Parathyroidectomy for the treatment of hyperparathyroidism: Thirty-day morbidity and mortality.

OBJECTIVES/HYPOTHESIS: Evaluate morbidity and mortality rates for patients with different levels of hyperparathyroidism (HPT) undergoing parathyroidectomy (PTX), specifically comparing primary hyperparathyroidism to secondary and tertiary hyperparathyroidism. Assess predictive factors of increased morbidity and mortality. STUDY DESIGN: Retrospective national database review. METHODS: Patients undergoing PTX, defined by Current Procedural Terminology codes 60500, 60502, 60505, for the treatment of HPT, were identified in the American College of Surgeons National Surgical Quality Improvement Program database between 2006 and 2014. Incidence of morbidity and mortality was calculated for primary, secondary, and tertiary HPT. A t test, analysis of variance, and χ2 analyses were used to assess preoperative characteristics among the three groups. RESULTS: A total of 21,267 patients were included in the analysis. There was an overall 7.2% morbidity and mortality rate, including 45 (0.21%) deaths, a 1.8% readmission rate, and a 1.9% reoperation rate, but morbidity and mortality rates were widely divergent when comparing primary to secondary and tertiary HPT. PTX resulted in a 4.9% morbidity and mortality rate for primary HPT (n = 14,500), 26.8% morbidity and mortality rate for secondary HPT (n = 1661), and 21.8% morbidity and mortality rate for tertiary HPT (n = 588). The primary reason for readmission was hypocalcemia (18.3%). Hematoma (7.2%) and postoperative hemorrhage (3.3%) were the two most common causes of reoperation. Elevated preoperative serum creatinine, alkaline phosphatase, and hypertension resulted in a higher rate of complications after PTX (P < .0001). CONCLUSIONS: Although surgery for primary HPT is an extremely common and safe procedure with minimal morbidity and mortality rates, PTX for secondary and tertiary HPT has significantly higher rates of morbidity and mortality, requiring special attention in the postoperative period. Predictive factors of poor outcomes include hypertension, elevated creatinine, and elevated alkaline phosphatase. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:528-533, 2018.

Future Perspectives in Sleep Surgery.

Over the past few decades there has been a significant increase in research focusing on the pathophysiology, diagnosis, and treatment of sleep apnea. However, there is still a long way to go in creating standard evidence-based medical practice for the diagnosis, evaluation, and treatment of sleep apnea patients. Current and future directions of sleep surgery and other treatments are discussed here.

Updated Friedman Staging System for Obstructive Sleep Apnea.

In the practice of sleep medicine, the first step is identification of those patients at high risk for sleep apnea. Nearly every physician and every hospital has preferred methods of screening. Many patient questionnaires or surveys as well as some objective physical measurements have been suggested to predict the presence of sleep apnea. Screening is well established, and laboratory and home testing are widely available. An early assessment with a physical examination can help direct treatment planning. The Friedman tongue position, lingual tonsil hypertrophy grading, and the effects of oral positioning on the hypopharynx should be used in early assessment for treatment planning, and as screening tools to assess the sight of obstruction. Although these screening tools are not substitutes for drug-induced sleep endoscopy (DISE), they are crucial in early assessment as many patients do not require surgery or DISE early in the evaluation.

Parathyroidectomy for tertiary hyperparathyroidism: A systematic review.

OBJECTIVE: Analyze the efficacy and indications for parathyroidectomy as an intervention for tertiary hyperparathyroidism. DATA SOURCES: PubMed, MEDLINE, and Cochrane Library databases. REVIEW METHODS: A systematic literature search was performed using the. Original research articles in English were retrieved using the search terms ("tertiary hyperparathyroidism" OR "3HPT") AND "parathyroidectomy". Articles were analyzed in regards to their surgical indications, operative endpoints, comparison between different surgical interventions, characterization of disease recurrence rates, and evaluation of alternative medical management. RESULTS: Thirty studies met the criteria for inclusion. Among the studies that report indications for parathyroidectomy, persistent hypercalcemia as well as clinical manifestations of hypercalcemia despite medical therapy predicted which patients would eventually need surgical intervention. The majority of studies comparing the extent of parathyroidectomy recommended a more focused approach to parathyroidectomy when warranted. All studies found that parathyroidectomy was an effective treatment for 3HPT. Three studies discussed alternative conservative approaches. CONCLUSION: Interestingly, hyperparathyroidism alone is not an indication for surgery without other findings; rather, symptomatic hypercalcemia appears to be the main indication. Most studies recommend limited or subtotal parathyroidectomy for 3HPT. The operative endpoint of surgery is not necessarily a return of PTH to normal, but a >50% drop in PTH level even if PTH remains above normal. Additionally, "success" or "cure" is defined as normal calcium levels regardless of whether or not PTH is elevated. It appears the goal of surgery for 3HPT is not a normal PTH value, but a normal calcium level at least six months postoperatively.

