Modified adenotonsillectomy to improve cure rates for pediatric obstructive sleep apnea: a randomized controlled trial.

OBJECTIVE: To compare the efficacy of adenotonsillectomy (T&A) with and without pharyngoplasty (tonsillar pillar closure) in the treatment of pediatric obstructive sleep apnea-hypopnea syndrome (OSAHS). STUDY DESIGN: Randomized single-blind controlled study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Sixty pediatric patients with a clinical diagnosis of OSAHS presenting between January 2009 and December 2010 were enrolled and randomized to undergo either standard T&A (n = 30) or T&A with pharyngoplasty (n = 30). Surgical cure was defined as apnea-hypopnea index (AHI) <5 plus OSA-18 health-related quality-of-life (HRQL) score <60. Other outcomes included postsurgical AHI and minimum oxygen saturation (SpO(2)) improvement, changes in OSA-18 scores at 1 month, and postsurgical days to resume normal diet and activity. RESULTS: Three patients from each group did not undergo surgery. Of the 54 patients treated, 8 from the pharyngoplasty group and 2 from the standard group were lost to follow-up. Intention-to-treat analysis revealed no difference in cure rate between groups (standard 60%, pharyngoplasty 56.6%, P = .793). Limiting analysis to those patients with complete data, a higher, but not significantly increased, cure rate with pharyngoplasty was noted (72% vs 89.5%, P = .155). Greater OSA-18 improvement (P = .036) and greater (although nonsignificant) AHI improvement and earlier return to normal function were noted with pharyngoplasty. CONCLUSION: The addition of pharyngoplasty to traditional adenotonsillectomy did not significantly improve OSAHS cure rates as measured by sleep testing and HRQL, although a nonsignificant increase in cure rate was observed in those who completed the study protocol. An unexpectedly high rate of patient dropout rendered the study statistically underpowered and therefore inconclusive.

Dead Sea salt irrigations vs saline irrigations with nasal steroids for symptomatic treatment of chronic rhinosinusitis: a randomized, prospective double-blind study.

BACKGROUND: Intranasal steroids are 1 of the most frequently prescribed medications for the treatment of chronic rhinosinusitis (CRS), and saline irrigations are commonly used as an adjunct to medical therapy. We aimed to compare the efficacy of Dead Sea salt (DSS) irrigations and DSS nasal spray vs saline irrigations and topical nasal steroid spray in the treatment of symptoms of CRS. METHODS: A total of 145 symptomatic adult patients without acute infection were initially enrolled and 114 completed the study. Patients completed a Sino-Nasal Outcomes Test 20 (SNOT-20) survey (primary outcome metric) and underwent endonasal examination, acoustic rhinometry, and smell testing (secondary outcome metrics). Patients were randomized to 2 groups. The experimental group (n = 59) self-administered hypertonic DSS spray and DSS irrigation; the control group (n = 55) self-administered fluticasone spray and hypertonic saline irrigation and spray. Patients and staff were blinded to group assignment. Outcomes were reassessed at 4 weeks. RESULTS: The 2 groups were homogeneous with respect to pretreatment primary and secondary outcome metrics. Dropout rates were 30% in the DSS group and 36.6% in the control group. Both groups showed significant improvement in mean SNOT-20 scores following treatment; however, the degree of improvement was not significantly different between groups (p = 0.082). There were no significant changes in secondary outcome metrics between the 2 groups. CONCLUSION: For patients with CRS, treatment with DSS irrigations and sprays appears as effective for symptom reduction as a combination of hypertonic saline irrigations and sprays and a topical steroid spray.

Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome.

OBJECTIVE: In previous reports of transoral robotic surgery (TORS) for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS), patients underwent routine tracheotomy. We aim to assess the feasibility of performing robotically assisted partial glossectomy without tracheotomy and to assess efficacy by comparing OSAHS outcomes with those of established techniques. STUDY DESIGN: Historical cohort study with planned data collection. SETTING: Tertiary care center. SUBJECTS AND METHODS: Forty consecutive patients underwent TORS for OSAHS between October 2010 and June 2011 and were followed up with regard to complications, morbidity, and subjective and objective outcomes. Data from 27 of these patients who underwent concomitant z-palatoplasty with 6-month follow-up were compared with those of 2 matched cohorts of patients, who underwent either radiofrequency (radiofrequency base-of-tongue reduction [RFBOT]) or coblation (submucosal minimally invasive lingual excision [SMILE]) reduction of the tongue base and z-palatoplasty. RESULTS: No major bleeding or airway complications were observed. Postoperative pain and length of admission were similar between groups. All groups saw Epworth score and snore score improvement. Patients undergoing robot-assisted surgery took longer than their SMILE and RFBOT counterparts to tolerate normal diet and longer than RFBOT patients to resume normal activity. Apnea hypopnea index (AHI) reduction averaged 60.5% ± 24.9% for TORS versus 37.0% ± 51.6% (P = .042) and 32.0% ± 43.3% (P = .012) for SMILE and RFBOT, respectively. Only the robotic group achieved statistically significant improvement in minimum oxygen saturation. Surgical cure rate for TORS (66.7%) was significant compared with RFBOT (20.8%, P = .001) but not compared with SMILE (45.5%, P = .135). CONCLUSION: Robotically assisted partial glossectomy feasibly can be performed without the need for tracheotomy. This technique resulted in greater AHI reduction but increased morbidity compared with the other techniques studied.

