bluuebunny/crossref_metadata_2025 huggingface dataset:
A Rare Case of a Second Primary Nasopharyngeal Angiofibroma
Authors: Torre Carlos A. , Busquets Jose M.
Published: February 2015

Objective

1) Present what is to our best knowledge the first reported case of a patient with a contralateral second primary angiofibroma. 2) Discuss the details of the clinical presentation, workup, and management of this patient.

Method

This is a case report of a 24‐year‐old man presenting with a contralateral second primary angiofibroma 5 years after endoscopic removal of the primary tumor. His medical charts from 2005 until present time were reviewed.

Results

Nasopharyngeal angiofibromas can receive their blood supply from bilateral carotid systems. Also, a case of a patient with bilateral angiofibromas was previously reported in the literature. Our case is different in that it deals with a contralateral second primary angiofibroma. Before endoscopic removal of the first angiofibroma, angiography confirmed that its main feeder came from the ipsilateral internal carotid artery system. When the tumor recurred it involved the contralateral external carotid system. With all these factors considered, we excluded the possibility of this being a case of recurrent angiofibroma, even though this possibility was originally considered.

Conclusion

We present a case of a contralateral second primary angiofibroma diagnosed 5 years after endoscopic removal of the original primary tumor. This is to our knowledge the first case of such nature reported in the English literature.
Hyperbaric Oxygen versus Steroid on Facial Nerve Injury
Authors: Toros Sema Z. , Karaca Çiğdem T. , Güneş Pembegül , Oysu Cagatay , Ertugay Çiğdem K. , Naiboğlu Barış
Published: February 2015

Objective

Our aim in this experimental study was to evaluate the effects of hyperbaric oxygen (HBO), methylprednisolone (MP), and combined HBO‐MP treatments on traumatic facial nerve regeneration by histopathological examination of the facial nerve in rats.

Method

Four groups of rats were created with 5 subjects in each group after exposure to facial nerve injury: group 1 (HBO), group 2 (control), group 3 (HBO‐MP), and group 4 (MP). Sacrified specimens were examined according to axonal degeneration, vascular congestion, macrovacuolization, axon diameter, and the thickness of myelin sheath.

Results

There was significant difference regarding axonal degeneration, vascular congestion, and axon diameter between group 3 (combined HBO‐MP) and the control group. Besides lesser axonal degeneration and vascular congestion, larger diameter of axons were observed in group 3 (combined HBO‐MP). There was significant difference regarding vascular congestion and axon diameter between group 4 (MP) and the control group. Furthermore, we observed thicker myelin and lesser axonal degeneration in group 3 (combined HBO‐MP) in comparison to the group 4 (MP). However, there was no significant difference in the histopathological findings between group 1 (HBO) and the control group.

Conclusion

The histopathological results in our study suggested that the combination therapy with HBO and MP had additive beneficial effect on the regeneration of facial nerve in an experimental animal model and may provide better treatment outcomes than isolated MP or HBO therapy.
Alternaria Inhibits Defense Mechanism for Virus Infection
Authors: Wada Kota , Kobayashi Takao , Matsuwaki Yoshinori , Arai Chiaki , Kita Hirohito , Moriyama Hiroshi , Edamatsu Hideo
Published: February 2015

Objective

It has been suggested that fungi may have trigger effects for CRS. It was reported that PBMCs from CRS patients produced IL‐5, IL‐13 and INF‐gamma by Alternaria. Kobayashi reported that Alternaria produced potent Th2‐like adjuvant effects in the airway. We hypothesized that Alternaria inhibits Th1‐type defense mechanisms against virus infection.

Method

The functional responses were assessed by expression of cell surface molecules by FACS (MHC Class II, CD40, CD80, CD86, OX40L and CCR7). IL‐6, IP‐10, and I‐TAC were measured by ELISA kits (R&D Systems). TLR3 mRNA and protein expression were detected by real time–PCR and Western blotting.

Results

Alternaria and Poly I:C induced surface molecules of MHC Class II, CD40, CD80, CD86, OX40L, and CCR7 and IL‐6 production in a concentration‐dependent manner. But, Alternaria significantly inhibited IP‐10, I‐TAC, and IFN‐gamma production induced by Poly I:C. TLR3 mRNA expression and protein production by Poly I:C were significantly inhibited by Alternairia. It was considered that these reactions were caused by heat‐resistance and over 100 molecular weight substance from Alternaria.

Conclusion

From these results, it was found that the presence of Alternaria inhibited a production of IFN‐gamma by inhibiting expression of TLR3 and inhibited a production of IP ‐10 and I‐TAC. Alternaria inhibits defense mechanisms against virus infection. It was suggested that Alternaria caused suppression for innate immune systems.
An Esthesioneuroblastoma Mimicking a Fibro‐osseous Lesion
Authors: Thompson Christopher F. , Bhuta Sunita , Suh Jeffrey D.
Published: February 2015

Objective

1) Present the unique radiology and pathology of a coarsely calcified pediatric esthesioneuroblastoma (ONB) that was incorrectly suggested preoperatively to be a fibro‐osseous tumor. 2) Review the clinical presentation, radiographical and pathological findings, treatment, and prognosis of ONBs.

Method

The PubMed database was searched from 1958 to 2011, limited to the English language, using keywords esthesioneuroblastoma, radiology, and calcification.

