bluuebunny/crossref_metadata_2025 huggingface dataset:
Induced Hypotension for Nasal Surgery: Remifentanil versus Esmolol
Authors: Basyoni M.A. , Alsarraf Abdulmohsin J.
Published: August 2013

Objectives:

Compare the efficiency and safety of using remifentanil versus esmolol infusion for induction and maintenance of controlled hypotension. The study evaluates this effect on the quality and dryness of the operative field in endoscopic sinus surgery (FESS). Design: Prospective, randomized, patient‐ and observer‐blinded study.

Methods:

Thirty patients undergoing FESS were randomly assigned to receive either remifentanil or esmolol for inducing controlled hypotension. The same surgeon blinded to the hypotensive agent used and hemodynamic variables performed all operations. He used a six point scale of 0‐5 to assess the surgical field (0= bloodless and 5= uncontrolled bleeding).

Results:

Controlled hypotension was achieved at the target mean pressure of 50‐55 mmHg for both remifentanil and esmolol groups. There were no statistical differences between the groups in duration of anesthesia, duration of hypotension, hemodynamic changes, or PaCo2 or PaO2 measurements. Category scale values for surgical conditions were ideal in both groups: 2.61±0.32 in the remifentanil group and 2.48±0.21 in the esmolol group, with no significant difference between the two groups.

Conclusions:

Both remifentanil and esmolol infusion provide consistent and sustained controlled hypotension, and both are effective in providing a dry surgical field during functional endoscopic sinus surgery.
Olfactory Bulb Volume in Nasal Polyposis
Authors: Amali Amin , Sadeghi Mohammad , Sazgar Amir A. , Langroudi Maziar M. , Farshchi Samireh
Published: August 2013

Objectives:

There is still a debate about the relation of olfactory bulb volume (OBV) to olfactory function. Many studies suggest that olfactory deprivation decreases olfactory bulb volume. The aim of this study was to compare the olfactory threshold and olfactory bulb volume of patients with nasal polyps and healthy individuals.

Methods:

This was a case control study that was carried out in Valiasr hospital of Tehran University of Medical Sciences in 2010‐2011. 22 patients with nasal polyps were compared with 37 healthy individuals. Olfactory threshold test and magnetic resonance imaging (MRI) were performed in all participants. Age, gender, left OBV, right OBV, total OBV, and olfactory threshold were recorded.

Results:

There was no significant difference between the age, gender, and olfactory bulb volume of patients of the two groups (P > 0.05). However, the difference between olfactory threshold of the two groups was significant (P < 0.0001). Also, olfactory function and threshold showed no significant relation with olfactory bulb volume (P > 0.05).

Conclusions:

The results of this study show that MRI and OBV cannot be trusted in determining the olfactory function of patients with nasal polyps. However, further research needs to be done in order to establish this relationship. Also, considering the duration of olfactory dysfunction may be helpful in this research.
Preoperative Concerns in Patients Undergoing Endoscopic Sinus Surgery: A Multi‐institutional, Prospective Study
Authors: Yeung Jeff , Brandt Michael G. , Rotenberg Brian , Franklin Jason H. , Kilty Shaun , Doyle Philip
Published: August 2013

Objectives:

Patient‐centered care is recognized as being fundamental to successful medical practice. The effectiveness of patient‐centered care has classically been measured by post‐treatment outcomes, such as patient compliance and psychosocial responses. To date, systematic assessment of patient concerns prior to treatment has been limited. Functional endoscopic sinus surgery (FESS) is an elective surgery for chronic sinusitis that carries a clear, defined set of risks. This study aimed to determine the concerns of patients undergoing FESS for chronic sinusitis.

Methods:

Study Design: Multi‐institutional, prospective survey of patient concerns. Methods: Two hundred patients undergoing endoscopic sinus surgery for chronic rhinosinusitis with or without polyposis were recruited. They completed a validated survey assessing their concerns regarding the risks and outcomes of surgery. Data were analyzed using descriptive statistics.

Results:

Generally, patients had a low degree of concern prior to undergoing surgery, though significant individual variability existed. Subjects felt the greatest level of concern regarding potential need for revision surgery and wait time for surgery. Additionally, rare post‐operative complications, such as orbital injury and cerebrospinal fluid leak, generated higher levels of concern.

Conclusions:

Patient concern prior to undergoing elective surgery is generally low. However, patients’ areas of greatest concern may not align with those perceived by the physician. Our findings highlight topics that require careful discussion during the informed consent process for patients undergoing FESS.
Preservation of Bilateral Nasoseptal Flap Vascular Pedicles: Rescue Flap Modification for Endonasal Skull Base Surgery
Authors: Griffiths Chester F. , Cutler Aaron , Duong Huy , Karimi Kian , Barkhoudarian Garni , Carrau Ricardo , Kelly Daniel
Published: August 2013

Objectives:

The nasoseptal flap (NSF) has significantly reduced the incidence of postoperative cerebrospinal fluid (CSF) leaks in endoscopic skull base surgery. In the traditional endonasal approach, the NSF vascular pedicle is frequently sacrificed during the sphenoidotomy, thus eliminating the flap as a reconstruction option should a large CSF leak be encountered. In addition, extensive mucosal removal may result in postoperative crusting, hyposmia, or anosmia.

Methods:

Introduce the concept and surgical technique of bilateral mucosal and septal olfactory strip (SOS)‐preserving rescue flaps, ensuring availability of both vascular pedicles while also promoting rapid healing and reducing the risk of postoperative epistaxis and olfactory dysfunction. Retrospective analysis of patient records who underwent endoscopic tumor/cyst removal with bilateral nasoseptal rescue flaps from August 2011 until December 2012 (15 months).