Abnormalities of molecular regulators of proliferation and apoptosis in carcinoma of the oral cavity and oropharynx.

OBJECTIVE: Abnormalities in genes regulating cell proliferation and death may affect disease outcome in squamous cell carcinoma (SCC) of the head and neck. METHODS: Proliferative activity (Histone H3 in-situ-hybridization (HISH) labeling index (LI)) and the genes and/or gene products of Cyclin D-1, c-erbB-2, Bcl-2, p21, and p53, were investigated in 35 patients with SCC of the oral cavity and oropharynx, previously studied for p27 expression. RESULTS: Overexpression or very low expression of Cyclin D-1 was associated with unfavorable disease outcome and shorter time-to-recurrence. High c-erbB-2 expression was significantly associated with shorter overall survival and was synergistic with low p27 expression. Bcl-2, HISH LI, p21 expression, and p53 mutation and protein analysis were not significantly predictive, but there were trends suggesting shorter disease-free/overall survival for patients with undetectable Bcl-2, high HISH, and mutant p53. CONCLUSIONS: Several cell proliferation and death regulators appeared to predict disease outcome. Limited evidence of cooperativeness among regulators was also seen.

Complications associated with the Sistrunk procedure.

OBJECTIVE: To assess the type and rate of complications in the postoperative period of pediatric patients undergoing the Sistrunk procedure. STUDY DESIGN: A retrospective review of patients with a diagnosis of thyroglossal duct cyst who had not had corrective surgery previously. An attempt to standardize the study was made as follows: all patients had surgery under the direction of one surgeon, using the Sistrunk procedure with minor modifications from its original description. Complications were divided into major and minor categories. METHODS: Charts were reviewed for age, sex, preoperative assessment, and postoperative follow-up. Complications were recorded. A postoperative telephone survey was conducted. RESULTS: A minor complication rate of 29% was observed. There were no recurrences or major complications. CONCLUSIONS: The Sistrunk procedure remains the operation of choice for removal of the thyroglossal duct cyst. When the surgery is properly performed, with attention to key surgical landmarks, the risk of major complication is minimal. Complications that do occur are minor and wound related.

Treatments for snoring: a comparison of somnoplasty and an oral appliance.

OBJECTIVES: Objectives of the study are 1) to test the effectiveness of somnoplasty (radiofrequency volumetric tissue reduction of the soft palate) for the control of loud, socially disruptive, snoring; 2) to test the long-term efficacy of this treatment by spouse report; and 3) to compare the effectiveness of somnoplasty with another treatment. STUDY DESIGN: Twenty patients with complaints of loud snoring and a respiratory disturbance index no greater than 15 respiratory events per hour with sleep-related episodes of oxygen desaturation no lower than 80% were offered an experimental treatment. Ten were treated with somnoplasty, and a comparison group of 10 matched patients used an oral appliance. All were restudied in the laboratory wearing a device programmed to count minutes of sleep during which snoring was loud, soft, or absent. METHODS: For the 10 somnoplasty patients, a spouse rating of snoring determined whether the patient received one or more treatments. Five patients had a single treatment to three sites, and five others had two such treatments. Ten patients wore an oral appliance of the tongue-retaining type (Snore X, Fremont, CA). RESULTS: Seven of the 10 somnoplasty patients met the improvement criteria set for reduced loud snoring (a spouse rating of 3 or less on a 10-point scale, and 10% or less of sleep time in loud snoring in the laboratory). The comparison group also had a significant improvement in the percentage of sleep time in loud snoring while wearing the Snore X appliance. CONCLUSION: Since there was no significant difference between the two groups in percentage of sleep time spent in loud snoring while treated, the choice of method to control snoring must be based on factors other than efficacy.

Early detection and treatment of postoperative pharyngocutaneous fistula.