Results

Esthesioneuroblastomas present with nasal obstruction, pain, hyposmia and epistaxis. Imaging shows a destructive, soft tissue mass without calcifications. Treatment includes surgery, radiation and chemotherapy. Ten year survival is significantly decreased in Hyams high‐grade pathological tumors. We present a 12 year‐old female with Kadish C and Dulguerov‐Calcaterra T3N0M0 esthesioneuroblastoma that on CT and MRI revealed a coarsely calcified 3.8 × 3.5 × 4.1 cm mass involving the right nasal vault and paranasal sinuses. Due to the extensive calcifications, it was incorrectly suggested preoperatively to be a fibro‐osseous lesion. She underwent endoscopic‐assisted resection with postoperative radiation and is disease‐free 9 months post‐treatment.

Conclusion

Our case highlights a unique radiographic presentation of esthesioneuroblastoma and emphasizes that this uncommon neuroectodermal malignant tumor always be in the differential for unilateral nasal cavity lesions. Optimal treatment requires a multidisciplinary approach and long‐term clinical surveillance is essential.
IgG4‐Related Sialadenitis: Pearls and Pitfalls in Management
Authors: Ohta Nobuo , Kurakami Kazuya , Suzuki Yusuke , Ishida Akihiro , Kakehata Seiji
Published: February 2015

Objective

A new concept of IgG4‐related sialadenitis characterized by high serum IgG4 levels and tissue infiltration of IgG4‐expressing plasmacytes has recently been proposed. To determine appropriate serum levels of IgG4 for monitoring disease activity, a total of 36 serum samples and 8 tissue samples from patients with IgG4‐related sialadenitis were studied.

Method

The patient group consisted of 6 men and 4 women with an average age of 60 years (range, 47 to 74 years). Serum levels of IgG4 and the density of IgG4‐positive plasmacytes in affected tissues were studied.

Results

All patients had elevated serum IgG4 levels (>135 mg/dL), and IgG4‐positive plasmacytes (IgG4+ plasma cells/IgG+ plasma cells >50%) were observed in the involved salivary glands. Six patients with IgG4‐related sclerosing sialadenitis with high IgG4/IgG ratios and prominent infiltration of IgG4‐positive plasmacytes in the involved salivary glands had systemic complications, including pancreatitis, retroperitoneal fibrosis, and/or inflammatory pseudotumor of the lung after swelling of the salivary glands. All 6 of these patients were successfully treated with systemic corticosteroids.

Conclusion

In the 6 patients with systemic complications, treatment with systemic corticosteroids reduced the salivary gland enlargement and lowered serum IgG4 concentrations. These results suggest that IgG4 levels and IgG4/IgG ratios may be used as additional indicators of disease activity and as biomarkers for potential life‐threatening complications.
Effect of Caffeic Acid on Nasal Polyp Derived Fibroblasts
Authors: Hong Sung M. , Lee Heung‐Man , Chung Seung W. , Park H. , Cho Jung S. , Um Ji Y. , Lee Hye R.
Published: February 2015

Objectives

Caffeic acids are known to have anti‐oxidant, anti‐inflammatory, immunomodulatory, and tissue reparative effects. The purposes of this study were to determine the effect of caffeic acid on transforming growth factor (TGF)‐β1‐induced myofibroblast differentiation and collagen production, and to determine whether caffeic acid is involved in the antioxidant effect.

Method

Nasal polyp‐derived fibroblasts (NPDFs) were pre‐treated with caffeic acid (5‐25 µM) for 2 hours and stimulated with TGF‐β1 (5 ng/mL) for 24 hours. The expression of α‐SMA, collagen types I and III, and Nox4 mRNA was determined by a reverse transcription‐polymerase chain reaction, and the expression of α‐SMA protein was determined by immunofluorescence microscopy. The amount of total soluble collagen production was analyzed by the Sircol collagen dye‐binding assay. The reactive oxygen species (ROS) generated by NPDFs were determined using 2′,7′‐dichlorfluorescein‐diacetate. siNox4 was used to determine the effect of Nox4.

Results

The expression of α‐SMA and production of collagen were significantly increased following TGF‐β1 treatment. In contrast, the level of expression of α‐SMA and the level of production of collagen were decreased by pre‐treatment with caffeic acid. The activation of Nox4 and the subsequent production of ROS were also reduced by pre‐treatment with caffeic acid. The expression of α‐SMA was prevented by inhibition of ROS generation with siNox4.

Conclusion

Caffeic acid may inhibit TGF‐β1‐induced differentiation of fibroblasts into myofibroblasts and collagen production by regulating NADPH oxidase‐derived ROS.
Endoscopic Marsupialization of Maxillary Odontogenic Cysts
Authors: Jain Kunal S. , Goyal Parul
Published: February 2015

Objective

Management of maxillary odontogenic cysts consists of transoral resection or curettage. Large lesions require extensive dissection, leading to perioperative morbidity and need for extensive reconstruction. 1) Describe the use of transnasal endoscopic marsupialization for the management of maxillary odontogenic cysts. 2) Understanding this approach can minimize morbidity with effective treatment.

Method

Case series. Endoscopic sinus surgical techniques were used to treat large benign maxillary odontogenic cysts in five patients between June 2008 and October 2011.

Results

Patients underwent endoscopic marsupialization after creation of a wide maxillary antrostomy. Molars associated with the cystic lesions were displaced into portions of the maxillary sinus in 2 cases. The molars were dissected and removed through the transnasal dissection in each of these cases. Histological and radiological findings were consistent with 1 odontogenic keratocyst, 3 dentigerous cysts, and 1 radicular cyst. The lesions were able to be marsupialized endoscopically with relief of the patient’s initial symptoms and no recurrence. Follow‐up has shown an excellent functional outcome in all cases.