Results:

In total, 95 (80%) of 118 patients (mean age 51 years; 78 pituitary adenomas, 7 RCC, 10 other pathologies), including 20 (21%) with prior surgery, underwent bilateral rescue flaps. Unencumbered visualization, mobility of the endoscope and instruments, and access to the sphenoid sinus/parasellar region was experienced in all cases. One patient underwent conversion to a formal NSF without complication. No patient had postoperative arterial epistaxis.

Conclusions:

This modification of the nasoseptal rescue flap technique is an effective bilateral mucosal preserving approach. In addition to maintaining both vascular pedicles, it likely reduces the risk of major postoperative epistaxis, preserves olfaction by maintaining the SOS, and promotes rapid mucosal healing while not hindering exposure or limiting instrument maneuverability.
Prospective Study of the Impact of Thyroid Hormone Replacement on Nasal Functions in Hypothyroid Patients
Authors: Akbarov Elnur , Birkent Hakan , Karacalioglu Ozgur , Karakoc Omer , Akcam Murat T. , Gerek Mustafa
Published: August 2013

Objectives:

Thyroid hormone deficiency is known to have many systemic effects on the human body. Although some of these manifestations are very well known, its effect on nasal functions has not been studied thoroughly. In this paper, evaluation of nasal functions in hypothyroid patients was performed, and their subsequent response to thyroid hormone replacement was prospectively studied.

Methods:

Prospective evaluation of nasal functions and concurrent determination of serum thyroid status was executed in a cohort of post‐operative total thyroidectomy patients prior to and following thyroid hormone replacement therapy. Nasal function parameters, including nasalance, nasal resistance, mucociliary transport, and olfaction, are compared before and after treatment using paired samples t‐test.

Results:

Twenty‐four post‐thyroidectomy patients (15 female, 9 male; mean age 34.96±12.47) were included in the study. All subjects were hypothyroid (mean TSH 129.2±64.46 mIU/L) prior to replacement. Following hormone therapy, their mean TSH dropped to 1.58±0.88 mIU/L. Nasalance showed a significant increase from 45.67±8.41 to 49.63±9.26 (p=0.0069) after replacement. Change in total nasal resistance from 0.28±0.16 Pa/cm3/s to 0.29±0.13 Pa/cm3/s was non‐significant (P = 0.7747). Mucociliary transport time decreased significantly from 9.62±4.00 min to 5.70±2.07 min after replacement (P < 0.0001). Olfaction was measured by a visual analog scale (VAS) and Brief Smell Identification Test (B‐SIT). VAS showed a significant improvement from 7.12±2.30 to 8.66±0.96 (P < 0.0001), and B‐SIT also revealed a significant improvement from 35.08±31.34 to 80.17±23.52 (P < 0.0001) after replacement.

Conclusions:

Thyroid hormone replacement therapy following total thyroidectomy has a measurable impact on nasalance, mucociliary transport, and olfaction in hypothyroid patients.
Exploring the Clinical Value and Implications of Routine Pathological Examination of Turbinate Specimens
Authors: Haffey Timothy M. , Rajasekaran Karthik , Sindwani Raj
Published: August 2013

Objectives:

Inferior turbinate surgery for nasal obstruction can be performed in a variety of ways. Only a few of these methods produce tissue that can be sent for pathologic analysis. According to the College of American Pathologists (CAP), turbinate tissues are not exempt from pathology evaluation. Our objectives were to evaluate the clinical value and implications of routine pathological examination of turbinate specimens.

Methods:

A retrospective chart review was performed between January 2008 and August 2011 at a tertiary medical center for patients who underwent an inferior turbinate reduction procedure for nasal obstruction.

Results:

1,300 consecutive cases from 17 surgeons were identified. Among these patients, 223 (17%) underwent an isolated turbinate reduction procedure and 505 (39%) underwent a reduction procedure in conjunction with a septoplasty. The remaining had a turbinate reduction procedure in addition to another head and neck procedure. 591 (45%) of the turbinate reduction procedures were performed by methods that were tissue producing. Only 137 (23%) of these specimens were sent for pathologic analysis. All received a ‘gross’ examination and 123 (90%) also underwent histologic analysis. No abnormalities were reported in any of these specimens.

Conclusions:

In the majority of turbinate reduction procedures, there is no specimen produced for pathologic analysis. We found that most surgeons do not submit turbinate tissues for pathologic examination even when a specimen is produced, demonstrating a lack of clarity in the policy regarding the handling of turbinate tissues. We found no abnormal pathology results, which challenges the clinical utility in analyzing turbinate tissues removed in turbinate surgery for nasal obstruction.
Safety and Efficacy of Arista Powder in 514 Nasal Septal and Sinus Surgery Patients
Authors: Phillips P. Perry
Published: August 2013

Objectives:

Determine the safety and efficacy of Arista powder in preventing postoperative bleeding during nasal septal and sinus surgery at a community hospital and surgery center.

Methods:

514 consecutive patients undergoing nasal septal and or sinus surgery from March 4, 2008 until December 11, 2012 were treated with Arista powder to control hemostasis without intranasal packing material. These patients were prospectively accrued.

Results:

One of 514 patients experienced bleeding requiring packing of the nose postoperatively, and no patients encountered any drug reactions or complications. No patients required blood transfusion. No patients developed scarring requiring a second surgical intervention.