Fever during the early postoperative period traditionally has not been considered an indication of a postoperative wound infection or breakdown. Atelectasis is considered the most likely source for these early fevers. We studied 200 consecutive patients who underwent major head and neck surgery that involved reconstruction with a pharyngeal suture line. Patients were divided into 2 groups: those who had preoperative irradiation and those who did not. All patients had prophylactic antibiotic coverage, and all patients had identical suture material for closure. We showed a high correlation between fever (>101.5 degrees F) that developed in the first 48 hours and eventual fistula formation and wound infection. We also studied length of hospitalization and number of days until decannulation and resumption of oral feedings. Our data indicate that in those patients in whom fistulas developed, early detection led to earlier healing and rehabilitation.

Prognostic significance of p27 expression in carcinoma of the oral cavity and oropharynx.

OBJECTIVE: To study the role of p27, a cyclin-dependent kinase inhibitor, as a prognostic indicator in squamous cell carcinoma of the oral cavity and oropharynx. STUDY DESIGN: Retrospective review of 35 patients with squamous cell carcinoma of the oral cavity and oropharynx who presented to Rush-Presbyterian-St. Luke's Medical Center, Chicago, Illinois, between 1986 and 1995. METHODS: Inclusion criteria were the availability of clinical information, archival pretreatment biopsy material, and a minimum follow-up of 24 months. p27 staining was scored for frequency and intensity of tumor cell expression following immunoperoxidase staining using standard techniques. Samples of squamous epithelium from the uvula of 15 nonsmoking patients without past or present squamous cell carcinoma were used as normal controls. RESULTS: The association of p27 staining and other factors with response to treatment was evaluated by Fisher's Exact Test and with overall and disease-free survival by the Kaplan-Meier method with multivariate Cox regression. Low levels of p27 expression correlated significantly with unfavorable treatment response (P<.0001), shorter overall survival (P = .0001), and shorter disease-free survival (P = .003). Tumor site (alveolus) was also associated with shorter disease-free (though not overall) survival, but the association with p27 was independent of stage and site in multivariate analysis.

Prognostic significance of Bcl-2 expression in localized squamous cell carcinoma of the head and neck.

This study was conducted to determine whether Bcl-2 overexpression in localized squamous cell carcinoma of the head and neck (SCCHN) might serve as a marker for tumors unlikely to respond to standard treatment. Tissue samples from 33 patients undergoing surgery or irradiation for early-stage SCCHN during the year 1977 to 1992 were stained for Bcl-2. All patients had either T1N0 lesions of the oral cavity, pharynx, or larynx or T1N0 or T2N0 lesions of the true vocal cords. Of the 33 patients, 26 remained disease-free after at least 3 years of follow-up; the remaining 7 patients developed either tumor recurrence or a second primary tumor, 4 of which were fatal. Twelve patients had tissue specimens staining positive for Bcl-2; 6 of these patients had a poor outcome, and 6 had a good outcome. The relationship between poor outcome and overexpression of Bcl-2 in tumor cells was statistically significant (p = .0047 by Fisher's exact test). For tumors overexpressing Bcl-2, there was no significant difference in recurrence rate between those undergoing surgery and those undergoing radiotherapy as the primary mode of treatment. The overexpression of Bcl-2 in early lesions in this study predicted a cure rate of 50%, as opposed to the generally expected 90%, suggesting that Bcl-2 is a significant prognostic indicator in early SCCHN. Future studies will determine if altering the treatment will improve outcome in these patients.

Bupivacaine for postoperative analgesia following endoscopic sinus surgery.

This prospective study was conducted to examine pain after endoscopic sinus surgery (ESS). The hypothesis was that a long-acting anesthetic agent would result in patients experiencing less pain in the 24-hour postoperative period and therefore needing fewer oral analgesics. We randomized 100 patients undergoing ESS to receive either lidocaine (1% or 2%) with epinephrine or bupivacaine (0.25% or 0.5%) with epinephrine as an anesthetic and for a sphenopalatine block. Postoperative pain was assessed with a standard numeric pain assessment scale at baseline and at 2, 6, and 24 hours after surgery. The use of analgesics during this period was also documented. We compared the results between patients receiving bupivacaine and those receiving lidocaine, as well as between patients who required nasal packing and those who did not. We discovered that in general, pain after ESS was less severe than expected. We further found that the type of anesthetic used did not significantly affect postoperative pain; pain score changes and use of analgesics were similar between the two anesthesia groups. Postoperative pain was also similar between the "packing" and "no packing" groups. Although patients receiving packing had consistently lower increases in pain (and in fact many patients in this group had decreases in pain from baseline), none of the differences between group means was statistically significant.

Endoscopic sinus surgery with partial middle turbinate resection: effects on olfaction.