Conclusion

Benign maxillary odontogenic cysts can be effectively treated using transnasal endoscopic approaches. The techniques are less invasive and can reduce morbidity compared to transoral techniques.
Endoscopic Repair of CSF Fistulas and Meningoencephaloceles
Authors: Emmanuelli Juan , Avellan Irene , Sanchez Mariana
Published: February 2015

Objective

Spontaneous CSF fistulas are related with an alteration of the embryologic closure of the skull base, from a simple thinning of the duramater in the cribriform area or the fontanel to a meningoecephalocele anywhere in the skull base. Endoscopic skull base surgery has improved tremendously the morbidity and the postoperative care in these patients, in relation with a craniotomy. We present our experience in the Domingo Luciani Hospital and in Sanatrix Clinic treating these patients endoscopically with excellent results, without intensive care unit and just one day in the hospital.

Method

Fifteen patients were operated with spontaneous CSF leak from 2004 to 2011, 4 of them were meningo or meningoencephaloceles, and the location were 1 in the frontal sinus, 1 in the lateral wall of the sphenoid, 6 in the cribriform plate, 5 in the fovea etmoidalis, and 2 in that planum sphenoidale.

Results

The fistulas were repaired either with free graft, 1 layer or with 2 layers, cartilage and middle turbinate mucoperiosteum; just in 1 case we delivered a septal flap. Of the 15 patients, 13 resolved the leak completely, without any morbidity. In 2 of them the leak reappears when they stop the postoperative medication, with 86.7% success rate.

Conclusion

Endoscopic repair of the CSF fistulas is safe, reliable, with little morbidity and with a very short stay in the hospital.
Human Papillomavirus in Sinonasal Diseases
Authors: Suzuki Mikio , Hasegawa Masahiro , Deng Zeyi , Maeda Hiroyuki , Kiyuna Asanori , Uehara Takayuki
Published: February 2015

Objective

This study investigated prospectively the role of human papillomavirus (HPV) in various sinonasal diseases.

Method

HPV presence and viral load and physical status of HPV‐16 were examined by polymerase chain reaction‐based methods using fresh frozen samples obtained from 13 patients with IP (IP group), 11 with squamous cell carcinoma in the maxillary sinus (SCC group), and 39 with chronic inflammatory lesions (inflammatory group).

Results

The presence of the HPV genome was detected in 46.1%, 27.3%, and 7.6% of patients in the IP, SCC and inflammatory groups, respectively. The IP group showed significantly higher HPV‐positive rates than the inflammatory group. All types of HPV detected were high‐risk HPV, especially HPV‐16. The relative HPV‐16 copy numbers varied from 2.5 to 1524.1 per 50 ng genomic DNA. Viral load was higher in the IP and SCC groups than in the inflammatory group. In the IP group, no significant relationship was found between HPV‐16 viral load and clinical characteristics, or between physical status and clinical characteristics.

Conclusion

HPV infection is involved in the pathogenesis of IP, and high viral load and integration of HPV have an important role in malignant lesion in association with IP.
Image‐Guided Sphenoidotomy
Authors: Jiang Rong‐San , Wu Shang‐Heng , Liang Kai‐Li
Published: February 2015

Objective

To study the efficacy of image‐guided surgery (IGS) in the fenestration of the sphenoid sinus in patients with chronic rhinosinusitis who received functional endoscopic sinus surgery (FESS).

Method

A group of 205 patients who received FESS incorporating IGS were enrolled. Another group of 178 patients who underwent FESS before an imaging‐guided system was available and chosen for comparison. The fenestration rate of the sphenoid sinus was compared between different groups of patients with and without IGS.

Results

The fenestration rates of the sphenoid sinus were 93.3% for patients without nasal polyps, 94.2% for patients with nasal polyps, and 91.2% for revision FESS when operated with IGS, were 100% for patients without nasal polyps, 98.1% for patients with nasal polyps, and 91.3% for revision FESS when operated with IGS, and were 89.8% for patients without nasal polyps, 88.62% for patients with nasal polyps, and 68.6% for revision FESS when operated without IGS. The fenestration rate of the sphenoid sinus in revision FESS without IGS was significantly lower than others.

Conclusion

Our results showed IGS improves the successful fenestration rate of the sphenoid sinus in revision FESS.
Inverted Papilloma Ooriginating from the Opticocarotid Recess
Authors: Srinivasan Ramya , Portillo Elyse , Takashima Masayoshi
Published: February 2015

Objective

1) Understand the relationship of the opticocarotid recess with the surrounding structures. 2) Explain the pathophysiology and natural history of an inverting papilloma (IP) in the sphenoid sinus. 3) Examine the significance of a neoplasm originating from the anterior clinoid.

Method

This case report was conducted in a tertiary hospital setting in June 2011. The subject, a 49‐year‐old woman, presented with an inverting papilloma originating from the opticocarotid recess causing optic nerve dehiscence. The intervention was endoscopic excision. Outcome was measured by clinical examination, and follow‐up patient analysis is ongoing.

Results

The patient was found to have an inverting papilloma (IP) of the sphenoid sinus. During endoscopic sinus surgery, the inverted papilloma was visualized originating from the sphenoid sinus and causing bony erosion in the area of the opticocarotid recess. An area of optic nerve dehiscence was identified, and the sheath of the optic nerve was clearly visualized once the tumor was peeled off the optic canal. Pathology confirmed the diagnosis of inverting papilloma and was negative for carcinoma. Follow‐up clinical examination of the patient revealed that endoscopic excision effectively removed the neoplasm without local complications or recurrence.