Conclusions:

The results demonstrate a highly effective and safe role for Arista powder in controlling bleeding postoperatively in a large population of nasal septal and sinus surgery patients.
Surgical and Anatomic Considerations in Endoscopic Revision of Failed External Dacryocystorhinostomy
Authors: Liang Jonathan , Hur Kevin , Merbs Shannath L. , Lane Andrew P.
Published: August 2013

Objectives:

Identify key clinical and anatomic considerations in endoscopic revision DCR (r‐EnDCR) following failed external dacryocystorhinostomy (ExDCR). Study Design: Case series.

Methods:

A retrospective review was performed of patients undergoing r‐EnDCR after failed ExDCR over the past 6 years. Those with primary or previous EnDCR, proximal nasolacrimal procedures, and nasolacrimal lesions were excluded. All patients had pre‐operative maxillofacial computed tomography (CT). Data were collected on patient demographics, clinical characteristics, and radiographic findings. We developed a classification system for the anterior ethmoid‐lacrimal fossa complex.

Results:

Twenty‐five r‐EnDCRs were performed on 22 patients (18 female, 4 male; average age 50.0 yrs) after failed ExDCR. Concurrent sinusitis and previous maxillofacial trauma was seen in 8% (2/25) and 12% (3/25), respectively. CT analysis demonstrated agger nasi pneumatization in 88% (22/25), of which 77% (17/22) partially overlapped the medial aspect of the lacrimal fossa, resulting in a DCR ostium located within the middle meatus. The presence of ipsilateral septal deviation, concha bullosa, and middle turbinate lateralization or scarring to the lateral nasal wall was seen in 24% (6/25).

Conclusions:

ExDCR is a highly successful operation for nasolacrimal duct obstruction. When failures do occur, variability of the anterior ethmoid anatomy often plays an important role. CT imaging and endoscopy, which are not routinely performed prior to ExDCR, can help define the pattern of agger nasi pneumatization as it relates to the failed surgical DCR ostium. An understanding of the relationship between the agger nasi cells and the lacrimal fossa is essential for successful r‐EnDCR.
Surgical Relationship of the Nasolacrimal System to the Anterior Maxillary Line: Performing Safe Mega‐antrostomy
Authors: Sarber Kathleen M. , Weitzel Erik K. , O'Connor Peter
Published: August 2013

Objectives:

In patients with chronically diseased maxillary sinuses, poor mucociliary clearance may result from long‐standing inflammation or scarring from previous surgery. Endoscopic extended maxillary mega‐antrostomy is a recently described technique that facilitates mucus clearance and sinus irrigation in terminally dysfunctional maxillary sinuses by allowing the sinus to drain by gravity alone. As the procedure is a modification of the medial maxillectomy and it is standard to perform dacryocystorhinostomy (DCR) at the end of a medial maxillectomy procedure, it was our intent to determine if a DCR is likewise indicated after mega‐antrostomy. As a first step towards this answer, we aimed to study the relationship of the lacrimal system to the mega‐antrostomy procedure using cadaveric dissection.

Methods:

In 12 operated sides, the nasolacrimal duct was violated 42% of the time during anterior dissection. The average anterior‐posterior distance was 29.8mm. Lacrimal system violation occurred at an average of 3.7mm posterior to the anterior maxillary line. Unpaired Student t‐test was performed to determine if the limit of anterior dissection was associated with lacrimal system penetration.

Results:

More anterior dissection was significantly associated with lacrimal system penetration (6.1mm negative penetration to 4.6mm positive penetration p=0.038) however the overall AP diameter was not significantly related to penetration (p=0.511).

Conclusions:

Our results indicate that lacrimal system injury is highly likely to occur during mega‐antrostomy. To this end, DCR is indicated after mega‐antrostomy. However, using the maxillary line as a surgical landmark, damage may be avoided by maintaining a distance of >7mm from the anterior most aspect of the dissection.
Validation of EPOS 2012 Disease Control Assessment in Chronic Rhinosinusitis
Authors: Snidvongs Kornkiat , Sacks Raymond , Harvey Richard J.
Published: August 2013

Objectives:

1) Validate a clinical staging system on disease “control” in chronic rhinosinusitis (CRS) proposed by the European Position Paper on Rhinosinusitis (EPOS) 2) Propose a new, data driven staging system.

Methods:

Prospective study over a 12‐month period of CRS patients who underwent endoscopic sinus surgery in tertiary care. The Sinonasal Outcome Test‐22 and endoscopy score along with patient's and physician's report on clinical progress were recorded at 6 and 12 months. Ordinal regression was used for modeling symptoms and endoscopic findings to build up “disease control” criteria. Patients were defined as either “controlled,” “partly controlled,” or “uncontrolled” according to both EPOS and proposed criteria. The agreements with physician's and patient's report were analyzed.

Results:

106 patients were assessed (49.1% female, age 49.0±13.9yrs). Nasal obstruction was the only symptom which predicted patient's report (maximum likelihood (ML) ‐3.6, P = 0.02). Mucosal inflammation (ML ‐2.4, P < 0.001) and thick and/or purulent discharge (ML‐2.5, P = 0.01) predicted physician's report. A new “NOSE” staging system of nasal obstruction, systemic medication used, and endoscopic inflammation was proposed. EPOS system had fair agreement (k 0.29, P < 0.001) with physician's and slight agreement (k 0.18, P = 0.01) with patient's report, while the NOSE system had better agreement with both physician's (k 0.40, P < 0.01) and patient's report (k 0.32, P < 0.01). Both systems predicted treatment outcome at 12 months (both, P < 0.05).