Changing Rates of Morbidity and Mortality in Obstructive Sleep Apnea Surgery.

Objective Whereas uvulopalatopharyngoplasty (UPPP) was the standard surgical procedure for obstructive sleep apnea prior to 2007, multilevel surgery has become the standard since that time. This study compares morbidity and mortality rates of the stand-alone UPPP with those of multilevel sleep surgery that includes UPPP. Methods Patients undergoing UPPP between 2007 and 2014 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. UPPP was defined by Current Procedural Terminology codes 42145 and 42950. Primary outcomes were incidence of morbidity and mortality. Rates were compared between a control group with UPPP only and a group with multilevel surgery. Results A total of 2674 cases were analyzed. The incidence of complications in the UPPP-only group was 1.6% (0.09% fatal); in the multilevel surgery group, 4.63% (0.19% fatal). The difference in overall and nonfatal complications is statistically significant ( P < .01); however, values for fatal complications are too low for comparison. There is a statistically significant ( P < .01) positive correlation ( R2 = 0.92) between year of operation and rate of complications, with increased incidence of complications in more recent years. Discussion Complication rates for multilevel sleep surgery are higher than those of stand-alone UPPP, and overall complication rates have been increasing in recent years. As UPPP supplemented with multilevel surgery is now the standard surgical treatment for most cases of obstructive sleep apnea-hypopnea syndrome, historical complication rates based predominantly on patients undergoing UPPP only underestimate complication rates of modern sleep surgery. Implications for Practice It is reasonable to inform patients that multilevel procedures bring an increased risk of complications, and patient selection should be guided accordingly.

Long-Term Incidence of Velopharyngeal Insufficiency and Other Sequelae following Uvulopalatopharyngoplasty.

Objective The aim of this study is to (1) assess incidence of long-term velopharyngeal insufficiency (VPI) and (2) determine other sequelae following classic and modified uvulopalatopharyngoplasty (UPPP and mUPPP) for treatment of obstructive sleep apnea (OSA). Data Sources Medline, PubMed, Cochrane Library database. Review Methods A systematic review was performed following standard Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Original research articles reporting on sequelae of UPPP and mUPPP for treatment of OSA, at a mean of 1 year follow-up, were included. Articles were retrieved using keywords UPPP complications and UPPP questionnaire. A random-effects model was used for pooling data. Results A total of 24 studies were included in this review. Complications included VPI (24 studies, n = 191), difficulty swallowing (7 studies, n = 83), taste disturbances (4 studies, n = 10), voice changes (7 studies, n = 46), foreign body (9 studies, n = 427), and dry pharynx (7 studies, n = 150). When pooling all studies together, VPI was the least common sequelae reported in 8.1% of the cases. Foreign body sensation was the most commonly reported sequelae at 31.2%, with difficulty swallowing (17.7%), dry pharynx (23.4%), voice changes (9.5%), and taste disturbances (8.2%) being the most to least likely. Conclusions The long-term effectiveness of UPPP and mUPPP is limited by the number of studies reporting short-term follow-up only. Despite this, long-term data suggest that complications such as VPI are more common than previously reported. Other sequelae, such as foreign body sensation, may be one of the most frequently expected complications after UPPP surgery.

The effect of oral positioning on the hypopharyngeal airway.