Conclusion

Inverting papillomas originating from the region of the opticocarotid recess are an atypical entity and have the potential to cause rare, but serious, complications. The authors are unaware of any reported cases of an IP originating from this area. Early, effective management is crucial given the vital structures at risk.
Controlled Nasolabial Angle Treatment
Authors: Hermann Diego R. , Balsalobre Leonardo , Pascoto Gabriela R. , Stamm Raquel , Stamm Aldo E. C.
Published: February 2015

Objective

To evaluate the nasolabial angle (NLA) treatment with the septal‐columellar strut suture in a controlled and precise technique.

Method

Twelve patients of both sexes (8 women and 4 men), who had nasolabial angle not compatible with sex (we consider the angle between 90° and 95° suitable for men and 95° to 100° for women) underwent open approach rhinoplasty. A special ruler protractor type (developed for this purpose) was used to indicate how much the caudal septum should be resected to maintain these angles accurately. Then the columellar strut was fixed to the caudal septum with 2 sutures (one superior and another one inferior). Patients were evaluated using digital photography before surgery, immediately postoperatively (PO), and 6 months after surgery. Patients were followed prospectively.

Results

In those 8 women evaluated, the ANL was between 95° and 100° in the immediate postoperative period. The 6‐month postoperative evaluation revealed that 5 had a variation of 3°, and 3 of them had variations between 3° and 5°. Of the 4 evaluated men, all had ANL between 90° and 95°, and their 6‐month postoperative evaluations revealed variations of 3° in 2 patients and variations between 3° and 5° in the other 2.

Conclusion

The nasolabial angle can be treated in a controlled and precise way, using a special ruler protractor and the columellar strut‐septal suture.
Impact of Long‐term Diving on Otolaryngology
Authors: Gurpinar Berk
Published: February 2015

Objective

1) Determine the negative effects of diving in otolaryngology. 2) Review the literature and give a brief description of pathologies related to diving.

Method

Between May 2011 and February 2012, 90 male subjects were prospectively examined in Kasimpasa and Golcuk Military Hospitals. The study group consisted of 45 military divers, and the rest, nondivers, were determined as the control group. The data included the age, sex, and experience of diving in terms of years. Detailed otolaryngologic examination, including endoscopy, was performed. Continuous data were displayed as mean ± standard deviation (SD). The Mann‐Whitney U test was used to determine statistically significant variances.

Results

In the study group, the mean age was 30.71 ± 5.932 years, and total time in diving was 7.289 ± 6.083 years. In the control group, the mean age was 32.21 ± 4.784 years. In the study group 26 of 45 subjects had exocytosis (57.7%), and 34 had inferior turbinate hypertrophy (75.5%). Correlation of exocytosis and the inferior turbinate hypertrophy between the 2 groups was statistically significant (P <. 0001). Age was not statistically correlated between the 2 groups, implying the 2 groups were identical (P =. 831)

Conclusion

Although the negative effect of cold water on the external ear canal is studied thoroughly, inferior turbinate hypertrophy in long‐term divers was not familiar up to now. This study shows that diving has negative effects on external ear anatomy and the nasal cavity.
Maxillary Sinus Septation Causing Chronic Sinusitis
Authors: Sullivan Corbin , Conley Stephen , Sewell Steven
Published: February 2015

Objective

1) Report a unique case of a complete maxillary sinus septation (MSS) obstructing the ostio‐meatal complex with resulting chronic unilateral maxillary and ethmoid sinusitis. 2) Report a novel treatment of a MSS with dual approach via Caldwell‐Luc and endscopic maxillary antrostomy. 3) Perform a literature review of MSS.

Method

This is an individual case report of a pediatric patient treated in 2010 for chronic right maxillary and ethmoid sinusitis resulting from an obstructive complete MSS. Initial treatment was medical, followed by a unique combined surgical approach. The patient was followed clinically and with computed tomography (CT).

Results

The patient did not have recurrence of sinusitis either clinically or on imaging during the follow‐up period.

Conclusion

This is a unique case of MSS causing chronic sinusitis. There is scant mention of MSS in otolaryngology literature, with most mentions coming from oral and maxillofacial surgery literature. This may present an area for future investigation in relation to both imaging findings and surgical approach to rhinosinusitis.
Recurrent Massive Allergic Fungal Sinusitis in Children
Authors: Arora Vipin , Singh P. P.
Published: February 2015

Objective

1) To evaluate the clinical and radiological profile of massive allergic fungal sinusitis (AFS) in children. 2) To evaluate the efficacy of external open sinus surgery for recurrent massive AFS in children.

Method

Retrospective review of clinical and radiological records at tertiary care university hospital. Twelve pediatric patients (age 9‐15 years, mean 13.2 years) of recurrent massive AFS who had skull‐base erosion, intracranial extension with unilateral or bilateral intraorbital involvement on CT scan were included in study. All patients had undergone multiple unsuccessful endonasal operations (range, 3‐5; mean, 3.8). Patients were operated by bilateral lateral rhinotomy and transfrontal approaches (3), transantral endoscopic approach (7), and combined lateral rhinotomy and transnasal approach (2). All patients received postoperative antibiotics and steroids. Postoperative follow‐up was done, and symptoms were evaluated (range, 14‐24 months; mean 17.5 months).

Results

Nasal obstruction and discharge were the most common presenting complaints. Aspergillus flavus was the most common fungus isolated. All the patients had subjective improvement of symptoms following surgery. Noncontrast CT scan done at least 1 year following surgery showed recidivism of disease in 8.3% cases.

