQLI) with sleep stages and OSA.

Methods:

Twenty‐one subjects referred for polysomnography (PSG) by a primary care provider to the Wilford Hall Ambulatory Surgery Sleep Center prospectively underwent PSG, completed three surveys (ESS, SAQLI, and NOSE), and had a head and neck examination to include Fujita and Mallampati classification, tonsil size, palatal phenotype, and percent glottis visible at rest and on jaw jet on nasopharyngoscopy. In addition to demographics and standard PSG data (AHI, RDI, RERA, and lowest oxygen saturation), time in each sleep stage was calculated. Regression modeling was used for analysis.

Results:

Nine of twenty‐one subjects had OSA (7 mild and 2 severe). Initial regression analysis revealed trends towards increased Stage I and II sleep and decreased stage III and rapid eye movement (REM) sleep with OSA. SAQLI scores correlated with Stage I and II sleep and inversely with Stage III and REM sleep. No anatomic data trended towards significance between OSA or primary snoring subjects.

Conclusion:

This pilot study suggests subjects with OSA are less likely to achieve deep sleep and have worse quality of life scores. Typical anatomy used in sleep surgery did not correlate with time in sleep stages.
Quality‐of‐Life Assessment before and after Uvulopalatopharyngoplasty Patients with Syndrome Diagnosis of OSA
Authors: Beilke Silvia C. A. S. B. , Peccini Isabele F. C. , Lorenzetti Fabio T. M.
Published: August 2013

Objectives:

Quality of life is dependent on socioeconomic, cultural, and health variables. Obstructive sleep apnea syndrome (OSAS) is an important and prevalent disease associated with poor quality of life in many patients. There are few studies in the literature discussing the surgical treatment for OSA with quality of life. The Short Form‐36 (SF‐36) is an instrument for measuring quality of life. It has been applied in various situations with good sensitivity. 1) Describe the quality of life in patients with OSA before and after performing uvulopalatopharyngoplasty. 2) Extend the literature on the relationship between uvulopalatopharyngoplasty and quality of life of patients with OSA.

Methods:

A descriptive study, conducted between August and December 2012. We applied the SF‐36 questionnaire before and after uvulopalatopharyngoplasty in 11 patients (10 males and 1 female) between 27 and 67 years old, diagnosed with mild, moderate, or severe OSA (believing in the positive influence of such surgery on quality of life of these patients).

Results:

11 patients showed improvement in the overall assessment of quality of life. There was improvement in functional capacity in 6 (54.4%) patients; limitation on the physical aspects in 4 (36.36%), the pain in 7 (63.63%), the general state of health in 9 (81.81%), vitality in 5 (45.45%), social aspects in 5 (45.45%), emotional aspects in 5 (45.5%), and mental health in 5 (45.5%), and there was no worsening in any domain (P < 0.05 in all domains).

Conclusions:

In addition to polysomnographic analysis and the AHI, the questionnaires about quality of life may be relevant in assessing the therapeutic outcome for OSAS.
Relationship between Epiglottis and Severity of Obstructive Sleep Apnea
Authors: Serin Gediz M. , Aksoy Elif A. , Polat Senol , Emre Emrah , Unal Omer Faruk , Tanyeri Hasan M.
Published: August 2013

Objectives:

The aim of this retrospective case‐control study was to define epiglottis morphologies and to investigate the relationship between the angle of the laryngeal surface of the epiglottis (ALSE) and the severity of obstructive sleep apnea (OSA) using flexible optic laryngoscopy (FOL) images.

Methods:

Eighty‐three patients with OSA (Group 1) and 87 patients with no complaints of OSA (Group 2) were evaluated. The ALSE was measured using ImageJ through FOL images. ALSE measurements were compared between the two groups. The correlation of ALSE measurements to the respiratory disturbance index (RDI) was analyzed.

Results:

Group 1 comprised 79 male and 4 female patients with a mean age of 43 years. Group 2 comprised 72 male and 15 female patients with a mean age of 39 years. The mean ALSE measurement was 139.7 degrees in Group 1 and 140.08 degrees in Group 2 and was not significantly different between the two groups (P value greater than 0.05). The mean RDI in Group 1 was 28.83, showing evidence of a low correlation between ALSE measurements and RDI. Epiglottis morphology revealed three different shapes: concave epiglottis and slightly observed petiole, minimally concave epiglottis with petiole dominancy, and severe concave epiglottis (omega epiglottis).

