Poor Dental Health as a Risk Factor for Alveolar Ridge Malignancies.

OBJECTIVE: To determine the association between poor dental health and risk of oral cavity squamous cell cancer (OCSCC) at individual tumor subsites. STUDY DESIGN: Case-control and cross-sectional METHODS: A case-control study was performed using a population-based cohort in North Carolina (Carolina Head and Neck Cancer Epidemiology Study [CHANCE]). A secondary cross-sectional analysis was performed with an institutional cohort (WashU/Siteman). Cases were adults with primary OCSCC and an identifiable tumor subsite. In the CHANCE cohort, controls were adults without head and neck cancer. In the Washington University/Siteman cohort, patients with tongue cancer served as the comparator group. We used number of missing teeth (categorized 0-6, 7-24, 25-28) as a surrogate for poor dental health, which was self-reported in CHANCE and measured on a pretreatment computed tomography scan in the WashU/Siteman study. Adjusted odds ratios (aORs) for missing teeth were estimated for each tumor subsite using binomial logistic regression models. RESULTS: Near complete tooth loss (25-28 teeth) was associated with a 3.5-fold increased risk of alveolar ridge malignancy (aOR: 3.51; 95% confidence interval [CI]: 1.14-11.01, P = .03) in the CHANCE study. This association was confirmed in our cross-sectional analysis (WashU/Siteman study) where missing 25-28 teeth was associated with an increased risk of alveolar ridge compared to tongue cancer (aOR: 4.60; 95% CI: 1.97-11.10, P = .001). CONCLUSIONS: This study suggests an association between poor dental health and risk of alveolar ridge cancer independent of smoking, alcohol use, age, race, and sex. Future prospective and translational studies are needed to confirm this association and elucidate the mechanism of dental disease in alveolar ridge malignancies.

Outcomes of Mesh Cranioplasty in Scalp-Free Tissue Reconstruction: A Systematic Review and Meta-analysis.

OBJECTIVE: To systematically review the literature to determine the prevalence and risk of the free flap and postoperative complications in scalp-free tissue reconstruction with synthetic mesh cranioplasty. DATA SOURCES: Search strategies created with a medical librarian were implemented using multiple databases in May 2021. REVIEW METHODS: Two reviewers independently performed the review, data extraction, and quality assessment. Cohort studies of patients with scalp-free tissue reconstruction with or without mesh cranioplasty were included. Studies that did not report whether mesh was used or did not separate outcomes by mesh use were excluded. The primary outcomes were free flap failure and postoperative complications. A random-effects model was used for the meta-analysis to estimate prevalence and prevalence ratios (PRs). RESULTS: A total of 28 studies and 440 cases of scalp-free tissue reconstruction were included. The pooled prevalence of free flap failures and postoperative complications in patients with mesh cranioplasty was estimated at 7% (95% confidence interval [CI], 3%-17%; p = .85, I2 = 0%) and 21% (95% CI, 14%-31%; p = .44, I2 = 0%), respectively. In a subgroup analysis, mesh cranioplasty was not associated with a significantly increased risk of free flap failure or postoperative complications when compared to cases without mesh cranioplasty; pooled PR 1.21 (95% CI, 0.50-2.88; p = .90, I2 = 0%) for free flap failure and PR 1.85 (95% CI, 0.89-3.85; p = .28, I2 = 19) for postoperative complications. CONCLUSION: Synthetic mesh cranioplasty does not significantly increase the risk of free flap compromise or postoperative complications. A higher prevalence of postoperative recipient site complications was observed in patients with mesh cranioplasty.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Hypoglossal Nerve Stimulator Outcomes for Patients Outside the U.S. FDA Recommendations.

OBJECTIVES: The hypoglossal nerve stimulator (HGNS) is currently approved for the treatment of obstructive sleep apnea (OSA) in patients with an apnea-hypopnea index (AHI) of >15 to ≤65 events/hour, and a central apnea index (CAI) <25% of the AHI, no complete concentric collapse on drug-induced sleep endoscopy, and a recommended body mass index (BMI) <32 kg/m2 . We present 18 patients implanted as a salvage procedure despite being outside these guidelines. METHODS: We included all patients who underwent HGNS but who did not meet all FDA guidelines. Demographic data, previous OSA treatments, polysomnographic (PSG) parameters from baseline and HGNS titration PSG, Epworth sleepiness score (ESS), and BMI were compared before and after surgery. RESULTS: Eighteen patients were identified: 94.4% male, median age 63 years. Seven underwent previous sleep surgery. Four had an AHI <15 (mean 10.5 events/hour), four had an AHI >65 (mean 86.9 events/hour), two had an elevated CAI (mean 31.3% of AHI), and 12 had a BMI >32 kg/m2 (range 32.1-39.1). Median AHI decreased from 25.3 to 3.75 events/hour on titration polysomnography (P = .0006), oxyhemoglobin saturation nadir increased from 82% to 88.5% (P = .0001) and median ESS dropped from 11 to 7.5 (P = .0016). Fifteen (83.3%) patients achieved surgical success (decrease in AHI >50% and AHI <20 events/hour) and 12 (66.7%) had an AHI <5 events/hour. Neither patient with CAI >25% was successfully treated. Median adherence = 33.5 hours/week. CONCLUSION: Our success rate for patients outside the Food and Drug Administration guidelines for HGNS (67%) was similar to the 1-year STAR trial results (66%). Future studies are necessary to consider expansion of these guidelines. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:866-872, 2020.