Conclusion

Individualized external open sinus surgery for massive AFS is effective management for patients who have undergone repeated unsuccessful endonasal procedures. Rate of recidivisim (8.3 %) is less compared to that reported for endonasal procedures (10‐100%). Morbidity, complications and cost of single external procedure for massive AFS is less as compared to repeated endonasal procedures.
Use of HRCT‐MRI Fusion Imaging in the Detection of Cerebrospinal Fluid Leaks
Authors: Agbetoba Abib A. , Delman Bradley , Bederson Joshua , Govindaraj Satish
Published: February 2015

Objective

1) Determine the accuracy of high resolution computed tomography and magnetic resonance fused imaging in detecting skull base cerebrospinal fluid leaks. 2) Develop a comprehensive algorithm for the diagnostic workup of anterior skull base cerebrospinal fluid leaks.

Method

We retrospectively reviewed 16 cases of patients who underwent HRCT‐MRI fusion studies with intraoperative fluorescein localization for the evaluation and repair of CSF leaks during a 3‐year period between 2008 and 2011 at the Mount Sinai Medical Center.

Results

Sixteen HRCT‐MRI fusion studies were evaluated from 16 different patients suspected of having CSF leaks. Eleven out of the 16 subjects had a confirmed diagnosis of CSF leak on intraoperative nasal endoscopy. HRCT‐MRI fusion imaging accurately identified the CSF leak and its location in each of the 11 subjects yielding a sensitivity of 100%. Three of the 16 patients were found to have no signs of active leak or skull base defect on intraoperative nasal endoscopy, 2 of which correlated with negative findings on fusion imaging.

Conclusion

HRCT‐MRI fusion is an excellent imaging modality that not only provides accurate identification and localization of CSF leaks but also acts as a great adjunct for intraoperative localization and repair. HRCT‐MRI fusion should be incorporated into the diagnostic algorithm for management of CSF leaks.
Allergic Rhinitis and Changing Nasal Congestion after Continuous Positive Airwary Pressure
Authors: Skirko Jonathan R. , James Kathryn T. , Levine Corinna G. , Shusterman Dennis , Weaver Edward M.
Published: February 2015

Objective

Among continuous positive airway pressure (CPAP) users, self‐reported allergic rhinitis has been associated with relative worsening of subjective nasal congestion. This study’s aims were to test the associations between objective allergic rhinitis status and 1) change in objective nasal congestion after CPAP initiation, or 2) objective CPAP use.

Method

Objective allergic rhinitis status was established by skin‐prick test of 17 region‐specific aeroallergens in CPAP patients with baseline turbinate hypertrophy. Objective nasal congestion was measured by acoustic rhinometry (combined bilateral minimal cross‐sectional area, MCA) at baseline and 3‐months later in subjects using CPAP. Objective CPAP use was measured at 12 months.

Results

This cohort study included n = 81 subjects from a larger parent trial on turbinate hypertrophy in CPAP patients. In this cohort, MCA did not change significantly in subjects with allergic rhinitis (n = 51, paired t‐test P =. 18) or in controls (n = 30, paired t‐test P =. 67) after initiation of CPAP, and there was no significant difference in change between groups (t‐test P =. 28). CPAP use in allergic rhinitis subjects (1.9 ± 2.7 h/night) was not significantly different from controls (2.4 ± 3.0 h/night; Mann‐Whitney U test, P =. 28), but statistical power was limited for the observed difference (power 12%).

Conclusion

Allergic rhinitis did not predict worsening of objective nasal congestion with CPAP initiation or decreased CPAP use, but confounding, eligibility criteria, limits of objective nasal measurements, and insufficient statistical power may have blunted a true effect. Further studies are needed.
Application of a Novel Bioabsorbable Tonsil Patch
Authors: Melder Patrick C.
Published: February 2015

Objective

1) To learn if application of a novel bioabsorbable material is feasible for use as a posttonsillectomy patch. 2) To determine, based on the limited number of cases, if there is subjective evidence of decreased pain and quicker return to normal diet. 3) To determine if further research is warranted.

Method

The current study was a nonrandomized clinical study in a private practice. Biodesign 4‐layer tissue grafts (COOK Medical) were placed in the tonsillar fossa after tonsillectomy. Patients were then questioned on postoperative pain, need for narcotic use, and days to return to normal diet.

Results

The main objective to determine feasibility of placement of a bioabsorbable patch was achieved in all 10 cases. The average placement time per side was 10 minutes, adding 20 minutes/case. Patients were seen at either postopeartive days 2 and 10, and patients were questioned about expected level of pain, need for narcotics, and return to normal diet. All patients on average were noticing significant decreases in pain at days 3 and 4, noted with decreased narcotic intake and return to normal diets. No adverse events were noted with the Biodesign® material.

Conclusion

First, the study demonstrates the feasibility of using Biodesign as a bioabsorbable patch after tonsillectomy. Second, the initial results of this pilot study are very encouraging in providing evidence that a non‐energy–based device can provide consistent postoperative pain reduction. Further study is warranted to better measure outcomes.
Changes of Site of Obstruction in Obstructive Sleep Apnea According to Position
Authors: Kim So Young , Lee Woo Hyun , Rhee Chae‐Seo , Lee Chul Hee , Won Tae‐Bin
Published: February 2015

Objective

To evaluate the changes of site of obstruction in obstructive sleep apnea (OSA) patients according to sleep position.

Method

From December 2010 to December 2011, 113 OSA patients underwent drug‐induced sleep endoscopy in the supine and lateral positions. Obstruction site was classified as soft palate (SP), tongue base (TB), lateral wall (LW), larynx (LX), and no obstruction (NO). Patients with a nonsupine RDI above 10 were classified as nonpositioners (NP) and below 10 as positioners (PR).