Few studies have investigated the effects of endoscopic sinus surgery (ESS) on olfaction. In particular, the effect of surgical manipulation of the middle turbinate on olfaction has not been established. Using the University of Pennsylvania Smell Identification Test (UPSIT) and patient questionnaires, the authors performed a prospective study of olfaction in 64 patients undergoing ESS. Thirty-eight patients (59%) underwent partial middle turbinate resection; in the remaining 26 patients (41%), the middle turbinate was preserved. All patients were reevaluated approximately 8 weeks after surgery by endoscopic examination, questionnaire, and the UPSIT. Patients who underwent no resection had a median decrease in UPSIT score of 1.4, and those who underwent resection had a median decrease of 0.5; this difference was not statistically significant. Further, no correlation was found between changes in UPSIT score and follow-up time, sex of the patient, or the patient's subjective assessment of postoperative olfaction. It is concluded that middle turbinate resection has no effect on olfaction.

Intralesional vinblastine for treating AIDS-associated Kaposi's sarcoma of the oropharynx and larynx.

Kaposi's sarcoma (KS), the most frequent malignant neoplasm associated with acquired immunodeficiency syndrome, often involves the oropharynx and larynx. This study evaluated the efficacy of intralesional vinblastine sulfate injection in oropharyngeal and laryngeal KS. Twenty-four human immunodeficiency virus-positive patients with a total of 26 KS lesions were treated with injections of 0.1- or 0.2-mg/mL vinblastine sulfate solution. Subsequent injections were administered at 4- to 5-week intervals if necessary until the lesions resolved or stabilized. Complete regression was achieved in 16 lesions (62%), 20% to 50% reduction in 4 lesions (15%), and less than 20% reduction in 3 lesions (12%). Two lesions (8%) did not respond, and 1 (4%) grew despite the injections. Thirteen patients experienced no adverse effects. Eleven patients reported pain not relieved by acetaminophen; 5 of these 11 also had ulceration secondary to the injection. Both pain and ulceration were self-limiting. We conclude that vinblastine injection is a viable option for treatment of oropharyngeal and laryngeal KS lesions.

Composite mucochondral flap for repair of cerebrospinal fluid leaks.

BACKGROUND: Cerebrospinal fluid leaks from defects in the anterior cranial fossa present a difficult management problem. Particularly when the defects are large, conventional techniques may not be sufficient to close them. We describe a new technique for treating such CSF leaks using a composite mucochondral flap from the nasal septum. METHODS: We treated five patients with the composite mucochondral flap. All patients were women aged 29-60 years. Two patients had an encephalocele, one had an esthesioneuroblastoma, and one had adenocarcinoma; one leak was spontaneous. RESULTS: The CSF leak was successfully closed in all five patients. No patients have experienced recurrence; the longest follow-up has been 39 months. The donor site on the septum healed without complication in all patients. CONCLUSIONS: The composite flap is useful for repairing large defects or after radiotherapy or trauma. The advantage of skeletal support to counter the pressure exerted by CSF seems clear.

Three-dimensional imaging for evaluation of head and neck tumors.

OBJECTIVE: To determine the usefulness of three-dimensional imaging in addition to computed tomography in presurgical examination of patients with head and neck tumors. DESIGN: Two-dimensional computed tomographic information from 31 patients with oral facial tumors was converted to three-dimensional images. SETTING: University teaching hospital. PATIENTS OR OTHER PARTICIPANTS: A consecutive sample of 31 patients with oral facial tumors. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Improved treatment planning with the use of three-dimensional images used in conjunction with computed tomographic scans. RESULTS: The three-dimensional images from patients with minimal tumor invasion of bone or with massive soft-tissue tumors allowed easy appreciation of tumor dimensions, an important factor in treatment planning. In patients with small soft-tissue tumors with no evidence of bone involvement on two-dimensional scans, massive tumors with complete bone destruction, and recurrent tumors, the three-dimensional representations added little to the obvious presentation of the two-dimensional scans. CONCLUSIONS: Three-dimensional imaging is a useful adjunct to diagnosis and treatment planning in patients with minimal tumor invasion of bone or with massive soft-tissue tumors.

Platysma myocutaneous flap for repair of hypopharyngeal strictures.

Hypopharyngeal strictures, either isolated or in conjunction with laryngeal and esophageal strictures, can occur following lye ingestion. Extensive stricture formation requires reconstruction to create a functional funnel system that empties below the cricoid. Esophageal replacement is not a substitute for adequate hypopharyngeal reconstruction. The pectoralis major muscle is often inadequate, because it yields too much bulk and often leads to continued aspiration. The platysma myocutaneous flap for hypopharyngeal reconstruction has not been previously reported. The inferiorly based platysma myocutaneous flap was used in two of our patients with lye burns, and bilateral superiorly based flaps were used in one. All are able to eat normally and have no significant stenosis. The platysma myocutaneous flap is a relatively simple and reliable alternative that is within the capability of every head and neck surgeon.