Conclusions:

The disease control assessment by EPOS staging system has slight agreement with patients and physicians. A new system using nasal obstruction, diseased mucosa, and discharge is proposed.
Viral Disruption of Olfactory Progenitors Is Exacerbated in Allergic Mice
Authors: Ueha Rumi , Kondo Kenji , Ueha Satoshi , Yamasoba Tatsuya , Sumanta Mukherjee , Lukacs Nicholas W. , Kunkel Steven L.
Published: August 2013

Objectives:

Viral infection in the upper respiratory tract (URT) is a major cause of olfactory impairment. Allergic inflammation such as asthma or rhinosinusitis often exacerbates smell problems in patients with viral infections by a mechanism that remains unclear. Here, we examined the effects of allergic airway inflammation on the progression of virus infection and on olfactory lineage cell populations in a mouse model of respiratory syncytial virus (RSV) infection.

Methods:

Balb/c mice were immunized subcutaneously and intraperitoneally with cockroach antigen (CR) on day −22, then administrated intranasally with CR every 4 days from day −8 to day 0 to induce asthma and allergic inflammation (allergic mice). Allergic and control mice were infected intranasally with RSV line 19 on day 0. RSV‐RNA in the nasal mucosa and olfactory bulb were quantified by reverse transcription polymerase chain reaction (RT‐PCR). The numbers of OMP+ mature olfactory neurons (ORNs), Sox2+ olfactory progenitor cells (OPs), and CK5+ basal cells (BCs) were determined by immunohistochemical staining.

Results:

RSV‐RNA rapidly decreased and became undetectable on day 14 in control mice, whereas RSV‐RNA persisted over 14 days in allergic mice. There were no changes in OMP+ORN or CK5+BC numbers following RSV infection. In control mice, Sox2+OP numbers were significantly reduced on day 2 but recovered thereafter. In allergic mice, this decrease was more severe and prolonged.

Conclusions:

Allergic background impedes RSV clearance in the URT and exacerbates viral disruption of Sox2+OPs. These results provide novel insight into the mechanism underlying the exacerbation of virus‐induced olfactory impairment in allergic airway inflammation.
Hyoid Advancement in Females with OSA: Comparison of Two Techniques
Authors: Mickelson Samuel A. , Capp Casey
Published: August 2013

Objectives:

1) Describe the effectiveness of hyomandibular advancement performed alone versus hyomandibular advancement along with other pharyngeal procedures versus hyoid advancement to the thyroid cartilage (hyo‐thyroid advancement) along with other pharyngeal procedures, in adult females with obstructive sleep apnea hypopnea syndrome (OSAHS).

Methods:

Retrospective case series, 2001‐2011. Setting: Private practice. Subjects: 48 females with OSAHS: Hyomandibular advancement performed alone (N=12, age 51.8+7.2, body mass index [BMI] 27.8 kg/m2), Hyo‐mandibular advancement along with ancillary procedures (N=23, age 50.8+11.3, BMI 32.9 kg/m2), and hyothyroid advancement along with ancillary procedures (N=13, mean age 49.7+12.4, BMI 29.4 kg/m2.

Results:

Polysomnography: Respiratory disturbance index (RDI), Apnea hypopnea index (AHI), Lowest oxygen saturation (LSAT), Epworth Sleepiness Score (ESS). Hyo‐mandibular advancement alone had the lowest success rate [RDI fell: 32.5/hr to 28.0/hr (14.2% reduction), AHI fell: 30.8/hr to 23.4/hr (24.0% reduction), LSAT improved: 84.2% to 83.5%, overall success rate 36.4%]. Hyo‐thyroid advancement along with ancillary procedures had an intermediate success rate [RDI fell: 27.6/hr to 21.8/hr (21.0% reduction), AHI fell: 26.3/hr to 21.6/hr (18.3% reduction), LSAT improved: 85.8% to 87.3%, overall success rate 58.3%]. Hyo‐mandibular advancement along with ancillary procedures had the highest success rate [RDI fell: 26.5/hr to 13.7/hr (48.3% reduction), AHI fell: 25.5/hr to 12.6/hr (50.6% reduction), LSAT improved: 81.8% to 87.8%, overall success rate 61.1%]. BMI was unchanged. ESS scores improved in all groups.

Conclusions:

Hyomandibular advancement, coupled with other pharyngeal procedures, is more effective than hyothyroid advancement coupled with other pharyngeal procedures and more effective than hyomandibular advancment performed alone.
Nasal Anatomy Abnormalities and Objective Sleep‐Disordered Breathing Severity
Authors: Leitzen Keith , Lindsay Robin W. , Brietzke Scott E.
Published: August 2013

Objectives:

1) Explore the association between nasal anatomy and sleep disordered breathing (SDB) severity as measured by polysomnogram (PSG). 2) Explore the association between nasal anatomy and validated subjective measures of snoring, nasal obstruction, and daytime somnolence.

Methods:

A detailed nasal anatomy assessment on 100 subjects (80% male) including the nasal septum, internal/external nasal valves, and turbinates was performed. Subjects additionally completed the Snore Outcomes Survey (SOS), Nasal Obstruction and Symptom Evaluation (NOSE) instrument, and Epworth Sleepiness survey (ESS) which are all validated, disease‐specific surveys. Nasal anatomy assessments were then compared to PSG, SOS, NOSE, and ESS results.

Results:

The mean age was 42 (range=22‐72) and mean BMI was 28.9 (range=20.8‐39.8). Sixty‐nine patients (69%) were found to have OSA (mean AHI=13.1, range=0‐64). OSA severity was associated with age (spearmans rho=0.386, p=0.0001), male sex (0.229, p=0.022), BMI (0.279, p=0.005), and neck circumference (0.356, p=0.0003). No nasal anatomy measurement was found to correlate to ESS results or objective SDB severity measured by PSG. The sample size should have provided over 90% power to detect a significant association if one existed. The SOS score was correlated to an observed change in inferior turbinate size with oxymetazalone (‐0.252, p=0.116). The NOSE score was correlated to turbinate hypertrophy (0.299, p=0.0025), internal nasal valve collapse (0.258, p=0.0101), and septal deviation (0.204, p=0.418). Subjective snoring was correlated to PSG measured SDB severity (0.273, p=0.0065).