Results

There were 85 men and 28 women with a mean age of 42.7 years. Mean BMI was 27.1, and mean RDI was 37.5. The PR (position responder) group was 49 patients, which accounts for 43.36% of all enrolled OSA patients (113 patients). Their site of obstruction in supine position was TB (20), SP(13), LW(11), and LX(5). In the lateral position 32 showed no obstruction, 8 showed obstruction at the LW, and the remaining 9 patients showed obstruction at SP. In the NP group (64, 57%), site of obstruction in the supine position was TB (20), SP (11), LW (26), and LX (7). In the lateral position, obstruction was observed at the LW (39), SP (16), TB (5), and LX (4).

Conclusion

Site of obstruction according to sleep position was evaluated for the first time. TB obstruction showed marked improvement when sleep position changed from supine to lateral. Obstruction in the lateral position was mostly due to obstruction at the LW, and position dependency is mostly determined by LW collapsibility.
Comparing Ways of Assessing Tongue Base Obstruction in Obstructive Sleep Apnea
Authors: Koh Lynn , Mok Paul Kan‐Hwei
Published: February 2015

Objective

To determine if awake clinical evaluation methods like Friedman’s Tongue Position (FTP), endoscopic assessment of the hypopharynx using Mueller maneuver (MM), and during end expiration (EEPBOT) to assess tongue‐base obstruction correlate well with tongue‐base obstruction seen during drug‐induced sleep endoscopy (DISE).

Method

Pilot prospective study of 16 patients with moderate to severe OSA recruited over 1 year at a tertiary care center. These patients were evaluated in the clinic with the flexible nasendoscope and subsequently underwent full PSG and DISE with midazolam.

Results

The 16 patients studied had a mean AHI of 65 (range, 18.8 to 129). Fifteen out of 16 patients (93.7%) were found to have multi segment obstruction on DISE according to the original grading proposed by Pringle and Croft. Comparing the various awake dynamic maneuvers against DISE as a gold standard, MM was found to have sensitivity of 53%, FTP had a sensitivity of 80%, and EEPBOT had a sensitivity of 93%. Because of the skewed nature of the results (only 1 out of 16 patients [6.3%] was classified as not having obstruction), specificity results had no statistical value.

Conclusion

This small pilot study showed a good correlation between EEPBOT, FTP, and DISE. A poorer correlation between MM and DISE is seen. Our results suggest that EEPBOT and FPP are superior to MM in evaluating tongue‐base obstruction in OSA; however, further research is required to support these findings.
da Vinci System for Treatment of Sleep Apnea Syndrome
Authors: Baptista Peter M. , Alcalde Juan , de Abajo Jorge , Gallegos Vivian
Published: February 2015

Objective

Tongue base hypertrophy is frequently related with sleep apnea‐hypopnea syndrome (OSAHS). The objectives were: 1) To determine which patients are candidates for tongue base resection by means of trans ral robotic Surgery (TORS). 2) To evaluate the clinical results of this technique associated or not with other treatments.

Method

All patients were diagnosed with OSAHS with obstructing tongue base through polysomnography, office endoscopy, and drug‐induced sleep endoscopy (DISE). Ten patients with OSAHS and obstructive tongue base were surgically treated with TORS using the Intuitive da Vinci system and traditional surgical techniques for OSAHS between August and December 2011.

Results

The mean preoperative apnea‐hyponea index (IAH) was 40.67 (22.26‐78.21). Patients did not require tracheotomy, and no major complications were observed during or after surgery. Tongue base and epiglottis were managed securely, and no problems with hemostasis were observed. Swallowing pain was present a mean of 10 days after surgery with satisfactory response to therapy with corticoesteroids and nonsteroidal anti‐inflammatory drugs. One of the patients presented an epidermoid tumor in the right side of the tongue base causing the obstructive syndrome; it was resected with no affected margins using the TORS technique.

Conclusion

The DISE technique is a useful test to determinate which patients are candidates for tongue base surgery. All patients archived a significant improvement of their IAH and Epworth Sleepiness Scale (ESS). The Intuitive da Vinci system provides excellent visualization and tissue management with low morbidity.
Daytime Sleepiness and Sleep in Allergic Rhinitis
Authors: Chiba Shintaro , Ando Yuji , Watanabe Subaru , Kimura Akihiro , Moriwaki Hiroto
Published: February 2015

Objective

Over 20 million people in Japan suffer from hay fever caused by cedar pollen, and every year, they are disturbed with severe symptoms during a season of just 2 to 3 months. Clinically, there is a big problem with quality of life, including daytime sleepiness and sleep problems.

Method

To clarify the influence of hay fever on sleep and daytime sleepiness subjectively, 22 patients with hay fever caused by cedar pollen were enrolled. We evaluated sleep architecture and objective sleepiness before the season and during the season using PSG and MSLT.

Results

Wake time after onset (WASO) showed significant increase during the season compared to before the season: from 16.4 to 29.7 min. AHI does not change for the worse during the season. In 11 patients with nasal obstruction, total nasal resistance was >0.3pa/cm/sec, out of 22, rate of REM‐sleep decreased (from 24.2 to 20.8%), and mean MSLT decreased (from 12.4 to 8.5 min) significantly. Especially 4 out of 11 showed severe sleepiness that was recognized as disease (MSLT <5 min) during the season.

Conclusion

There are strong associations between nasal symptoms, especially nasal obstruction, sleep quality, and daytime sleepiness.
Diagnosing Obstructive Sleep Apnea: Predictive Value of Friedman Tongue Position
Authors: Friedman Michael , Hamilton Craig S. , Samuelson Christian G.
Published: February 2015

Objective

1) Assess the association between tongue position and risk of obstructive sleep apnea (OSA) as measured by both Mallampati (MP ‐including classic 3‐level and modified 4‐level scoring with tongue protrusion) and Friedman Tongue Position (FTP‐no tongue protrusion). 2) Determine which of these assessment scales best predicts OSA risk.

