bluuebunny/crossref_metadata_2025 huggingface dataset:
Nasal Mucus Glucose and Chronic Rhinosinusitis
Authors: Hatten Kyle M. , Palmer James N. , Lee Robert J. , Adappa Nithin D. , Kennedy David W. , Cohen Noam A.
Published: September 2014

Objectives:

Respiratory secretion glucose concentration is tightly regulated and contributes to airway innate immunity. Thus, we set out to quantify nasal mucus glucose concentration in chronic rhinosinusitis (CRS) patients and correlate these values to CRS symptoms.

Methods:

Prospective, single‐center study measuring nasal mucus glucose concentration in patients diagnosed with chronic rhinosinusitis and age/race matched controls from July 1, 2013, to January 1, 2014. Enrollment included subjects >18 years of age evaluated in academic otolaryngology practice. Subjects completed questionnaires including extensive history of medical and surgical therapies as well as CRS‐specific quality of life measurements (SNOT‐22). Subjects underwent nasal secretion sampling with sterilized Pope ear wicks. The nasal glucose concentrations of controls and subjects were analyzed with multivariate analysis to assess for confounding variables including systemic and topical glucocorticoid treatment.

Results:

Ninety‐five patients enrolled, and 3 patients were excluded because of history of sinonasal radiation. A statistically significant difference was measured between mean nasal glucose secretions of control subjects, 11.1 mg/dL (±1.0 mg/dL), compared to patients diagnosed with CRS, 18.4 mg/dL (±1.6 mg/dL) (P <. 01). No significant correlation was evident comparing nasal glucose concentrations to SNOT‐22 nor use of glucocorticoid (topical or systemic) therapy.

Conclusions:

CRS patients demonstrate elevated nasal glucose concentrations independent of therapeutic glucocorticoid use. However, nasal mucus glucose concentrations do not appear to correlate to CRS symptoms. The role of nasal mucus glucose concentrations in CRS pathophysiology has yet to be determined.
Nasoseptal Flap Reconstruction of Pediatric Sellar Defects: A Radiographic Feasibility Study
Authors: Purcell Patricia L. , Shinn Justin , Davis Greg E. , Otto Randolph , Parikh Sanjay R.
Published: September 2014

Objectives:

Computed tomography (CT) measurements were used to investigate the feasibility of performing vascularized nasoseptal flap reconstruction of sellar defects in children.

Methods:

Ten CT scans from children of each year of age from birth to 18 were obtained for 190 total subjects. Patients with incomplete pneumatization were excluded from analysis. Measurements of nasoseptal flap and sellar defect length were obtained for each subject using OSIRIX radiology software. Reconstruction was presumed feasible if the ratio of nasoseptal flap length to associated sellar defect length was greater than 1.

Results:

Of the 190 CT studies, 125 displayed complete pneumatization. Of these, 120 (96%) displayed a ratio of nasoseptal flap length to sellar defect length greater than 1, suggesting feasibility of flap reconstruction. Mean ratio of nasoseptal flap length to sellar defect length for all subjects was 1.47 (SD = 0.33) with 95% CI [1.41, 1.53]. Only 5 patients (4%) had inadequate nasoseptal flaps; mean age for these patients was 14.8 years (SD = 2.9), which is older than mean age of 11.6 years (SD = 4) for subjects with adequate measurements. The mean age difference did not meet significance with t‐test (P =. 069), likely due to the small number of patients with inadequate flaps. An inverse relationship was identified between age and ratio of nasoseptal flap length to sellar defect length (Pearson correlation coefficient –0.49).

Conclusions:

Flap length is not a limiting factor in nasoseptal flap reconstruction of sellar defects in children. Younger patients have higher ratios of nasoseptal flap length to sellar defect length than older patients.
Outcomes of Pressure‐Induced Cranial Neuropathies from Allergic Fungal Rhinosinusitis
Authors: Illing Elisa A. , Dunlap Quinn , Woodworth Bradford A.
Published: September 2014

Objectives:

Allergic fungal rhinosinusitis (AFRS) may present with significant bone erosion of the orbital walls or cranial base. Although proptosis is fairly common, cranial neuropathies are rarely reported. The objectives of this study are to describe strategies for AFRS‐induced neuropathies and evaluate ophthalmologic outcomes following endoscopic sinus surgery.

Methods:

A retrospective review of patients treated from January 2009 to December 2012 for AFRS‐induced cranial neuropathies was performed. Data regarding patient demographics, preoperative imaging, ophthalmologic symptoms, surgical intervention, histopathologic findings, and postoperative sinonasal and ophthalmologic outcomes were recorded.

Results:

Eight patients (average age 38 years; range, 18‐84 years) with AFRS presented with optic neuropathy or abducens nerve palsy. Subjects presented with unilateral visual loss secondary to optic nerve compression (n = 4), diplopia from unilateral (n = 2) or bilateral (n = 1) abducens nerve palsy, and bitemporal hemianopsia secondary to optic chiasm compression (n = 1). On average, the duration of ocular symptoms was 17 days (range, 2‐60 days). All patients underwent endoscopic surgical decompression of the sinuses and oral steroid therapy. Two individuals had an additional optic nerve decompression at the time of surgery. Six patients had complete return of nerve function, while 2 had partial recovery at an average of 5 weeks following surgery (range, 2‐12 weeks).

