Uvulopalatopharyngoplasty with an ultrasound scalpel or laser: is there a difference?

Uvulopalatopharyngoplasty (UPPP) is used for treatment of the obstructive sleep apnoea syndrome, mainly in the lower range of the apnoea-hypopnea index or partial upper airway obstruction. Significant severe pain after UPPP is associated in the area having surgery and therefore less pain causing methods should be investigated. In this study, we compared laser-assisted and ultrasound scalpel-performed UPPP. Sleep apnoea patients (n = 40) recruited to the study were divided into two groups. UPPP was performed with either laser-assisted or an ultrasound scalpel. Perioperative bleeding, operating room time and duration of operation together with histological injury of soft palate were analysed. A postoperative follow-up questionnaire included a self analysis of pain, dietary intake and pain drug consumption. In the same follow-up form, filled in by patients themselves, possible side effects and adequacy of pain medication together with any postoperative haemorrhage events were recorded during 10-day study period after UPPP. The ultrasound scalpel group had significantly fewer haemorrhagic events (P = 0.037) during postoperative follow-up time after UPPP when compared to laser-assisted group. The pain values of all 40 patients were significantly higher in the morning than in the afternoon (P < 0.001) or evening (P < 0.001). Pain increased up to the fifth postoperative day (visual analogue scale, VAS = 46). The significant relief of pain to the mild level (VAS < 30 mm) occurred at ninth and tenth postoperative day. The ultrasound scalpel used as a surgical method in UPPP did not offer significant comprehensive benefits in this study compared to laser-assisted UPPP. Exclusively, postoperative haemorrhage events were minor, paralleling findings of previous studies where ultrasound scalpel had been used for tonsillectomy. We conclude that the ultrasound scalpel is comparable to laser-assisted UPPP.

Long-term results of tracheostomy for severe obstructive sleep apnea syndrome.

Severe obstructive sleep apnea (OSAS) is most often accompanied by metabolic syndrome, obesity, diabetes and coronary disease. In its most severe form, it is a life-threatening condition, requiring active and immediate help. Nasal continuous positive airway pressure (CPAP) is the most efficient nonsurgical treatment for patients with OSAS. However, for anatomical, disease-related and subjective reasons, many patients cannot accept this treatment. A permanent tracheostomy may be one alternative in such patients who, in addition, often suffer from extreme obesity and severe heart disease. In this paper, we describe the long-term follow-up results of 7 patients suffering from OSAS and treated with permanent tracheostomy. All the patients (5 men, 2 women) were diagnosed using the static charge sensitive bed method and night-time oximetry for sleep analysis. The mean body mass index (BMI) of the patients ranged from 34 to 60 and the age from 41 to 64 years. All the patients had severe OSAS and long periods of low oxygen saturation (SaO2) levels. Six patients had a CPAP trial before tracheostomy. Only 2 patients tolerated the trial but, despite the continuous use of CPAP, they were nonresponders. Permanent tracheostomy was done according to normal routine in each patient. After primary healing of 2 days, they used silver cannulae, which also allowed them to speak. The patients were evaluated every year after the tracheostomy. After some practical difficulties including proper maintenance of the cannula, all the patients quickly learned the correct management. In postoperative sleep studies, nadir SaO2 levels had improved significantly, obstructive apneas had disappeared and the subjective quality of life had improved. No marked changes in BMI were found.

Prospective randomized comparison of endonasal endoscopic dacryocystorhinostomy and external dacryocystorhinostomy.

OBJECTIVES AND STUDY DESIGN: The advent of the rigid endonasal endoscope and the development of functional endoscopic sinus surgery (FESS) technique have awakened interest in an endonasal endoscopic dacryocystorhinostomy (EESC-DCR) in treating nasolacrimal obstruction. This prospective, randomized study compares EESC-DCR with traditional external dacryocystorhinostomy (EXT-DCR) for their success rates, surgical duration, and postoperative symptoms. PATIENTS AND METHODS: Sixty-four cases in 60 patients with primary acquired nasolacrimal sac or duct obstruction were divided into two subgroups by symptoms (simple epiphora/chronic dacryocystitis). These patients were randomized within both subgroups into two operation groups. Altogether 32 EESC-DCRs and 32 EXT-DCRs were performed. The final follow-up visit was at 1 year. The patency of the lacrimal passage was investigated by irrigation and patients were questioned about their symptoms. RESULTS: The success rate at 1 year after surgery was 75% for EESC-DCR and 91% for EXT-DCR after primary surgery. The difference was not statistically significant (P = .18). The success rate after secondary surgery with a follow-up time of 1 year was 97% in both study groups. The average duration for EESC-DCR was 38 minutes, and 78 minutes for EXT-DCR, (P < .001). CONCLUSIONS: EXT-DCR, when compared with EESC-DCR, appears to give a higher, although not statistically significant, primary success rate, but the secondary success rates are equal, indicating that these two different DCR techniques are acceptable alternatives.