Method

PubMed, MEDLINE, Cochrane Trial Registry (through 12/2011), and relevant article bibliographies were searched. All studies were assessed by 3 reviewers. Systematic review and random‐effects meta‐analysis of studies assessing the association of tongue position and risk of OSA were performed. Outcomes are reported as odds ratios (OR).

Results

Combined data from 5 studies (46,264 patients) revealed an overall OR of 2.436 (1.828, 3.248; P <. 001) for presence of OSA with MP/FTP 3 or 4 compared with MP/FTP 1 or 2. Sensitivity analysis revealed OR of 2.185 (1.643, 2.905; P <. 001) for MP 3/4 and 4.408 (2.651, 7.327; P <. 001) for FTP 3/4, respectively. Combined data from 2 studies (240 patients) revealed an OR for OSA per 1‐point increase in MP/FTP of 2.351 (1.430, 3.865; P <. 001). Sensitivity analysis revealed OR of 2.5 (1.225, 5.103; P =. 012) and 2.219 (1.109, 4.437; P =. 024) per 1‐point increase in MP and FTP, respectively.

Conclusion

Tongue position 3 or 4, whether classified by MP or FTP, is significantly associated with increased OSA risk. In the clinical assessment of patients with suspected OSA, FTP 3/4 appears to have a higher predictive value for OSA than classic MP 3 or modified MP 3/4.
Does Snoring Change the Palatal Sensation?
Authors: Seol Jeong hun , Kim Jae‐Myung , Cho Jae Hoon , Kim Ki‐Tae , Kim Jin Kook
Published: February 2015

Objective

Patients with obstructive sleep apnea syndrome (OSAS) have impaired responses in inspiratory resistive loading during sleep. This may be due, in part, to a change in the upper airway sensation. Therefore, we hypothesized that patients with OSAS had diminished upper airway sensation due to snoring.

Method

Case‐control study. Conducted: from May 2011 to March 2012. Participants were selected based on clinical evaluation and polysomnography. Two‐point discrimination was measured with modified calipers in the tongue and soft palate. Independent variables: snoring time components.

Results

Comparing polysomnography, patients with impairment of their palatal sensory input in 2‐point discrimination had longer longest‐snoring episodes than those with normal sensation (P =.010). And patients with decreased sensory input in 2‐point discrimination had longer average snoring episode duration than those with normal sensory input (P =. 043). However, the total snoring time and relative snoring time also increased in patients with sensory impairment, but statistical significance was not found (P =. 20, P =. 24 respectively).

Conclusion

Two‐point discrimination in the anterior tongue and soft palate was impaired in patients with OSAS. We speculate that this impairment might be due to a primary sensory function abnormality or secondary to nerve damage and/or hypoxemia caused by snoring. Further studies after treatment of OSAS are needed.
Effect of Upper Airway Stimulation on Snoring in Obstructive Sleep Apnea
Authors: Maurer Joachim T. , Hohenhorst Winfried , Knaack Lennart , Baskin Jonathan Z. , Lin Ho‐Sheng , Odland Rick , Anders Clemens
Published: February 2015

Objective

Previous studies showed that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). This study aims to: 1) Learn whether upper airway stimulation has an effect on snoring in patients with moderate‐to‐severe OSA. 2) Learn whether there is a correlation between the reduction of snoring and obstructive respiratory events.

Method

Upper airway stimulation systems were implanted in moderate‐to‐severe OSA patients (inclusion criteria: CPAP failure or intolerance, BMI <32, without complete concentric collapse during drug‐induced‐sleep‐endoscopy). Apnea‐hypopnea‐index (polysomnography) and snoring (5‐level categories by bed‐partner: no, soft, loud, very intense, intolerable by bed partner) were collected at pre‐implant and 2, 4, and 6 months post‐implant.

Results

Nine subjects were implanted, and all have completed month 6 visit. All 9 subjects reported loud or very intense snoring at pre‐implant. At the last visit, 4 subjects reduced from loud to no snoring, 4 subjects reduced from loud to soft snoring, and 1 subject reported no change. Reports from bed‐partners were similar. The average AHI among the 9 subjects reduced from 39.4 ± 9.3 (mean ± SD) to 16.7 ± 21.7 (P <. 05).

Conclusion

Preliminary findings suggest that upper airway stimulation improves snoring along with the improvement of sleep disordered breathing in patients with moderate‐to‐severe OSA.
Strategies to Improve CPAP Adherence: Zhenjiang Experience
Authors: Qian Wei , Haight James , Ma Yongming , Jiang Guochang
Published: February 2015

Objective

High dropout rate of CPAP is a big challenge. To improve the CPAP adherence, systemic upper airway management including subjective and objective nasal patency assessment, surgical and medical treatment to upper airway obstruction, and CPAP follow‐up strategies were carried on in the present study.

Method

A prospective study. A total of 169 OSA patients (women: 34; mean age, 42.9 years) and 41 healthy subjects (women: 9; mean age, 38 years) were undertaken for polysomnography and subjective and objective nasal patency assessment. CPAP users with upper airway disorder were treated with medication or surgically and followed for up to 3 years.