Conclusions:

Abnormal nasal anatomy was not correlated to PSG‐measured SDB severity. Specific measurements of abnormal nasal anatomy were correlated to subjective measures of snoring and nasal obstruction.
Prospective Outcomes Study of the Impact of Nasal Surgery on Sleep Quality
Authors: Stapleton Amanda L. , Gillman Grant
Published: August 2013

Objectives:

Evaluate the impact of functional nasal airway surgery on the quality of sleep in patients using validated outcomes measurements. Study Design: Prospective, single center, outcome study of sleep quality before and after functional nasal surgery in patients with nasal airway obstruction treated from August 1, 2011, to August 1, 2013. Patients >18 years old with symptomatic structural nasal airway obstruction treated surgically at an academic otolaryngology practice. Intervention: Primary septoplasty, revision septoplasty, functional septorhinoplasty.

Methods:

Patients completed the Nasal Obstruction Symptom Evaluation (NOSE) scale (0‐100 scale), Epworth Sleepiness Scale (ESS) (0‐21 scale), the Pittsburgh Sleep Quality index (PSQI) (0‐21 scale), and Likert scales pre‐operatively and at 3 months post‐operatively. The impact of nasal surgery outcome on sleep quality was analyzed. Linear regression analyses were carried out to identify independent variables affecting sleep outcomes in nasal surgery patients.

Results:

48 patients enrolled, and 7 were lost to follow‐up. 41 patients for preliminary analysis: 19 septoplasty, 4 revision, and 18 functional septorhinoplasty. Mean NOSE scores decreased from 67 pre‐op to 17 at 3 month follow‐up. ESS scores decreased from 7.8 to 5.8. PSQI decreased from 7.9 pre‐op to 5.0 post‐op. Additional analyses are ongoing.

Conclusions:

Nasal airway surgery does have an effect on sleep quality when evaluated using validated outcomes measurements. The NOSE score showed the most significant improvement in symptomatology. The ESS and PSQI also showed improved sleep quality after nasal surgery.
Provent Therapy for Obstructive Sleep Apnea: Impact of Nasal Obstruction
Authors: Friedman Michael , Pott Thomas R. , Lundgren Mary E. , Farajian Viken , Joseph Ninos J.
Published: August 2013

Objectives:

Prospective, two‐arm, clinical pilot study.

Methods:

Fifty obstructive sleep apnea patients who failed continuous positive airway pressure (CPAP) therapy enrolled in a 30 night Provent trial. Polysomnography was performed prior to trial (baseline) and day 10 of the study using Provent. Epworth sleepiness scale (ESS), quality of life index, and snoring intensity were assessed day 0 and 30. Nasal obstruction was determined prior to trial by endoscopy. Subjects were divided based on nasal patency (control: obstruction 80% were excluded).

Results:

Forty‐four patients completed the trial averaging 7.01± 0.66 hours/night of sleep and tolerating Provent 6.04± 1.3 hours/night (mean±SD). Control cohort (n = 24) showed statistically significant improvement in apnea‐hypopnea index (AHI), oxygen saturation and snoring. Control cohort had greater mean reduction in AHI (11.7±3.2 P = 0.005), ESS (0.63±1.1 P = 0.59), snoring (2.6±1.1 P = 0.04), mean increase in oxygen saturation (0.08±0.03, P = 0.04), and quality of life outcomes (0.72±0.31 P = 0.60) when compared with the obstruction cohort, n = 20, (AHI 4.7±5.8 P = 0.44; ESS 2.5±0.96 P = 0.08; snoring 1.3±0.52 P = 0.90; oxygen saturation 0.04±0.02, P = 0.03; quality of life outcomes 0.63±0.24, P = 0.80) (mean difference ± standard error of difference). Acceptance as a long‐term solution was equivalent between both groups (56%).

Conclusions:

Provent therapy was effective in reducing AHI in all patients. Patients without nasal obstruction had greater success in reducing AHI and snoring while improving quality of life and minimum oxygen saturation. Correction of nasal obstruction may be a valuable prerequisite for Provent therapy.
Safety and Effectiveness of Upper Airway Stimulation via the Hypoglossal Nerve for Obstructive Sleep Apnea
Authors: Steward David L. , de Vries Nico , Froymovich Oleg , Soose Ryan J. , Gillespie Marion B. , Maurer Joachim T. , Woodson B. Tucker
Published: August 2013

Objectives:

Determine safety and effectiveness of upper airway stimulation for treatment of obstructive sleep apnea (OSA) in a prospective, multi‐center trial; with subsequent randomized, controlled therapy withdrawal evaluation.

Methods:

This study enrolled and screened 900 adult subjects. Inclusion criteria were moderate‐to‐severe OSA (apnea‐hypopnea index [AHI] 20‐50), prior continuous positive airway pressure (CPAP) failure or intolerance, and body mass index (BMI) < 32. All qualified subjects underwent further screening with drug‐induced sleep endoscopy (DISE) to exclude those with concentric palatal collapse. 126 subjects meeting all inclusion/exclusion criteria then underwent surgical implantation of a right sided unilateral hypoglossal nerve stimulation electrode, with pulse generator and respiration sensor (Upper Airway Stimulation System, Inspire Medical Systems, Minnesota). Patients were evaluated at 2, 6, and 12 months. Primary outcome measures included AHI, oxygen desaturation index, Epworth Sleepiness Scale, and Functional Outcomes of Sleep Questionnaire at 12 months. Therapy withdrawal effect was evaluated by randomizing a subset of consecutive responders to one week of on or off therapy for controlled comparison.