Conclusions:

Three different morphologies were observed through FOL examinations. The ALSE measurements were not significantly different between patients with OSA (Group 1) and control subjects (Group 2). This might indicate that the ALSE cannot be used as a predictive factor in OSA pathophysiology.
Sleep Apnea Syndrome Appears Early, Complicated with Allergic Rhinitis
Authors: Asako Mikiya , Tomoda Koichi
Published: August 2013

Objectives:

The effect of allergic rhinitis on sleep apnea syndrome.

Methods:

75 outpatients had sleep trouble and consulted the sleep apnea clinic in the otolaryngology department of our hospital from November 2011 through October2012. They were arranged in 4 specific groups (with seasonal allergic rhinitis, with perennial allergic rhinitis, with both types of rhinitis, without allergies). This study was analyzed by Mann‐Whitney U‐test.

Results:

In our sleep apnea clinic, 35% had no allergic rhinitis and 65% had complicated allergic rhinitis (49/75), including 51%(25/49) with both perennial and seasonal allergic rhinitis, 37% (18/49) with only seasonal rhinitis, and 12% (6/49) only perennial allergic rhinitis. RIST (radioimmunosorbents tests) of people with both types of rhinitis were higher than in other groups (p<0.05). The age of people with both types was lower than without it (p<0.05). Although AHI (apnea hypopnea index) of people without rhinitis were higher than with seasonal rhinitis (p<0.05), AHI without is not much different from with both types of rhinitis.

Conclusions:

According to inflammation of allergic rhinitis as high RIST, sleep apnea with both perennial and seasonal allergic rhinitis developed young compared with sleep apnea and non allergic rhinitis. Sleep apnea was worse when complicated with severe allergic rhinitis. It is thought that nasal mucosal hypertrophy from inflammation of severe allergic rhinitis would cause nasal obstruction, and sleep apnea would worsen due to inflammation.
Target‐Controlled Infusion of Propofol‐Induced Sleep Endoscopy for Patients with Obstructive Sleep Apnea
Authors: Lin Hsin‐Ching , Friedman Michael
Published: August 2013

Objectives:

Drug‐induced sleep endoscopy (DISE) allows inspection of upper airway to accurately localize the anatomical region that collapses in obstructive sleep‐apnea‐hypopnea syndrome (OSAHS). The sedation technique adopted in most centers throughout Europe is the target controlled infusion (TCI) of propofol without oxygen supply. The goal of this paper is to compare the advantages of supplemental oxygen during this procedure.

Methods:

Medical records of 61 patients diagnosed with OSAHS by full‐night PSG who underwent drug‐induced sleep endoscopy (DISE) with propofol to evaluate the upper airway were retrospectively reviewed. No patients were on any premedication preoperatively before DISE. Besides applying standard anesthetic monitors, a bispectral index monitor (BIS) Quatro sensor was positioned on the forehead as per manufacturer's instructions. If patients had brisk response of limb movement, the sedative dosage was adjusted by specialized anesthesiologists. The demographic variables of age, gender, BMI and intraoperative presentations of effect site concentration of Propofol ((µg/mL)), BIS level, infusion time, and involuntary movement were collected for analysis.

Results:

By achieving the same level of sedation detected by the BIS monitor, the severe OSAHS patients needed a higher effect site concentration of propofol (5.3 ± 1.1 μg/mL in severe OSAHS vs. 4.5 ± 1.4 μg/mL in mild/moderate OSAHS, p=0.025, Mann‐Whitney U test) and obviously involuntary movement. No adverse effects or complications were noted during this procedure.

Conclusions:

Target controlled infusion of Propofol‐induced sleep endoscopy for OSA patients is a feasible and safe procedure. Severe OSAHS patients experienced worse saturation during overnight sleep and obviously involuntary response in sedated endoscopy even with higher predicted concentration of Propofol.
Biochemical and Biomechanical Properties of the Rabbit Nasal Septum
Authors: Watson Jeffrey , Gruissem Sophia , Yamaguchi Tomonori , Briggs Kris , Sah Robert , Masuda Koichi , Watson Deborah
Published: August 2013

Objectives:

1) Characterize biochemical and biomechanical properties of New Zealand White rabbit septal cartilage for future utilization in rabbit septal cartilage tissue engineering studies. 2) Determine whether tensile and bending properties vary when measured in different axes.

Methods:

Nasal septa were harvested from adult New Zealand White rabbits post‐mortem. Confined compression testing was performed. Samples cut in the vertical and anterior‐posterior (AP) plane were subjected to tensile testing and 3‐point bending. Biochemical assays determined the Glycosaminoglycans (GAG), total collagen, and DNA concentrations in each sample.