Hypoglossal Nerve Stimulation in Veterans with Obstructive Sleep Apnea.

OBJECTIVES: The hypoglossal nerve stimulator (HNS) is an effective treatment for obstructive sleep apnea (OSA) in a relatively healthy subset of the population. Our aim was to determine the efficacy of HNS in a veteran population with a high incidence of chronic disease and mental health disorders. Our secondary aim was to compare subjective outcomes and adherence between veterans with and without mental health disorders. METHODS: We included all patients who underwent HNS at our institution to date. Veterans were divided into two groups based on whether or not they carried a diagnosis of anxiety, depression, and/or post-traumatic stress disorder. Demographics, comorbidities, previous OSA treatments, adverse events, and adherence to therapy were recorded. Baseline and treatment outcome data were collected and analyzed including polysomnographic parameters, Epworth sleepiness scale score (ESS), and body mass index. RESULTS: Thirty-one patients were identified: 93.5% male, median age = 63.0 years. Median apnea hypopnea index (AHI) decreased from 30.0 to 3.0 events/hour (P < .001) and median ESS dropped from 11.0 to 6.5 (P < .001). There was no difference between groups with regard to change in AHI or ESS (P = .31 and .61). Twenty-six (89.7%) patients achieved surgical success (decrease in AHI > 50% and AHI < 20 events/hour) and 21 (72.4%) had AHI < 5 events/hour. The mean device usage was 5.4 hours/night which was not significantly different between groups (P = .55). CONCLUSION: Our cohort exhibited similar declines in AHI and ESS compared to published studies with adequate adherence to HNS. There were no significant differences in ESS or adherence to therapy between veterans with and without mental health disorders. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2275-2280, 2020.

Clinical use of the STOP-BANG questionnaire to determine postoperative risk in veterans.

OBJECTIVES: To determine whether STOP-BANG (snoring, tiredness, observed apnea, high blood pressure, body mass index, age, neck circumference, gender) scores are associated with immediate postoperative adverse events in veterans undergoing surgery. METHODS: In this prospective cohort study, veterans presenting to the presurgical clinic at a Veterans Affairs hospital answered the STOP-BANG questionnaire, which was scored as high risk (5-8), intermediate risk (3-4), and low risk (0-2) for obstructive sleep apnea (OSA), during a 6-month study period. Immediate postoperative respiratory and cardiovascular adverse events were recorded. RESULTS: The patient population included 1,080 veterans. Ninety-five patients (8.8%) experienced adverse events, of which 74 (6.9%) were respiratory and 21 (1.9%) were cardiovascular in nature. Patients with high-risk STOP-BANG scores (5-8) had significantly greater odds of having an adverse event odds ratio (OR) 2.1 (95% confidence interval [CI]: 1.4, 3.3) and hypoxia OR 2.8 (95% CI: 1.7, 4.6) compared to those with low- to intermediate-risk scores (0-4). Among patients with OSA, those with high-risk scores (5-8) had greater odds of an adverse event OR 3.9 (95% CI: 1.1, 13.9) and hypoxia OR 3.7 (95% CI: 1.1, 13.0) compared to those with low- to intermediate-risk scores (0-4). Patients without a history of OSA with high-risk scores (5-8) did not have significantly greater odds of an adverse event OR 1.5 (95% CI: 0.82, 2.6) or a hypoxic event OR 1.7 (95% CI: 0.87, 3.4) compared to those with low- to intermediate-risk scores (0-4). CONCLUSION: The STOP-BANG questionnaire was useful in the veteran population because high-risk scores were predictive of adverse events, in particular, hypoxia for patients with a previous diagnosis of OSA. In the future, this may direct studies and clinical activities aimed at optimizing safe and effective perioperative practices. LEVEL OF EVIDENCE: 2b Laryngoscope, 129:259-264, 2019.

Techniques for evaluation and management of tongue-base obstruction in pediatric obstructive sleep apnea.

PURPOSE OF REVIEW: Tongue-base obstruction (TBO) is a common cause of persistent obstructive sleep apnea (OSA) after tonsillectomy and adenoidectomy in children. This review discusses available diagnostic modalities and surgical treatment options for the management of TBO. RECENT FINDINGS: Recently, a systematic review that included nine studies using drug-induced sleep endoscopy (DISE) in the evaluation of children with persistent OSA after tonsillectomy and adenoidectomy identified the tongue-base as the most common site of obstruction. SUMMARY: TBO is a common and correctable cause of persistent OSA in children. Diagnostic modalities include awake flexible laryngoscopy, plain neck films, DISE, and cine MRI. Because DISE and cine MRI are performed in a sleep-like state, they are fairly reliable in identifying the site of obstruction. As continuous positive airway pressure is often poorly tolerated in the pediatric population, there is considerable interest in surgical options for TBO. Depending on the location and the severity of the obstruction, interventions such as lingual tonsillectomy, posterior midline glossectomy, tongue suspension suture, epiglottopexy, hypoglossal nerve stimulation, tongue-lip adhesion, and hyoid suspension may play a role in management.