Results:

All 126 subjects were successfully implanted. In general, subjects were middle aged (mean 54.5 ± 10.2 yrs), male (83%), with severe OSA (mean baseline AHI 32.0 ± 11.8). Transient dysarthria and dysphagia were noted in a minority of patients. Over 70% of subjects have completed the study, with the remaining scheduled to complete 12 month evaluation by April, 2013. Final safety and effectiveness outcomes will be presented.

Conclusions:

Implantation of an upper airway stimulation system involving unilateral hypoglossal nerve electrode placement appears safe and feasible, with transient dysarthria occurring infrequently. Effectiveness will be addressed after completion of 12 month follow‐up for all subjects.
Short‐term Outcomes of Obstructive Sleep Apnea Surgery: Revisiting the Complication and Mortality Rates following Uvulopalatopharyngoplasty
Authors: Zapanta Philip E. , Khoury Tawfiq
Published: August 2013

Objectives:

1) Determine current complication rates following uvulopalatopharyngoplasty (UPPP) per the American College of Surgeons’ National Surgery Quality Improvement Program 2006‐2010 data (NSQIP). 2) Compare this more diverse sample population to a larger but less diverse VA study (1991‐2001 data).

Methods:

Using the NSQIP database, we examined a prospective cohort of adults undergoing UPPP for obstructive sleep apnea with or without other simultaneous procedures performed between the years of 2006 and 2010. We determined the serious complication and mortality rates. Serious complications were defined by 17 specific life threatening complications. Patient mortality was recorded up to 30 days post‐operatively.

Results:

On average, patients (n = 808) were 41 years old, had a body mass index (BMI) of 32.6, were predominantly white (57%), and were predominantly male (74.8%). The serious complication rate was 3.5% (28/808) (95% confidence interval [CI] 2.0% to 4.9%), and the mortality rate was 0.1% (1/808) (95% CI 0.0% to 0.2%). Mallampati, age, BMI, or year of operation did not have a significant effect. For multilevel surgery, the odds ratio for complications was 1.99 (95% CI 0.89 to 4.44).

Conclusions:

Based on prospectively collected quality improvement data available in NSQIP, the incidence of serious complications and mortality from UPPP surgery in a more diverse patient population is not significantly different from a larger, less diverse 2004 VA study. Post‐operative complications in multilevel surgery for obstructive sleep apnea may be slightly higher than the complication rate in patients who only received single level surgery.
Sleep Surgery and Medical Malpractice
Authors: Tolisano Anthony M. , Bager Jennifer M.
Published: August 2013

Objectives:

Describe and analyze the causes and outcomes of lawsuits pertaining to sleep surgery in order to mitigate future litigation and improve physician education.

Methods:

The LexisNexis MEGA Jury Verdicts and Settlements database was reviewed for all lawsuits including settlements and trial verdicts related to sleep surgery. Data including type of surgery performed, plaintiff allegation, nature of injury, outcomes, and indemnities were collected and analyzed.

Results:

Fifty‐one cases met inclusion criteria. Of these, 30 were decided by a jury, 9 were settled out of court, and 10 were resolved by other means. Overall, 57% of known outcomes favored the defendant. The most common surgery performed was tonsillectomy (57%) followed by uvulopalatopharyngoplasty (45%), adenoidectomy (31%), and septoplasty (31%). No difference was found between outcomes when comparing the most common injuries cited, including wrongful death (p = 0.572), airway compromise (p = 0.376), and drug reaction (p = 0.443). If failure to recognize a complication (p = 0.034) or delay in diagnosis (p = 0.026) was a component of the legal allegations, the outcome significantly favored the plaintiff. The average settlement ($535,000) and plaintiff award ($1.52 million) were not significantly different (p = 0.13).

Conclusions:

The majority of outcomes favored the defendant with a trend towards higher payouts in cases settled by a jury when compared to a settlement. Type of injury did not predict outcome. Failure to recognize complications and delay in diagnosis strongly predicted a verdict in favor of the plaintiff.
Utility of Post‐reduction Radiographic Analysis of Mandible Fractures
Authors: Guy William M. , Pena Israel , Pattisapu Prasanth , Brissett Anthony E.
Published: August 2013

Objectives:

Recognize that immediate post‐reduction films: 1) Have a significant associated cost; 2) Do not alter management.

Methods:

A retrospective review of the medical record was performed on patients with mandible fractures operated on by the otolaryngology‐head and neck surgery service between November 1, 2010, and November 30, 2012, at a level 1 county hospital. The post‐operative imaging modalities were determined as well as if any changes in care were initiated by that image. Those patients who did have repeat imaging were evaluated to determine what led to the second image and what action was taken.

Results:

Fifty‐seven patients met inclusion criteria. Fifty‐five patients (96.5%) had a post‐reduction image with 45 (79.0%) having a computed tomography (CT; $1,965) and 10 (17.5%) having a Panorex ($282). No immediate intervention was performed. Eleven patients (19.3%) had a second post‐operative image with 4 (36.4%) receiving at least 1 panorex and 8 (72.7%) receiving at least one CT. Of these 11 patients, 8 (72.7%) underwent an intervention based on the imaging. Analysis showed imaging significantly affected the management of the second group of 11 but did not affect the first group of 55 (p=0.0000).