Results:

Confined compression demonstrated an average compressive modulus (HAO) of 0.82 (±0.23 MPa). In tensile testing, peak stress of samples cut in the vertical plane (6.61±1.28 MPa) were significantly greater (p=0.02) than in the AP plane (5.22±1.31 MPa). Tensile stiffness at failure strain for vertical (22.90±5.51 MPa) and AP (18.67±9.56 MPa) samples did not differ significantly (p > 0.05). The flexural moduli of samples cut in the vertical plane (39.31±16.6 MPa) and AP plane (39.32±20.24 MPa) were also not significantly different (p > 0.05). Biochemical characterization demonstrated an average concentration of 43.81±8.34 µg GAG, 104.71±21.52 µg total collagen, and 0.23±0.05 µg DNA per mg wet weight.

Conclusions:

Rabbit septal cartilage is anisotropic; tensile strength was higher in the vertical plane than in the AP plane. Compared with published properties of human septal cartilage, rabbit septal cartilage is mechanically stronger, stiffer, and less flexible. Rabbit septal cartilage has a similar DNA content, with higher GAG and total collagen levels than values published for human septal cartilage.
Laryngoscope Illuminance in an Academic Medical Center: Industry Standards and Implications for Quality Direct Laryngoscopy
Authors: Murphy Michael K. , Volsky Peter G. , Darrow David H.
Published: August 2013

Objectives:

Compare laryngoscope illuminance to established standards and identify maintenance and design features associated with poor light output.

Methods:

An observational study in a tertiary‐care medical center (level‐one trauma center, specialty cardiac hospital, and general hospital) was performed from January‐November 2012. Illuminance (lux) was chosen as the unit of measurement. Laryngoscopes in the main operating room (OR), cardiac OR, outpatient OR, emergency department/trauma bay (ED), and code carts were tested using a standard technique. International Standards Organization (ISO) and medical literature values were used for comparison. Maintenance practices were surveyed.

Results:

Six hundred ninety‐one laryngoscopes were tested. Devices varied by light source and design, including light‐emitting diode (LED), incandescent bulb (on‐blade and in‐handle), and xenon. The lowest illuminance was observed by incandescent designs (bulb on‐blade, 820±700 lux, n=237; bulb in‐handle 1860±1220 lux, n=79), followed by LED (4730±3210 lux, n=354), and xenon source (28800±34500 lux, n=21). Forty units (6%) failed to turn on at all, classified as failing, (11% bulb on‐blade, 6% LED). Compared to illuminance benchmarks for laryngoscopy in the medical literature (867 lux) and ISO (500 lux), 59% of incandescent laryngoscopes, 12% of LED laryngoscopes, and 10% of xenon units did not meet quality standards for laryngoscopy (7% devices overall). All units were cleaned by standard protocols, but no departments reported regular equipment maintenance.

Conclusions:

Up to 13% of laryngoscopes in an academic medical center were found to be substandard. Quality‐control programs may reduce numbers of deficient laryngoscopes in circulation, improving airway management and patient care.
Military Otolaryngology Resident Case Numbers and Board Passing Rates from 2001‐2010
Authors: Scalzitti Nicholas , Maturo Stephen C. , Brennan Joseph , Boston Andrew
Published: August 2013

Objectives:

1) Compare the caseloads of graduates from military otolaryngology residency programs to the national averages for the years 2001‐2010. 2) Measure residency outcomes by comparing the board exam pass rates of military otolaryngology graduates to their civilian complement.

Methods:

Resident caseload data and board exam passing rates were requested from each of the Department of Defense Otolaryngology residency programs for the years 2001‐2010. The American Board of Otolaryngology and the Accreditation Council for Graduate Medical Education provided the national averages for resident caseload for these years, as well as national passing rates on the certifying board exam. The pooled numbers from the military programs were then compared to the national averages for total cases, cases in defined categories, and board passing rates.

Results:

Data were available for all but one military otolaryngology residency program. Regarding total cases, only the years 2001 and 2003 showed a significant difference (p<0.05), with military residents completing more cases in those years. For the 10 year averages in individual categories, the military residents reported more cases in otology (299.6 vs. 261.2, p=0.009) and plastics/reconstruction (248.1 vs. 149.2, p=0.0003). No category showed a significant difference in 10 year average favoring the national average over the military. Military residents demonstrated a first‐time board exam pass rate identical to the national average (93%).