Conclusions:

Bone erosion of the sphenoid sinus walls by AFRS can lead to compression of surrounding neural structures producing cranial neuropathies. Identification of these symptoms and prompt surgical decompression and removal of disease along with aggressive medical therapy provided excellent outcomes in the current series of patients.
Experience in Training ICU Nurses to Perform Free Flap Monitoring to Accommodate Work Hour Restrictions
Authors: Khariwala Samir S. , Yueh Bevan
Published: September 2014

Objectives:

(1) Understand difficulties associated with free flap monitoring and duty hour restrictions. (2) Describe techniques used to train intensive care unit (ICU) nurses to conduct free flap monitoring. The implementation of resident duty hour restrictions has resulted in a variety of modifications to residency training programs in otolaryngology–head and neck surgery. In those programs using a home call system, monitoring of free flaps in the postoperative period can be associated with difficulties in resident duty hour compliance. We sought to use a carefully constructed training program to transition a portion of free flap monitoring to a skilled group of ICU nurses.

Methods:

A written reference manual describing the basic concepts behind free tissue transfer and normal free flap physiology was distributed. Nurses received a PowerPoint presentation and completed an online module designed to consolidate the didactic training. Finally, the responsibility of on‐the‐job training of the nurses was given to the otolaryngology house staff such that each nurse logged and documented 10 flap checks in the presence of a resident.

Results:

Thirty patients receiving free flaps were monitored by the ICU nursing team resulting in 100% flap survival.

Conclusions:

Transitioning the monitoring of free flaps in the perioperative period to ICU nurses can be accomplished through the following principles: (1) Leadership and participation by the microvascular surgeons at a given institution. (2) Faculty‐led didactic and web‐based training modules prior to actual training. (3) Significant involvement of the otolaryngology house staff, allowing the ICU nurses to gain proficiency.
Preliminary Findings: The Feasibility Study for a Randomized Controlled Trial of Clarithromycin in Chronic Rhinosinusitis
Authors: Bewick Jessica C. , Egro Francesco M. , Masterson Liam M. , Philpott Carl M.
Published: September 2014

Objectives:

There is currently conflicting level 1 evidence in the use of long‐term antibiotics for chronic rhinosinusitis. The primary aim of this study was to look at recruitment and retention of patients in preparation for a formal trial. The aim of this paper is to describe the preliminary outcomes in terms of symptomatic relief in patients with CRSsNP.

Methods:

Adult patients fulfilling the EPOS criteria for CRSsNPs with no prior surgery were recruited in 6 UK centers during 2013. Participants received a 12‐week course of clarithromycin 250 mg alongside topical mometasone and nasal douching, all twice daily. Follow‐up was at 3 months and 6 months. For the purpose of this analysis, the Sinonasal Outcome Test (SNOT‐22) score was recorded at baseline and both follow‐up assessments.

Results:

Preliminary data from 29 patients at 3 months and 24 patients at 6 months showed significant symptomatic improvement in mean SNOT‐22 scores on paired t tests at 3 months (40.4 to 33.7, P =. 026), which was sustained at 6 months (30, P =. 02). The number of subjects showing ≥9 point reduction in SNOT‐22 scores was 45% (n = 13), increasing to 58% at 6 months (n = 14). Nine patients have been listed for surgery to date.

Conclusions:

While the results here do not have the power of the full randomized controlled trial, the findings suggest that long‐term macrolides have the potential to achieve significant symptomatic reduction in approximately 50% of patients with CRSsNPs.
Radiofrequency Coblation versus Intramural Bipolar Cautery for the Treatment of Inferior Turbinate Hypertrophy
Authors: Shah Anil N. , Brewster Douglas , Mitzen Kelly , Mullin David P.
Published: September 2014

Objectives:

(1) Compare intramural bipolar electrocautery and radiofrequency coblation in the treatment of inferior turbinate hypertrophy with regard to objective and subjective improvement in nasal obstruction, rate and type of complications, experience during the procedure, and rate of recovery. (2) Describe 2 minimally invasive techniques in the management of turbinate hypertrophy with a comprehensive literature review of the efficacy of these methods.

Methods:

A prospective, randomized, single blinded study from 2008 to 2010 at a single tertiary medical center. Adult patients with inferior turbinate hypertrophy refractory to medical management were randomized to 2 groups based on which nostril they felt to be more obstructed. Patients were then treated with radiofrequency coblation in one nostril and intramural bipolar cautery in the other. Subjective and objective data, including use of a visual analog scale (VAS) for subjective outcomes, acoustic rhinometry, and nasal endoscopy, were then obtained from each patient comparing the 2 techniques.

Results:

Radiofrequency coblation was significantly less painful than intramural bipolar cautery for the early postoperative period (P <. 02), was considered less painful during the procedure (P =.03), and produced less crusting at 3 weeks (P =. 009). Both interventions were similar in subjective and objective improvements in nasal obstruction as measured by acoustic rhinometry and subjective VAS outcomes.

Conclusions:

Radiofrequency coblation seems to offer an equivalent alternative to bipolar electrocautery for the treatment of inferior turbinate hypertrophy with less discomfort during the procedure and early postoperative period.
Relationship between Pediatric Concha Bullosa and Septal Deviation
Authors: Amali Amin , Sazgar Amir A. , Sadeghi Mohammad , Saedi Babak , Langeroudi Maziar M. , Jafari Mehrdad , Hagh Ali B.
Published: September 2014

Objectives:

Investigate the frequency of pediatric middle turbinate pneumatization and present its possible effect on septal deviation.

Methods:

Computed tomography (CT) scans of 152 children (younger than 16 years old) were analyzed for the presence of middle turbinate pneumatization and nasal septal deviation.