Conclusions:

In this study, 96.5% of patients received postoperative imaging at a cost of $91,245 with no change in management. This supports the conclusion that routine post‐reduction imaging does not alter the immediate clinical course and should be reserved for those patients who have a postoperative clinical finding or complaint.
Medical Malpractice and the Liability of the Loss of Airway: The Otolaryngology Perspective
Authors: Hong Steven S. , Yheulon Christopher , Rieth Katherine , Cable Benjamin B.
Published: August 2013

Objectives:

Analyze malpractice litigation trends to better understand the causes and outcomes of suits involving loss of airway to prevent future litigation and improve physician education.

Methods:

Jury verdict reviews involving otolaryngologists and loss of airway were obtained from a computerized legal database, WESTLAW from 2001‐2011. Data were compiled on the demographics of the defendant, plaintiff, nature of injury, legal allegations, verdicts, and judgments.

Results:

Fourteen cases were identified and selected for review. Ten cases resulted in mortality, three cases in anoxic brain injury, and one case involved subglottic stenosis. Four cases were found in favor of the defendant, while ten cases resulted in plaintiff verdicts or settlements with an average award of $1,580,172. Seven cases involved loss of airway due to failed intubations. The most common procedures involved in the loss of airway were oropharyngeal procedures (29%). There were no cases involving a planned surgical airway. The most common legal allegation was delay in procedures (64%). No cases involved failure of informed consent.

Conclusions:

In cases of loss of airway, there is significant liability consigned to otolaryngologists. They are held accountable for recognizing an emergent airway, promptly and successfully securing the airway, and ensuring a protected airway throughout the patient's disposition. Thus, close oversight, prompt action, and unequivocal communication in emergent airways is imperative.
Volume Expansion of Tissue Engineered Human Nasal Septal Cartilage
Authors: Reuther Marsha S. , Briggs Kristen K. , Wong Van , Neuman Monica K. , Masuda Koichi , Sah Robert , Watson Deborah
Published: August 2013

Objectives:

1) Produce autologous human septal neocartilage constructs substantially larger in size than previously produced constructs. 2) Demonstrate that volume expanded neocartilage constructs possess comparable histologic and biochemical properties to standard size constructs. 3) Show that volume expanded neocartilage constructs retain similar biomechanical properties to standard size constructs.

Methods:

Human septal chondrocytes from 8 donors were used to create 12mm and 24mm neocartilage constructs. These were cultured for a total of 10 weeks. Photo documentation, histologic, biochemical, and biomechanical properties were measured and compared.

Results:

The 24mm diameter constructs were qualitatively similar to the 12mm constructs. They possessed adequate strength and durability to be manually manipulated. Histologic analysis of the constructs demonstrated similar staining patterns in standard and volume expanded constructs. Proliferation, as measured by DNA content, was similar in 24mm and 12mm constructs. Additionally, GAG and total collagen content did not significantly differ between the two construct sizes. Biomechanical analysis of the 24mm and 12mm constructs demonstrated comparable compressive and tensile properties.

Conclusions:

Volume expanded human septal neocartilage constructs are qualitatively and histologically similar to standard 12mm constructs. Biochemical and biomechanical analysis of the constructs demonstrated equivalent properties. This study shows that modification of existing protocols is not required to successfully produce neocartilage constructs in larger sizes for reconstruction of more substantial craniofacial defects.
Angioedema of the Upper Aerodigestive Tract: Risk Factors for Intubation and Review of Management Algorithm
Authors: Brook Christopher , Devaiah Anand K. , Mahoney Elizabeth
Published: August 2013

Objectives:

To define the risks associated with angioedema related airway obstruction and intervention, and to delineate the treatment algorithm used at our institution for airway management in patients with angioedema.

Methods:

Retrospective chart review of consecutive otolaryngology consultations for angioedema in the emergency department (ED) from 1999‐2003. All patients were evaluated by an otolaryngologist and underwent fiberoptic laryngoscopy.

Results:

177 patients were included in our study. 32 (18%) patients required intubation, 25 (14%) on initial presentation and 7 (4%) patients progressed from an initially stable airway to requiring intervention after reevaluation. ANOVA analysis demonstrated a statistically significant variance between location of edema and rate of intubation, with higher rates in the pharynx and larynx versus the lip and face. There was no difference between pharyngeal and laryngeal edema in rate of intubation, and there was no difference between oral cavity edema and other subsite in rate of airway intervention. Patients who required intubation after progression between serial evaluations were more statistically more likely to have edema that involved deeper portions of the aerodigestive tract. Patients who required intubation were statistically more likely to be older (average age 61.8 vs 55.1, P=0.03).

Conclusions:

In this large series of patients managed for aerodigestive angioedema we demonstrate risk factors associated with airway intervention and risk factors associated with clinical progression on serial examination to airway intervention. In addition, we demonstrate a successful management algorithm for patients with aerodigestive angioedema.
Deep Venous Thrombosis and Pulmonary Embolism in Otolaryngology Surgery Patients: An Analysis Using NSQIP
Authors: Zapanta Philip E. , Park Joseph
Published: August 2013

Objectives:

1) Compare rates of post‐operative deep venous thrombosis (DVT) and pulmonary embolism (PE) in otolaryngology surgery (OTO‐HNS) to other surgical fields. 2) Determine if otolaryngology and cancer are significantly associated with differing proportion of DVT and PE.

Methods:

Using the American College of Surgeons National Surgery Quality Improvement Program (NSQIP) database, 1,300,956 cases (2006‐2010) were analyzed for DVT and PE complications. Otolaryngology DVT and PE complication rates were compared to other specialties using Pearson's Chi‐Square test. These data were analyzed using a logistic regression analysis (Logit binomial model) to determine the association of OTO‐HNS and cancer with proportion of DVT or PE occurrence. Seventy‐three variables from NSQIP were identified as controls for patient demographics, pre‐operative, and intra‐operative factors.