Conclusions:

The results suggest that as a whole, the military otolaryngology residency programs are keeping pace with their civilian counterparts in resident education. Resident caseload has not been compromised by the war effort.
Older Adult Golf Cart and All‐Terrain Vehicle (ATV)–Related Craniofacial Injuries
Authors: Pate Mariah B. , White Lauren , Jin Chan , Waller Jennifer , McKinnon Brian J.
Published: August 2013

Objectives:

Analyze the etiologies of craniofacial and temporal bone injury in older adults involved in recreational vehicle trauma.

Methods:

A chart review at a level one trauma center from 2000‐2012 included 58 patients over 50 years old. Data obtained include the following variables: age, gender, race, mechanism of injury, intoxication, hospital stay, vehicle type, Glasgow coma score (GCS), injury severity score (ISS), and helmet use.

Results:

Of the 58 patients identified, the mean age was 60.5, and the majority were white (90%) and male (78%). Eleven patients (19.3%) had a craniofacial injury (CFI), and two patients (3%) had a temporal bone fracture. The most common CFI was an orbital wall fracture (64%), followed by maxilla (27%) and nasal bone fracture (27%). Patients with a closed head injury are nearly ten times as likely to incur a CFI (P = 0.0346), and those injured while intoxicated are over seven times more likely to have CFI (P = 0.0084). Patients with a temporal bone fracture are more likely to suffer concurrent additional CFI (P = 0.035). There were no statistical differences in the incidence of CFI in relation to age, race, sex, ISS, GCS, or vehicle type. CFI was not a predictor of the length of hospital stay or mortality. Helmet use and mechanism of injury are not related to the incidence of CFI.

Conclusions:

Recreational vehicle trauma is a risk to older patients. Alcohol is a strong risk factor for CFI. For patients with close head injuries and/or a temporal bone fracture, concurrent CFI should be anticipated.
Percutaneous Tracheostomy Boundaries Revisited
Authors: Kizhner Victor Z. , Bertetti Richard , Lebovics Robert S.
Published: August 2013

Objectives:

As percutaneous tracheostomies (PCT) which have various contra‐indications (CI) are increasingly performed by non‐otolaryngologists, the otolaryngologist's role is reviewed. The ability of tracheal palpation was the single criteria to perform PCT.

Methods:

A retrospective study analyzing adult PCT performed by otolaryngologists from 2011‐2012. All PCT were performed using the Ciaglia blue‐rhino‐tracheostomy kit and Shiley's tracheostomy cannulas. Most procedures were performed with the same anesthesiologist.

Results:

A total of 60 PCT were identified with subject ages 18‐91. None were converted to open tracheostomy. No bronchoscopic guidance was used. PCT was performed for the following CI: 2 bleeding disorder, 4 goiters, 4 cervical rigidity (surgical, traumatic and constitutional), 5 emergent tracheostomies, 1 head and neck cancer 9 short necks. Complications recorded were 1 wound bleeding and 1 pneumomediastinum, both controlled locally. Pertinent anatomy revealed the intubation tube was withdrawn to the level of 14cm and 16cm from incisor level in women and men respectively.

Conclusions:

PCT is a safe procedure. When performed by an otolaryngologist even the relative CI can be overcome. Tracheal palpation and an experienced anesthesiologist are mandatory for the procedure's success. The otolaryngologists’ advantage is a better anatomical understanding with the ability to convert the procedure to a formal tracheostomy as needed and avoidance of hypercarbia due to bronchoscope use. Otolaryngologists should be the first line providers in any tracheostomy
Peritonsillar Abscess Procedural Simulator
Authors: Chen Nan , Chang C. W. David
Published: August 2013

Objectives:

To develop a locally constructed, low‐cost model for simulation of drainage of peritonsillar abscess to help new residents gain familiarity with the instrumentation and essential steps involved in the procedure.

Methods:

A two‐piece latex moulage model shaped from a plaster mold was constructed to replicate an oropharynx with a unilateral tonsillar abscess. Cream‐colored viscous liquid sandwiched between the outer tonsil moulage and the palate moulage simulated the abscess. The construct was then placed behind a silicone CPR dummy mask.

Results:

Initial impressions by faculty and senior residents during a simulation lab were favorable in that the models sufficiently replicated the anatomy of oropharynx in the presence of a peritonsillar abscess. Completion of the simulated task required bimanual dexterity and comfort with use of headlight and instrumentation within an enclosed space similar to that required in the real situation. Cost of the models was estimated at less than one dollar each, using materials easily found at local hobby stores.

Conclusions:

Production of a low‐cost simulator for drainage of peritonsillar abscess is feasible and may provide a reasonably realistic environment to allow residents to practice and develop this skill. Further study is needed to formally assess face, construct, and content validity of this simulator for teaching and assessment of procedural competency.