Results:

The incidences of lamellar, bulbous, and extensive concha bullosa were 29.6%, 14.5%, and 7.2%, respectively. The data revealed that 53 patients (67.9%) with concha bullosa also had septal deviation as opposed to 50% (37 out of 74 cases) frequency of septal deviation in patients without concha bullosa. Among the 37 patients with right side concha bullosa, 59.5% had a deviated septum to their left side while 21.6% had a deviation to the right side. Out of those patients with concha bullosa on the left side (38 cases), 44.7% had a right side septal deviation and 13.2% had a left‐side septal deviation that revealed a significant relationship between the position of concha bullosa and the side where the septum deviated (P <. 001). The comparison of these ratios showed a significant relationship between the occurrence of septal deviation and concha bullosa (P =. 024).

Conclusions:

A possible relationship was found between middle turbinate pneumatization and the mechanism of development of septal deviation in children.
Self‐Crosslinked Hyaluronic Acid Hydrogel (PureRegen Gel Sinus) in Ethmoidectomy: A Randomized, Controlled Trial
Authors: Matheny Keith E. , Tseng Ewen , Carter Kenny B. , Cobb William B. , Fong Karen J.
Published: September 2014

Objectives:

Evaluate the safety and efficacy of a novel, self‐crosslinked hyaluronic acid (HA) hydrogel (PureRegen Gel Sinus) compared with carboxymethylcellulose (CMC) viscous foam (Stammberger SinuFoam) in promoting healing when applied following ethmoidectomy.

Methods:

Prospective, randomized, controlled, double‐blinded clinical trial, with 4 surgeons operating in 2 community hospitals. Thirty patients with bilateral chronic rhinosinusitis underwent bilateral ethmoidectomy. Intraoperatively, each patient received 2 mL of HA hydrogel in one ethmoid cavity, and 2 mL of CMC contralaterally. The material applied within each ethmoid cavity was randomly assigned before surgery. A fifth independent surgeon, blinded to the material used to treat each ethmoid cavity, evaluated postoperative endoscopic video at 1 and 2 weeks for edema, crusting, and mucopurulence and at 6 and 12 weeks for re‐mucosalization and scarring/synechiae. SinoNasal Outcome Test (SNOT‐20) data were collected preoperatively and at each postoperative visit. A small sample of the cohort underwent endoscopic mucosal biopsy for histologic analysis.

Results:

Twenty‐nine of 30 patients completed the protocol. The difference in edema, crusting, and mucopurulence at 1 and 2 weeks was not statistically significant; however, at 6 and 12 weeks, the HA hydrogel showed statistically significant reduction in synechiae formation (P <. 05), with a trend toward superiority in re‐mucosalization (P =. 08). Histologic analysis of 6 subjects at 12 weeks also showed a trend toward a greater amount of regenerated cilia present in the HA hydrogel‐treated ethmoid cavities (P =. 22). The cohort showed a 75.18% improvement in SNOT‐20 analysis.

Conclusions:

Self‐crosslinked hyaluronic acid hydrogel provides superior wound healing to carboxymethylcellulose after ethmoidectomy.
Sinonasal Symptomatic Outcomes following Laser Treatment of Epistaxis Related to Hereditary Hemorrhagic Telangiectasias
Authors: Wu Edward C. , Peng Kevin A. , Thompson Christopher F. , Suh Jeffrey D. , Wang Marilene B.
Published: September 2014

Objectives:

(1) Characterize baseline sinonasal symptoms for hereditary hemorrhagic telangiectasia (HHT) patients. (2) Analyze changes in sinonasal symptoms before and after laser surgical treatment for HHT.

Methods:

Retrospective chart review of sinonasal outcome test‐22 (SNOT‐22) scores before and after one or more laser surgical treatments for HHT‐related epistaxis between January 1, 2010, and December 31, 2013, in a tertiary academic medical center with an HHT Foundation‐approved Center of Excellence. All HHT patients who had undergone one or more laser surgical treatments by 1 of 2 otolaryngologists were included in the analysis. Preoperative and all subsequent postoperative SNOT‐22 scores were compared using unpaired t tests. Subgroup analysis was performed for patients who underwent more than 1 laser surgery.

Results:

A total of 21 consecutive HHT patients underwent laser surgery for recurrent epistaxis. Compared with preoperative scores, patients reported significantly improved (P <. 05) SNOT scores at 2 weeks postoperatively for dizziness, difficulty falling asleep, waking up at night, getting a good night's sleep, waking up tired, reduced concentration, feeling of frustration, and sadness. The same cohort reported significantly worse nasal obstruction at 2 weeks postoperatively. Patients who underwent more than one surgery experienced overall symptomatic improvement after the second surgery.

Conclusions:

HHT patients experienced a short‐term improvement in sinonasal symptoms, especially those producing social and emotional consequences, following laser surgery for HHT‐related epistaxis. This study once again underscores the important role of the otolaryngologist in managing sinonasal manifestations of HHT.
Sinus Disease following Total Laryngectomy: A Radiographic Review
Authors: Kidwai Sarah M. , Parasher Arjun K. , Agbetoba Abib A. , Iloreta Alfred M. , Govindaraj Satish , Miles Brett A.
Published: September 2014

Objectives:

(1) Compare the incidence of radiographic sinus disease before and after laryngectomy by retrospective analysis of preoperative and postoperative computed tomography (CT) scans. (2) Analyze the change in pre‐existing radiographic sinus disease via a subset analysis.

Methods:

A single‐institution retrospective chart review was conducted. Patients who received a total laryngectomy or total laryngopharyngectomy between 2002 and 2012 with preoperative and postoperative CT scans were included. The Lund‐Mackay (LM) Scores for each sinus as well as the total LM score were recorded for both scans. The assessment of differences in these scores is based on McNemar's statistic for each sinus and on a paired t‐test for the total LM score.