Digital fluoroscopy before and after laser uvulopalatopharyngoplasty in obstructive sleep apnea. Importance of pharyngeal collapsibility and hyoid bone position.

PURPOSE: To study the changes in pharyngeal behavior after laser uvulopalatopharyhgoplasty (LUPPP). MATERIAL AND METHODS: The dynamic changes in the upper airway size were evaluated with digital fluoroscopy in 24 patients with obstructive sleep apnea (OSA) before and after LUPPP and in 16 normal controls, while they were awake and breathing normally. Cephalometric measurements were also made. The patients were classified into the categories of good and poor responders by means of a static-charge-sensitive bed. RESULTS: Following LUPPP, collapsibility at the velopharyngeal level was within the normal range m 15 of 17 good responders, but only in 2 of 7 poor responders (p = 0.0086). The minimum airway size at the same level showed a similar trend. In 3 of 7 poor responders the hyoid bone was positioned more caudally than in the good responders (p = 0.017). CONCLUSION: Digital fluoroscopy provides information on the change in upper airway behavior after LUPPP.

Bacteriological evaluation of 194 adult patients with acute frontal sinusitis and findings of simultaneous maxillary sinusitis.

In a prospective study bacteriological findings from frontal and maxillary sinus secretes were analyzed. Frontal sinus trephination was performed to 103 and maxillary irrigation to 192 patients. Main pathogens in the frontal as well as in the maxillary sinus secretes were Haemophilus influenzae and Streptococcus pneumoniae. beta-lactamase production of H. influenzae was found in 17% of frontal and in 16% of maxillary sinus samples. Bacteriological findings were supported by the staining results. The portion of anaerobic pathogens in cultures were poor, though Bacteroides fragilis antigen was detected in 8 frontal and 6 maxillary sinus samples. The acute frontal sinusitis should be treated with respective antibiotics. Complications seem not to develop in the acute phase and the disease can primarily be treated conservatively. It should however be controlled properly to avoid prolonged disease and late complications.

Operative treatment of frontal sinusitis.

When the medical therapy fails trephination is the primary operation indicated in acute eroding sinusitis when drainage is necessary to avoid severe complications. In recent years also endoscopic transnasal surgery has been recommended for exenteration of the underlying disease in the ostiomeatal unit as well as for opening of the obstructed nasofrontal duct in acute phase of the disease. In Turku University Central Hospital endoscopic frontal sinus surgery is still reserved for cases with prolonged or delayed disease performed as a secondary operation after trephination and CT examination. Failures are common after these operations and both types of surgical treatment may be needed. Three percent of our patients developed a persistent chronic infection inside the frontal sinus. In these cases external osteoplastic approach is recommended. In these operations we have used bioactive glass as obliteration material with promising clinical results.

The effect of laser-uvulopalatopharyngoplasty on the nasal and nasopharyngeal volume measured with acoustic rhinometry.

Nasal breathing is considered as an important factor in sleep apnea and snoring, and nasal obstruction can lead to an increased respiratory resistance and to inflammatory reactions in the nasal mucosa. Uvulopalatopharyngoplasty is an effective treatment for sleep apnea and snoring. Different operation techniques with minor variations have been introduced during the last few years. Uvulopalatopharyngoplasty with laser technique (LUPPP) has made it possible to perform the operation in local anesthesia. Acoustic rhinometry is a new method for the evaluation of the nasal cavities and the nasopharynx. We measured the volume of nasal cavities and nasopharynx of 29 patients using acoustic rhinometry before and 6 months after the LUPPP operation. There was a tendency to a better nasal patency in the turbinate area, but no change was found in the nasopharyngeal volume. Acoustic rhinometry is a useful tool for measuring the turbinate area, and this part of the nasal cavities seems to be influenced by the LUPPP operation, maybe due to a better ventilation or reduction of the inflammation of the nose. However, technical and methodological improvements are needed before reliable measurements are achieved from the nasopharynx area.