OBJECTIVES: It is generally assumed that mouth opening decreases the hypopharyngeal cross-sectional area (HA) and that tongue protrusion (TP) increases the HA. We hypothesize that a substantial number of patients do not exhibit this expected pattern. STUDY DESIGN: Prospective cohort conducted at a tertiary academic center. METHODS: With a flexible fiberoptic scope in position, the hypopharyngeal airway was visualized and assessed in 189 patients with the mouth closed. Patients were then asked to open the mouth with the tongue in neutral position (MOTN) to determine the effect on the airway. The same methodology was used to compare the airway with the MOTN versus TP. Basic demographics, including age, gender, body mass index, and presence and severity of obstructive sleep apnea (OSA), were collected. Student t test, Mantel-Haenszel chi-square, and Cochran-Armitage analyses were assessed for significant relationships and trends with oral positions. RESULTS: Although mean HA decreased with MOTN (P < 0.0001), 33% of patients exhibited an increase in HA. Similarly, mean HA increased with TP (P = 0.0018); however, 38% of patients demonstrated a decrease in HA. There was no significant relationship in HA between OSA and non-OSA patients. For those with OSA, increasing severity trended toward a higher incidence of smaller HA with TP (P = 0.038). CONCLUSION: The airway is typically most obstructed with mouth opening (MOTN) and most patent with tongue protrusion (TP). Nevertheless, hypopharyngeal changes with MOTN and TP followed a paradoxical pattern in one-third of our population. This may have implications in patient selection for targeted OSA treatment. LEVEL OF EVIDENCE: 4. Laryngoscope, 127:1471-1475, 2017.

Validity of the epworth sleepiness scale as a screening tool for obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To determine whether the Epworth Sleepiness Scale (ESS) can be improved by having a bed partner or roommate ("partner") also fill out the questionnaire; and to assess the applicability of the eight items in the questionnaire, particularly in an urban population. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was conducted to identify charts of subjects with an ESS score collected from both the subject and a partner. Consensus scores were also identified. Self-reported ESS scores were compared to partner and consensus ESS scores. The number of subjects who did not drive was determined. RESULTS: One hundred consecutive charts were included in this study. Mean ESS score was significantly higher when scored by the partner (10.4 ± 5.8) compared to the subject (7.2 ± 4.7). In 73% of cases, the subject underestimated their score compared to the score given by the partner. The mean difference in score was 3.2 ± 3.5. Mean consensus ESS score was 12.3 ± 5.4. Using an ESS score of ≥10 as abnormal, subject scores did not correlate with the presence of obstructive sleep apnea (OSA; P = .095). Partner and consensus scores, however, did correlate with the presence of OSA (P = .003 and P =.039, respectively). Thirty-five percent of our subjects did not drive. CONCLUSIONS: The difference in mean ESS score obtained from the subject compared to partner implies that this diagnostic form should be completed as a consensus between the patient and partner to provide a more accurate score. LEVEL OF EVIDENCE: 4 Laryngoscope, 2016 127:525-531, 2017.

Impact of Minimally Invasive Multilevel Surgery on Mild/Moderate OSA.

OBJECTIVE: To assess 10-year data on subjective and objective improvements in patients with mild to moderate obstructive sleep apnea (OSA) after single-stage multilevel minimally invasive surgery. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic center. SUBJECTS AND METHODS: A chart review was conducted of 601 patients diagnosed with mild to moderate OSA who were treated with single-stage multilevel minimally invasive surgery from January 2005 to January 2015. Patients were treated with a combination of procedures that included various nasal procedures, palatal stiffening, and radiofrequency tongue base reduction. Demographics and objective and subjective parameters were collected; all patients were included who had a mean of 6 months of follow-up data available. Pre- and postoperative values were compared. RESULTS: A total of 601 patients were included in this study (67.0% male; age, 38.2 ± 9.4 years; mean body mass index, 27.4 ± 4.1 kg/m(2)). Mean apnea-hypopnea index decreased significantly from 19.8 ± 5.9 events per hour preoperatively to 12.7 ± 7.6 events per hour postoperatively (P < .0001), with a 45.9% rate of "surgical success." Mean daytime sleepiness decreased significantly from 12.1 ± 4.8 to 6.8 ± 2.9 (P < .001) per the Epworth Sleepiness Scale. Mean snoring intensity showed a significant decrease from 8.8 ± 0.8 to 4.0 ± 2.1 (P < .001). CONCLUSION: Ten-year experience shows that treatment with single-stage multilevel minimally invasive surgery decreases objective and subjective measures in selected patients with mild to moderate OSA. Although not curative, this technique helps to control symptoms in a population of patients who refused CPAP.