Results:

Surgical removal of the larynx creates an anatomical disconnect between the sinonasal cavity and distal respiratory tract. Normal nasal airflow is disrupted, resulting in alterations to the nasal mucosa, mucociliary clearance, and nasal flora. While the incidence of sinonasal disease in patients undergoing total laryngectomy has been studied via subjective scoring methods, this study is the first to evaluate radiographic sinusitis via an objective measure by comparing Lund‐Mackay scores before and after total laryngectomy. There were no significant differences in the LM scores between preoperative and postoperative scans within each sinus (P value >.05) or in the total LM score (t statistic >0.56).

Conclusions:

In patients undergoing total laryngectomy, disruption in nasal airflow has been correlated with altered sino‐nasal physiology and decreased subjective symptoms. However, our study shows no significant change in radiographic evidence of sinonasal disease after laryngectomy.
Surgical Management of Spontaneous and Traumatic Anterior Skull Base Meningoceles: Technique and Pitfalls
Authors: Naseri Iman , Arnaoutakis Demetri , Petr Michael , Salem Whitney B. , Sandhu Sukhwinder J. , Tavanaiepour Daryoush
Published: September 2014

Objectives:

A majority of anterior skull base meningoceles are often managed via the endoscopic endonasal approach (EEA) for the excision and repair of the cerebrospinal fluid (CSF) leak, in addition to the reconstruction of the skull base defect. The aim of the study was evaluation of an institutional case series to identify specific risks and strategies for successful management of anterior skull base meningoceles.

Methods:

Case series review of all surgical cases involving repair of any anterior skull base meningocele spanning 3 years.

Results:

A total of 18 patients were managed surgically for repair of meningocele with or without CSF rhinorrhea. All patients had postoperative follow‐up to one year. EEA was used in 17 patients, and one had a combined transcranial with endoscopic approach. Four patients had meningoceles with a larger than 1.0‐cm bony skull base defect. Large spontaneous meningoceles along the ethmoid were likely to include cerebrovascular structures within their intranasal component. Nasal airway obstruction was the initial presenting symptom in all large spontaneous ethmoid meningoceles, rather than CSF rhinorrhea (present in all large traumatic ones).

Conclusions:

The endoscopic technique is a safe and effective approach to repair of anterior skull base defects involving both ethmoid and sphenoid regions. Successful repair of lateral sphenoid wall defects depends on gaining sufficient access via incorporating extended approaches, such as trans‐pterygopalatine approach. Preoperative angiography may be warranted, especially in spontaneously appearing anterior skull base meningoceles with a bony defect larger than 1.0 cm.
Transorbital Transnasal Endoscopic Combined Approach to Anterior and Middle Skull Base: Laboratory Investigation
Authors: Alqahtani Abdulaziz A. , Dallan Iacopo , Castelnuovo Paolo
Published: September 2014

Objectives:

Orbital approaches provide significant trajectory to the skull base and are used with different designed pathways. The aim of this study is to investigate the feasibility of a combined endoscopic transorbital and transnasal approach to the anterior and middle cranial fossa.

Methods:

Cadaveric dissection of 5 silicon‐injected heads. A total of 10 bilateral transorbital approaches and 5 extended endonasal approaches were performed. Identification of the surgical landmarks, main anatomical structures, feasibility of combined approach, and reconstruction of the superior orbital defect were examined. Rod lens endoscope (with 0° and 45° lenses) and endoscopic instruments were used to complete the dissection.

Results:

The transorbital approach showed great versatility and provided the surgeon a direct route to the anterior and middle cranial fossa. Anterior/posterior ethmoid arteries, optic nerve, and superior orbital fissure were the landmarks for the superior orbital wall craniectomy. Transorbital avascular plane showed no conflict with major nerves or vessels. Large exposure area from crista galli to the third ventricle was demonstrated with significant control of different neurovascular structures. The combined transorbital transnasal approach provided considerable value in form of extent of the exposure and the free hand movement of the 2 surgeons.

Conclusions:

Combined transorbital transnasal approach demonstrates better visualization and control of the ventral skull base and can overcome the current surgical limits of a single approach. Combination of these 2 minimally invasive approaches should reduce the overall morbidity. Clinical trials are needed to evaluate the virtual applications of this approach.
Adjustable Minimally Invasive Hyoid Myotomy and Suspension with Uvulopalatopharyngoplasty for the Treatment of Obstructive Sleep Apnea
Authors: Van Tassel Jason R.
Published: September 2014

Objectives:

Examine the efficacy of minimally invasive hyoid myotomy and mandibular suspension with adjustable tensioning for hypopharyngeal obstruction in conjunction with uvulopalatopharyngoplasty in the surgical treatment of obstructive sleep apnea.

Methods:

Retrospective chart review in a private practice. Twenty consecutive patients with multilevel obstructive sleep apnea over a 12‐month period were included. Patients underwent hyoid myotomy and suspension and uvulopalatopharyngoplasty with or without tonsillectomy either staged or performed at the same time for those patients who had not undergone uvulopalatopharyngoplasty previously. The hyoid was suspended to the posterior surface of the mandible using the Siesta Encore system and desired tension set through a single small submental incision. Patients underwent clinical examination and sleep study prior to surgery and approximately 3 months postoperatively. The primary outcome was a successful surgical result, defined as respiratory distress index lower than 20, and 50% or greater decline in respiratory distress index, and no oxygen desaturations below 85% on the postoperative sleep study.