Upper airway size and collapsibility in snorers: evaluation with digital fluoroscopy.

This study addressed the question of whether there are any differences in the size and collapsibility of the upper airway measured by digital fluoroscopy, between snorers and controls whilst they were awake and breathing normally; and whether there are any correlations between these measurements and other clinical data. The dynamic changes of the upper airway size were evaluated using digital fluoroscopy in 33 patients and 16 normal controls. The measurements were compared with findings in an overnight sleep study, including a static-charge-sensitive bed (SCSB) and oximeter recordings. The minimum anteroposterior dimension at the velopharyngeal level was smaller in patients with partial upper airway obstruction than in controls (p<0.005); patients with complete obstruction did not differ from the controls. The velopharyngeal airways were also more collapsible in patients with severe partial obstruction (p<0.01) than in controls. At the oropharyngeal and hypopharyngeal levels, the dimensions and the collapsibilities were similar in patients and controls. The velopharyngeal collapsibility correlated with body mass index (p

Pre- and postoperative evaluation of patients with nasal obstruction undergoing endoscopic sinus surgery.

Functional endoscopic endonasal sinus surgery (FESS) is at present the surgical method of choice for many clinicians treating chronic sinusitis and nasal polyposis. Postoperatively, patients have felt that patency of the nasal airway is improved, although all previous studies have failed to objectively measure changes produced. By using anterior active rhinomanometry, decreased unilateral and total nasal resistance was measured. Although improvement in total resistance was not statistically significant, reduction in unilateral resistance was. All patients demonstrated subjective improvements in unilateral and total nasal patencies. The reduction in nasal resistance was more pronounced in baseline resistance values than after decongestion, indicating that FESS had a positive effect on mucosal edema but did not alter the structural anatomy of the main nasal passages.

MRI and plain radiographics in acute frontal sinus infections.

Twenty-seven patients with acute frontal sinusitis, collected during a 4-month period, were examined with plain radiographics and MRI both at the time of diagnosis and one month later. Findings in the frontal and ethmoidal sinuses were recorded. Frontal sinus trephination was performed in 13 of the 27 cases. The study shows that MRI is as reliable as X-ray in diagnosing an acute paranasal sinus infection with clinical symptoms. Frontal sinusitis is not an isolated disease affecting only the frontal sinuses: Mucosal pathology can also be found widely in the ethmoidal cells, and this pathology seems to persist in many cases for weeks. MRI showed its capability in confirming these findings. MRI was not found to be an over-diagnosing method in registering the secretions and mucosal swelling during an acute paranasal sinus infection.

Increase of acute frontal sinusitis in southwestern Finland.

The number of patients hospitalized for acute infection in the frontal sinuses at the Department of Oto-Rhino-Laryngology of Turku University Hospital has increased markedly during the last decade. Causes for this increase were evaluated by comparing the backgrounds and medical findings of the 134 patients treated in the years 1977-81 and those of the 421 patients treated in the years 1982-86. Nasal polyps and history of allergic rhinitis were considerably more common in the latter patient group. The disease also seems to recur increasingly in the same patients. Of the aerobic bacteria Streptococcus pneumoniae and Haemophilus influenzae were the most common pathogens and the share of H. influenzae increased slightly, becoming the commonest pathogen in the latter 5-year period. Increasing air pollution in the city area of Turku is worth consideration and should be investigated further.

Frequent irrigation in maxillary sinusitis therapy.

190 cases of maxillary sinusitis with retention of secretions were treated by frequent irrigation through an irrigation tube inserted via inferior turbinate sinus. The technique of the tube insertion through a Lichtwitz needle is described. Repeated irrigations do not need any anaesthesia and are better approved by the patients than the usual puncture irrigation. The response seems to be at least equally good as has been observed in similar patient series by repeated puncture irrigations. The patients' requests of reinsertion of irrigation tube in cases of recurrencies gives addition support to the recommendation to accept such a therapy.