Results

Average bilateral nasal cavity volume (2‐5 cm from nostril) was 4.97 mL in OSA subjects and 6.43 in healthy subjects (P <. 01), and average nasal respiratory resistance was 2.03 Pa·cm‐3·s‐1 in OSA subjects and 0.44 in healthy subjects (P <. 01). There was no significant nasal patency difference among mild, moderate, and severe OSA patients. In 59 CPAP users, 27 were treated with nasal steroid spray and/or decongestant, whereas 10 were treated surgically (8 septoplasty and 2 tonsillectomy + UPPP). A total of 38 patients (64%) kept using CPAP over 4 hours per day, 9 (15%) dropped out, and 12 (21%) were lost in the 3 years follow‐up.

Conclusion

The incidence of nasal patency disorder was higher in OSA patients. Nasal airway assessment was helpful to foresee and deal with the problems with CPAP treatment, which would encourage patients to adhere to the treatment with medical or surgical interferences.
The Morphology of Nasopharyngeal Inlet in Obstructive Sleep Apnea
Authors: Tanyeri Hasan M. , Aksoy Elif A. , Serin Gediz M. , Polat Senol , Unal Omer F.
Published: February 2015

Objective

Routine flexible optic laryngoscopy (FOL) displays obstructive sleep apnea (OSA) related airway passages from nasopharynx to hypopharynx. Tip of the flexible endoscope awaiting at the nasopharyngeal inlet allows us to visualize the morphology of this area. We wanted to evaluate the impact of nasopharyngeal inlet (NPI) morphology on OSA severity.

Method

The videos obtained during FOL examinations of NPI were examined in 83 patients (10 women, 73 men). Two main morphologies, wide and narrow, were depicted. The narrow NPI group was further divided into kidney‐shaped, elliptical, and circumferential. The wide NPI group was divided into circumferential and kidney‐shaped.

Results

Forty‐five patients had narrow NPI morphology, and 38 had wide NPI morphology. The wide NPI group had 20 circumferential and 18 kidney‐shaped morphologies. The narrow NPI group had 34 kidney‐shaped, 6 circumferential, and 5 elliptical morphologies. Mean RDI of the narrow group was 30.378 ± 22.358, and the wide group was 14.511 ± 13.901. Mean RDI of the narrow circumferential group was 45.317 ± 30.56, the narrow elliptical group was 23.74 ± 10.787, and the narrow kidney‐shaped group was 28.718 ± 21.47. Mean RDI of the wide circumferential group was 11.3 ± 13.203, and the mean RDI of the wide kidney‐shaped group was 17.772 ± 14.586. The wide morphology groups had lower RDI levels compared to the narrow morphology groups (P <. 0005).

Conclusion

Morphology of nasopharyngeal inlet may be evidence of OSA during routine FOL examinations. Further analysis of the subgroups supported evidence of narrowing by means of increased RDI levels.
Upper Airway Surgery in Patients with Sleep Apnea
Authors: Rocke Daniel , Sharp Scott R. , Puscas Liana , Wiener Dana , Lee Walter T.
Published: February 2015

Objective

1) Evaluate the safety of outpatient and overnight observation of sleep apnea surgery patients using new preoperative screening criteria. 2) Compare the cost‐effectiveness of outpatient and overnight observational sleep apnea surgery compared to surgical intensive care admission using new preoperative screening criteria.

Method

Retrospective chart review of patients undergoing sleep apnea surgery at the Durham VA between May 2008 and January 2012. A new preoperative protocol was used to triage postoperative care between intensive, routine, or discharge home. Postoperative complications were assessed in each group, and a cost comparison was conducted between groups.

Results

A total of 115 patients underwent sleep surgery between July 2008 and January 2012. Eleven patients were excluded, leaving 104 patients in the final analysis. The average follow‐up was 3.6 months. The overall complication rate was 12.5%. Fifty‐eight patients were triaged to intensive postoperative care, 21 patients were triaged to routine postoperative care, and 24 patients were not monitored overnight. All of the respiratory and bleeding complications occurred in the immediate postoperative period. All of the complications were adequately handled under the new protocol. The savings over the 3.6 years of this study was $125,275.

Conclusion

Certain patients with sleep apnea can safely be triaged to less than intensive postoperative care. In institutions like the Durham VA, where all sleep apnea patients were historically triaged to intensive care postoperatively, this will lead to significantly lower cost and more efficient use of scarce postoperative resources.
Dermatitis Artefacta: Facts for a Facial Plastic Surgeon
Authors: Grover Nancy , D’Souza Alwyn
Published: February 2015

Objective

1) To report a large scalp lesion secondary to dermatitis artefacta, requiring reconstruction. 2) To emphasize the need for a multidisciplinary approach involving dermatologist, psychiatrist, and facial plastic surgeon for optimizing outcome. 3) To highlight specific issues in the patient’s care in the perioperative period.

Method

Case report of a 44‐year‐old white female patient who presented to our combined dermatology–facial plastic surgery clinic with a large lesion on her scalp and a known diagnosis of dermatitis artefacta.

Results

The scalp lesion had gradually increased in size over 4 years. Prior to this she was being followed up by the dermatologists for this and other multiple, bizarre ulcerating areas on her face; the patient had associated depression. A diagnosis of dermatitis artefacta was made by the dermatologists and supported by the psychiatrists. She was treated with antibiotics for the excoriating lesions and local dressing for the scalp wound initially. Regional reconstruction of scalp was subsequently carried out to achieve closure of the scalp defect, with the active involvement of the dermatology and psychiatry teams.

Conclusion

1) Close monitoring is required postoperatively, as these patients can be passively noncompliant with treatment, inducing self‐harm repeatedly because of lack of insight in causing skin damage. 2) Prompt discussion in a multidisciplinary setting with earlier input from facial plastic surgeons will potentially minimize the extent of reconstructive surgery required.