Results:

Nineteen (95%) of 20 patients achieved a successful outcome. The average preoperative respiratory disturbance index (RDI) was 52.7. The average postoperative RDI was 11.8 (P <. 005). The average preoperative body mass index was 27.3. The average decrease in the RDI was 78%. All patients in the study reported clinical improvement of symptoms. There were 2 minor wound complications and no major complications.

Conclusions:

For patients with multilevel obstructive sleep apnea, minimally‐invasive mandibular hyoid suspension appears to be highly efficacious for the treatment of hypopharyngeal airway obstruction when performed in conjunction with uvulopalatopharyngoplasty.
The Effect of Upper Airway Surgery on Continuous Positive Airway Pressure Levels and Patient Adherence
Authors: Ayers Christopher M. , Lohia Shivangi , Nguyen Shaun A. , Gillespie M. Boyd
Published: September 2014

Objectives:

(1) Determine the effect of upper airway surgery (UAS) on continuous positive airway pressure (CPAP) pressure by systematic review and meta‐analysis. (2) Determine if a decrease in CPAP pressure from UAS could increase CPAP adherence.

Methods:

A systematic review and meta‐analysis was performed. Studies were eligible for inclusion if a CPAP titration was performed both prior and following upper airway surgery in patients with obstructive sleep apnea (OSA). Studies that compared adherence to CPAP before and after upper airway surgery were included to evaluate the secondary objective.

Results:

A total of 11 articles involving 323 patients were included in the review. There was a mean reduction in CPAP pressure of 1.44 cmH2O [95% confidence interval [CI], –2.09 to 0.78], indicating that UAS reduced CPAP pressure on average. Four of the 11 papers with a total of 80 patients evaluated CPAP adherence. CPAP adherence was improved by 0.62 hours on average [95% CI, 0.22 to 1.01].

Conclusions:

CPAP remains the mainstay treatment of moderate to severe OSA, but due to high levels of nonadherence, surgical intervention will play a role even in patients who are unlikely to be fully cured by surgery. UAS decreases the apnea‐hypopnea index, improves symptoms, and modestly reduces CPAP pressure while improving CPAP adherence in the majority of patients. The evidence suggests that UAS may have an important adjunctive role on the management of OSA.
Effects of Obstruction Length and Height on Predicting Velopharyngeal Surgery Outcome in Obstructive Sleep Apnea
Authors: Ye Jingying , Zhang Peng , Pan Chuxiong , Sun Nian , Kang Dan , Li Jingjing , Zhang Yuhuan
Published: September 2014

Objectives:

Measure obstruction length and height using drug‐induced sleep endoscopy (DISE) in obstructive sleep apnea syndrome (OSA) patients and to evaluate their effects on predicting velopharyngeal surgery.

Methods:

A single institution, prospective, nonrandomized trial of DISE in a consecutive group of patients undergoing velopharyngeal surgical procedure, which consisted of revised uvulopalatopharyngoplasty with uvula preservation and transpalatal advancement pharyngoplasty between July 1, 2012, and June 30, 2013. Eighty patients with OSA diagnosed by polysomnography were evaluated by DISE using dexmedetomidine before surgery. Obstruction length (defined as the distance from the most superior point of the collapse to the most inferior point of the collapse) and obstruction height (the distance from the posterior border of the nasal septum to the most proximal point of the collapse) were measured.

Results:

Out of 80 subjects studied, the mean obstruction length and obstruction height was 1.6 ± 0.8 (range was 0.4‐3.8) cm, and 3.4 ± 1.0 (range was 1.1‐5.0) cm, respectively. The obstruction length had correlations with body mass index (BMI), CT90, and lowest oxygen saturation (r = 0.247, 0.302, and –0.297, respectively, P <. 05). Forty‐three patients had postoperative polysomnography a ≥3 months. Preprocedure mean apnea hypopnea index (AHI) was 57.2 ± 17.3 per hour. Postoperative AHI was 22.7 ± 20.1 per hour. Twenty‐six patients (60.5%) were responders, and seventeen were nonresponders (39.5%). Multivariate logistic regression analysis revealed that obstruction length and height were the only independent predictors of upper airway surgery failure.

Conclusions:

Obstruction length and height can be accurately measured while apnea occurs during the patient's drug‐induced sleep. They are useful to help predict outcome to upper airway surgery in OSA.
First Use of Long‐Range Optical Coherence Tomography to Image Airway Structure in Awake Children
Authors: Lazarow Frances , Ahuja Gurpreet S. , Sharma Giriraj , Wang Alex , Su Erica , Chen Zhongping , Wong Brian J. F.
Published: September 2014

Objectives:

Identifying the appropriate operation(s) for children with sleep‐disordered breathing (SDB) remains a challenge, and current imaging modalities have major shortcomings. We have pioneered the use of long‐range optical coherence tomography (LR‐OCT) to provide real‐time images of the upper airway (UA) during sleep and wakefulness. Here we present our first use of LR‐OCT to image the UA of awake children. (1) Understand how LR‐OCT produces high‐resolution structural images by acting as an optical range‐finder. (2) Recognize how LR‐OCT can identify strictures and real‐time collapse of the airway.

Methods:

This study builds upon our experience using LR‐OCT to image 58 children under sedation. Here 10 awake children (SDB, 4‐15 years) underwent nasal endoscopy and LR‐OCT. We designed a high‐speed Fourier domain LR‐OCT system. Imaging probe and fiberscope were transnasally inserted in tandem and axial images were rapidly acquired (spiral scan, 500‐700 images, 30‐40 seconds). 3D models of each airway were reconstructed.