Results:

OTO‐HNS has decreased prevalence of DVT (OR=0.37; p<0.001) and PE (OR=0.43; p=0.001) compared to other surgeries specialties. Odds ratios for DVT and PE in OTO‐HNS patients with cancer were 4.35 (p<0.001) and 3.86 (p<0.001) respectively. However, OTO‐HNS was associated with significantly increased proportion of DVT (p<0.001) and PE (p=0.008) while cancer was associated with decreased DVT and PE (both p<0.001).

Conclusions:

Otolaryngology patients experience post‐operative DVT and PE less frequently than patients undergoing other types of surgery. However, when controlling for other potential risk factors, OTO‐HNS has increased risk for DVT and PE. Given the nature of the specialty, otolaryngologists may not be as aggressive in preventing DVT and PE as their peers. This may prompt otolaryngologists to revisit their standards of practice.
Do Obese Patients Need Larger Endotracheal Tubes?
Authors: D'Anza Brian , Knight Jesse , Greene J. Scott
Published: August 2013

Objectives:

1) Correlate tracheal airway size with Body Mass Index (BMI) and other height and weight measurements. 2) Discuss implications for choosing endotracheal tube sizes in adult patients of varying body habitus.

Methods:

This was a radiographic (computed tomography [CT]) study of 123 consecutive hospitalized patients undergoing tracheotomy over a 4‐year period (2007‐2011). Personal observation of the senior author was that obese patients do not have larger tracheas. In morbidly obese patients, the tracheal dimensions appeared to be even smaller. We expected BMI to not be a good predictor of airway size. We measured airway dimensions in axial CT imaging and made comparisons with their height, weight, BMI, gender, and age. Measurements were taken at the level of the first tracheal ring including anterior‐posterior length, width, and calculated area.

Results:

The linear regression model showed BMI was significantly inversely related to CT width after controlling for gender and age. For every 1 kg/m2 increase in BMI the CT width decreased by 0.05 points (P = 0.0389). Among all patients there was a trend for airway area to diminish with increasing BMI.

Conclusions:

The results support our hypothesis that obese patients do not have larger airways. Moreover, the results indicated a trend toward smaller airways as BMI increased. Specifically, as BMI increases, tracheal width appears to decrease. This information should help medical professionals avoid the tendency to use a larger tube to intubate an obese patient. Hopefully this will result in fewer airway injuries in a society where obesity has become an epidemic.
Operative Time and Cost of Resident Surgical Experience: Effect of Instituting an Otolaryngology Residency Program
Authors: Pollei Taylor R. , Barrs David M. , Bansberg Stephen F. , Hinni Michael L. , Walter Logan
Published: August 2013

Objectives:

Describe the procedure length difference between surgeries performed by an attending surgeon alone compared to the resident surgeon supervised by the same attending surgeon.

Methods:

Case series with chart review. Setting: Tertiary care center and residency program. Six common otolaryngologic procedures performed between August 1994 and May 2012 were divided into two cohorts: attending surgeon alone or resident surgeon. This division coincided with our July 2006 initiation of an otolaryngology—head and neck surgery residency program. Operative duration was compared between cohorts with confounding factors controlled. Additionally, the direct result of increased surgical length on operating room cost was calculated and applied to departmental and published resident case log report data.

Results:

Five of the six procedures evaluated showed a statistically significant increase in surgery length with resident involvement. Operative time increased 6.8 minutes for a cricopharyngeal myotomy (p= 0.0097), 11.3 minutes for a tonsillectomy (p< 0.0001), 27.4 minutes for a parotidectomy (p= 0.028), 38.3 minutes for a septoplasty (p< 0.0001), and 51 minutes for tympanomastoidectomy (p< 0.0021). Thyroidectomy showed no operative time difference. Cost of increased surgical time was calculated per surgery and ranged from $286 (cricopharyngeal myotomy) to $2142 (mastoidectomy). When applied to reported national case log averages for graduating residents, this resulted in a significant increase of direct training related costs.

Conclusions:

Resident participation in the operating room results in increased surgical length and additional system cost. Although residency is a necessary part of surgical training, associated costs need be acknowledged.
Interval versus Massed Training: How Do We Best Teach Surgery?
Authors: Kesser Bradley W. , Keeley Meg , Peirce‐Cottler Shayn
Published: August 2013

Objectives:

1) Compare two training paradigms, massed vs. interval training, when novice students learn to perform myringotomy with ventilation tube insertion (MVTI) on a validated simulator. 2) Determine if training paradigm affected confidence levels performing the procedure and comfort level working under a microscope.

Methods:

Between September 2011 and April 2012, 40 medical students were randomized to the interval group (n=19), in which they were trained to perform MVTI in five practice trials/day over 3 days, or the massed group (n=21) in which they were trained over 15 practice trials in one sitting. One week later, all students were tested in five final trials. Outcome measures included time to complete the operation and number and type of error made. Pre‐ and post‐test surveys were administered.

Results:

Students in both groups demonstrated a significant decrease in time between practice and final trials. There was no significant difference between the two groups in time to complete their final trials. No difference was observed in the number of errors committed per trial between practice and final trials (both groups) or between massed and interval groups in their final trials. Students in both groups showed significantly increased confidence in conducting the procedure and in using a microscope. In the final trials, participants in the interval group felt significantly more confident about their ability to perform the procedure than those in the massed group.

Conclusions:

Training method had little impact on proficiency in performing a simulated surgical procedure in this setting.