Results:

Five airways yielded data suitable for 3D volumetric reconstruction, and identified the dominant site of airway obstruction as well as structure of the tonsils, adenoids, base of tongue, and epiglottis. Cross‐sectional area of the axial airway level corresponding to these structures was calculated. Dynamic changes in 3D airway structure were visualized.

Conclusions:

The feasibility of LR‐OCT to identify regions of stricture and collapse in children's airways was established. Hence, patient‐specific surgical treatments can be developed for children with SDB. The next step is to transition to imaging children during sleep, as we have in adults.
The Influence of Drug‐Induced Sleep Endoscopy on Determining Candidacy for Upper Airway Stimulation Therapy
Authors: Ayers Christopher M. , Kezirian Eric J. , Woodson B. Tucker , de Vries Nico , Nguyen Shaun A. , Gillespie M. Boyd
Published: September 2014

Objectives:

(1) Determine the influence of drug‐induced sleep endoscopy (DISE) on the surgical decision for upper airway stimulation (UAS) therapy. (2) Learn the limitations of drug induced sleep endoscopy.

Methods:

This was a single‐blinded cross‐sectional study in which 4 surgeons with extensive experience with DISE reviewed blinded DISE video clips from 63 patients who were screened for participation in the STAR (Stimulation Therapy for Apnea Reduction) trial, a phase III trial of upper airway stimulation (UAS) of the hypoglossal nerve for moderate‐to‐severe sleep apnea (OSA). Each DISE clip was independently reviewed and graded by a surgeon who then predicted whether the patient was a candidate for UAS therapy.

Results:

Evaluators demonstrated a high level of 100% agreement with regard to the presence of palatal collapse in 81% of cases, but less complete agreement concerning hypopharyngeal collapse (64% of cases). The viewers had complete agreement with regards to the presence or absence of circumferential airway collapse in 59% of cases. The surgeons had a low level of complete agreement (44% of cases; mean kappa 0.343) as to whether a given case was a good candidate for UAS therapy.

Conclusions:

DISE continues to be a highly subjective study. Previous evidence found that patients with circumferential airway collapse on DISE respond poorly to UAS. Additional training will be necessary in the future in order to increase agreement among surgeons as to which patients are the best candidates for UAS therapy.
Postoperative Complications in Obstructive Sleep Apnea Patients: A Comparison between Single and Multilevel Surgery
Authors: Chan Ching Yee , Han Hong Juan , Toh Song Tar
Published: September 2014

Objectives:

Evaluate the difference in the postoperative complication rate between single and multilevel surgery performed on patients with obstructive sleep apnea (OSA).

Methods:

A retrospective outcomes analysis was performed on 238 patients with OSA who underwent surgery from January 2011 to December 2013 under the care of the third author in a tertiary referral center. Complications were defined as unexpected events needing additional medical attention within 30 days of surgery. These included but were not limited to: emergency department visits, nasal packing, cautery in the outpatient setting, hospitalization, and need for return to the operating room. Early complications were those occurring within the first 24 hours of surgery while late complications were defined as those occurring after 24 hours.

Results:

Of 238 patients, 88 underwent single level surgery and 150 underwent multilevel surgery. There were none lost to follow‐up. The main complication was bleeding. The complication rate was 5.7% in the single level group and 14.7% in the multilevel group. The difference in complication rate was significant, with P <. 05. The confidence interval was from 1.04 to 7.83 and the odds ratio was 2.85.

Conclusions:

There is an overall higher complication rate in obstructive sleep apnea patients undergoing multilevel surgery. However, the overall risk remains low and most complications are minor. This reminds us to be cautious in the management of such patients, especially if they have had multiple procedures performed.
Randomized Treatment Withdrawal of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea
Authors: Woodson B. Tucker , Gillespie M. Boyd , Lin Ho‐Sheng , Baskin Jonathan Z. , Padhya Tapan A. , Soose Ryan J. , de Vries Nico
Published: September 2014

Objectives:

Describe the therapeutic effect of upper airway stimulation (UAS) therapy withdrawal on objective and subjective measures of sleep apnea severity.

Methods:

From a cohort of 126 participants in a prospective therapy effectiveness trial, 46 subjects were randomized to therapy “ON” and “OFF” groups. Primary outcomes measures were apnea‐hypopnea index (AHI) and oxygen desaturation index (ODI) changes and secondary outcome measures included Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), sleep architecture, hypoxemia, snoring, and blood pressure.

Results:

Groups did not differ at pretreatment baseline or at 12 months of therapy in polysomnography or self‐reported measures. Following randomized controlled trial (RCT) therapy withdrawal, change in AHI and ODI significantly differed in “ON” and “OFF” groups (1.7 versus 18.2 and 1.6 versus 17.0 events/hour P <. 0001). Therapy withdrawal worsened ESS, FOSQ, snoring, hypoxemia, and arousal index in the therapy “OFF” but no change was observed in the “ON” group (P <. 001). The therapy “ON” group demonstrated a reduction in blood pressure at 12 months compared to baseline which was maintained through the RCT.

Conclusions:

Withdrawal of therapeutic UAS results in relapse of both subjective and objective measures of OSA.
Early versus Late Tracheostomy: A Systematic Review and Meta‐analysis
Authors: Liu C. Carrie , Livingstone Devon , Dixon Elijah , Dort Joseph C.
Published: September 2014

Objectives:

(1) Describe the outcomes of early versus late tracheostomy in the critically ill patient population. (2) Apply these findings to the clinical setting when deciding on the timing of tracheostomy.

Methods:

A systematic search was performed of the Medline, PubMed, and Embase databases, as well as the Cochrane Central Register of Controlled Trials. Randomized controlled studies investigating the outcomes of early versus late tracheostomies were included. The primary outcome of interest was the length of mechanical ventilation. Secondary outcomes include intensive care unit length of stay, incidence of pneumonia, and hospital mortality. The meta‐analysis was completed using RevMan 5.2 (Cochrane Collaboration, Oxford).

Results:

The systematic search yielded 14 studies. There was no significant difference in the length of mechanical ventilation, with a weighted mean difference of –7.28 days (95% confidence interval [CI] –17.66 to 3.10). There was a significant decrease in the length of intensive care unit (ICU) stay with a weighted mean difference of –12.1 days (95% CI –21.7 to –2.52). The weighted risk ratio for pneumonia was 0.79 (95% CI 0.65 to 0.97) and for hospital mortality was 0.84 (95% CI 0.64 to 1.09).

Conclusions:

Performing a tracheostomy within 8 days of intubation significantly decreased the length of ICU stay. It may also be associated with a modest decrease in the incidence of pneumonia. No difference was found in the length of mechanical ventilation or hospital mortality.
Effect of Symbiotic Treatment in Patients with Recurrent Aphthous Stomatitis
Authors: Mimura Maria A. M. , Hirata Cleonice H. , Borra Ricardo C. , Penido Norma O.
Published: September 2014

Objectives:

The recurrent aphthous stomatitis (RAS) is a chronic oral inflammatory disease and it still poses as a clinical problem without satisfactory treatment. The aims of the study were: (1) Evaluate the clinical outcome of RAS patients towards the use of symbiotic Lactofos/Simbioflora, analyzing symptoms, seizure frequency, number, duration, and size of the lesions. (2) Compare the immune profile of RAS patients through cytokine levels with each other and controls before and after treatment.

Methods:

We conducted double blind randomized clinical trial placebo controlled study with 60 patients with RAS and 30 controls in a period of 2 years (2011‐2012).

Results:

The symbiotic group showed improvement in pain compared with placebo (P =. 027), with no statistical difference for the other clinical variables assessed. The side effects observed were similar in both groups, but flatulence (P =. 003) and diarrhea (P =. 04) were significant for the symbiotic group. Significant differences were found in cytokine IFN‐Y, IL‐4, and IL‐6 in serum of peripheral blood mononuclear cells (PBMCs) of patients when compared with control and RAS groups. Regarding treatment over time we observed that IFN‐Y (P =. 023), IL‐4 (P =. 045), IL‐10 (P =. 000), and IL‐12p70 (P =. 027) showed significant difference or between treatments or during the time line.

Conclusions:

The symbiotic was effective in improving pain compared with placebo. Patients with RAS have a mixed profile of Th1/Th2 immune response when compared with the control group at baseline. The symbiotic induced Th1 and Th2 responses by increasing IL‐12 and IFN‐Y and IL‐4 and IL‐10, respectively.
Google Glass in Head and Neck Surgery
Authors: Lutch Matthew J. , Kohli Ajay , Cates Daniel , Lue Allen
Published: September 2014

Objectives:

(1) Implement the use of Google Glass in the operating room and in the office for teaching purposes and intraoperative consultations. (2) Recognize the potential for wearable technologies to maximally leverage the electronic medical record (EMR) as a platform to optimize communication between physicians and care for patients.

Methods:

Google Glass is a wearable camera with an optical head mounted display (OHMD) with voice control and internet connectivity via either wireless or Bluetooth‐smartphone tethering. The OHMD was used for procedures including tonsillectomy, endoscopic nasal polypectomy, office‐based vocal cord injection, and flexible transnasal laser laryngoscopy.

Results:

The smartphone technology was used to successfully broadcast the surgical procedures to consultant surgeons off‐site as well as mentor resident physicians during procedures. Procedures were performed without complications on patients under general anesthesia as well as patients under local anesthesia without sedation.

Conclusions:

We report, to our knowledge, the first uses of Google Glass in head and neck surgery. This feasibility study will review potentials for Google Glass, including resident teaching and intraoperative consultations. We will address lessons learned thus far in optimizing the view obtained from the OHMD. We will also discuss implications of wearable technology in the hospital environment from the standpoint of the future of telemedicine, the consent process, and the potential for novel user interfaces with the EMR.
Improving Patient Satisfaction in the Outpatient Otolaryngology Clinic
Authors: Orb Quinn T. , Wilson Kevin F. , Meier Jeremy D. , Error Marc E. , Johnson Steven , Ward Preston D.
Published: September 2014

Objectives:

(1) Determine patient and provider factors associated with patient dissatisfaction in an otolaryngology clinic. (2) Identify strategies to improve the patient experience.

Methods:

Patient satisfaction surveys were prospectively collected in an academic otolaryngology clinic from January 2011 through March 2013. Patient variables (age, insurance type, established vs new patient, diagnosis, and treatability of condition) and provider variables (years in practice, subspecialty, and clinic wait time) were retrospectively analyzed to determine factors associated with patient dissatisfaction. “Treatability” was graded on a scale of 1 to 5, with diagnoses having a clear treatment option (ie, tonsillectomy for chronic tonsillitis) = 1, and diagnoses with no therapeutic options available (ie, tinnitus) = 5.

Results:

The cohort included 820 patient satisfaction surveys and charts. Stepwise linear regression analysis identified no single patient or provider variable associated with poor satisfaction scores. Cluster analysis evaluating the interplay between variables identified 5 unique clusters of patients. Satisfaction scores in 4 of the clusters were in the 99th percentile, while the remaining cluster ranked in the 10th percentile. This cluster consisted of a higher proportion of new patients with difficult‐to‐treat otologic conditions who described their wait time as excessive and were more likely to be self‐pay.

Conclusions:

Several factors influence patient satisfaction in an otolaryngology clinic. In this study, variables associated with lower patient satisfaction scores included patients with longer clinic wait times, “difficult to treat” otologic diagnoses, and new patients. Addressing the issues common in this population to better meet their needs and expectations may improve overall patient satisfaction.
High‐Volume Tracheostomies in the Critically Ill Population: Analysis of Technique and Indications
Authors: Naseri Iman , Salem Whitney B. , Davis‐Malesevich Melinda
Published: September 2014

Objectives:

Analyze the frequency of and techniques used in performing tracheostomies. Understand the prevailing contraindications used in the decision between open versus percutaneous method. Evaluate outcomes among the 2 modes of tracheostomy procedures.

Methods:

Case‐series review of all patients who underwent a tracheostomy spanning 4 years within a tertiary metropolitan hospital. Clinical and demographic data were used to compare the 2 groups of patients with respect to average age, hospital stay, related emergency department (ED) visits, and other complications.

Results:

A total of 1333 tracheostomies were performed on 1302 patients. This included 452 (34%) open versus 881 (66%) via the percutaneous dilatational technique (PDT). There was no difference in short‐term complications between the 2 groups. The primary long‐term complication, tracheal stenosis, occurred most commonly in the PDT group. The contraindications practiced in decision for open versus PDT are not uniform among the various services performing tracheostomies. Approximately 26% of all discharged patients presented to the ED with respiratory or tracheostomy‐related complaint within 90 days of discharge.

Conclusions:

We present the largest tracheostomy case‐series containing a majority performed via the percutaneous technique. Tracheal stenosis is the most common long‐term complication seen primarily among PDT group, indicating that factors such technique may lead to such outcomes. Institutional adoption of absolute contraindications may be necessary to avoid long‐term complications. The development of an institutional common pathway for care and follow‐up may help avoid related ED visits.
How Much Does the Type of Tympanostomy Tube Matter? A Utility‐Based Markov Decision Analysis
Authors: Baik Grace , Brietzke Scott E.
Published: September 2014

Objectives:

Different types of tympanostomy tubes (TT) are available to the otolaryngologist with relative advantages and disadvantages. The objectives of this study are: (1) Use a utility‐based Markov Decision Analysis model to compare outcomes of short‐term grommet tubes, “intermediate” type tubes (Triune, Grace Medical, USA), and “permanent” T‐Tubes. (2) Use sensitivity analysis to determine the most important factors influencing outcomes with one type of TT versus another.

Methods:

A Markov cohort decision analysis model was created using computer software (Treeage Software, Inc. USA) comparing the 3 types of TT. Published data were used to determine key baseline model parameters. The model featured potential complications including eardrum perforation, early TT extrusion, and the need for possible repeat TT placement after extrusion. Outcomes were quantified using a 0.95 (one procedure, full recovery) to 0.6 (failed myringoplasty) utility scale. Utility values were discounted over time to incorporate real life inconvenience. Statistical analysis included simple descriptive statistics and contingency tables.

Results:

The intermediate TT accumulated superior total utility in 2‐, 4‐, and 6‐year models (2.48, 3.96, and 5.27 total utility) compared with grommets (2.32,3.82,5.18) and T‐tubes (2.42, 3.86, 5.18). Examining a hypothetical 3000 child cohort, T‐tubes resulted in an increased overall perforation rate (10.5% versus 2.0%, P <. 001 chi‐squared). Sensitivity analysis indicated that the rate of repeat TT placement and the inconvenience utility discount factor over time were the driving factors of the model.

Conclusions:

The intermediate TT may produce favorable outcomes as it combines a balance of a lower perforation rate than T‐tubes and a longer period of ventilation than grommet tubes.
Human Papillomavirus Infection in Benign Tonsil Swabs and Tonsillectomy Specimens
Authors: Cockerill Cara C. , Orvidas Laura J. , Moore Eric J. , Duresko Brian J. , Tombers Nicole , Cockerill Franklin R. , Pritt Bobbi S.
Published: September 2014

Objectives:

(1) Determine incidence of HPV (human papillomavirus) infection in routine tonsillectomy swabs and specimens. (2) Determine if vaccination impacts tonsillar HPV infection.

Methods:

This was a prospective study conducted from July 2012 to January 2014. Patients ages 1 to 100 years undergoing tonsillectomy for nonmalignant indications were enrolled. Demographic data and immunization status were collected. Specimens collected during surgery included a flocked swab and half of the left and right tonsil. All specimens were tested for HPV DNA using the polymerase chain reaction–based Roche Cobas Amplicor test and for the presence of E6/E7 mRNA using the Gen‐Probe Aptima HPV test.

Results:

Patients were stratified into 2 groups, pediatric (ages 1‐12 years) and adults (age 13 years and up) based on age of potential sexual maturity. In the pediatric group (n = 130) mean age was 5.2 years, 42% were female, 58% were male, and only 3 patients were fully vaccinated against HPV. In the adult group (n = 64) mean age was 24 years, 76% female, 24% male, and 47% were either fully or partially vaccinated. All specimens were negative for HPV infection via both testing methods. Internal controls confirmed the tests were functioning properly.

Conclusions:

This is the first study to examine fresh tonsil swabs and tonsillectomy specimens for HPV infection using a Food and Drug Administration–approved method. Interestingly, both adult and pediatric specimens were negative for HPV infection. The role of vaccination in oropharyngeal HPV infection remains unclear.