The relationship of the uvula with snoring and obstructive sleep apnea: a systematic review.

Currently, the relationship between uvula size and sleep-disordered breathing (snoring and obstructive sleep apnea) lacks data for objective interpretation. This study conducted a systematic review of the international literature for research describing the measurable characteristics of the uvula (i.e., size, length, width) and any association with snoring and obstructive sleep apnea (OSA). PubMED, Scopus, Google Scholar, Embase, and the Cochrane Library were each systematically searched from inception through November 15, 2016. We screened 1037 titles and abstracts. We conducted a full review of 54 downloaded articles. Sixteen articles met inclusion and exclusion criteria. The 16 studies included a total of 2604 patients. The selected articles included data and information for (1) normative data for uvular size in the control groups, (2) snoring and uvula size, (3) OSA and uvula size, and (4) overall uvula function. Our review noted variability in findings; however, in general, a uvular length > 15 mm was considered elongated and a uvular width > 10 mm was considered to be wide. The studies included in this systematic review reveal a relationship between uvula size, snoring, and OSA. Further, larger uvulas appear associated with more severe snoring and OSA. The direct correlation between uvula size and its relationship specifically to snoring and OSA remain as topics for future prospective research.

Transpalatal advancement pharyngoplasty for obstructive sleep apnea: a systematic review and meta-analysis.

The objective is to determine if apnea-hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve after transpalatal advancement pharyngoplasty (TPAP) with obstructive sleep apnea (OSA) in adults, using a systematic review and meta-analysis. Nine databases, including PubMed/MEDLINE, were searched through April 1, 2016. All studies that included patients who underwent TPAP alone were included in this analysis. Fifty-six studies were potentially relevant, 37 were downloaded and five studies met criteria with 199 patients (age: 42.5 ± 9.7 years and body mass index: 29.0 ± 4.0 kg/m2). The grand mean (M) and standard deviation (SD) for AHI (199 patients) pre and post-TPAP decreased from 54.6 ± 23.0 [95 % CI 51.4, 57.8] to 19.2 ± 16.8 [95 % CI 16.9, 21.5] events/h (relative reduction: 64.8 %). Random effects modeling demonstrated a mean difference (MD) of -36.3 [95 % CI -48.5, -24.1], overall effect Z = 5.8 (p < 0.00001), and I 2 = 85 % (significant inconsistency). The standardized mean difference (SMD) for TPAP demonstrated a large magnitude of effect for AHI -1.76 [95 % CI -2.4, -1.1]. For LSAT (70 patients), the pre and post-TPAP M ± SD improved from 81.9 ± 8.1 [95 % CI 80.0, 83.8] to 85.4 ± 6.9 [95 % CI 83.8, 87.0], with a MD of 3.55, overall effect Z = 1.79 (p = 0.07). Thus far, few studies have evaluated transpalatal advancement pharyngoplasty; therefore, we recommend additional studies, especially prospective studies. Research comparing TPAP to pharyngoplasty procedures without palatal advancement would help determine the optimal role for this procedure.

Cleft Lip and Cleft Palate Surgery: Malpractice Litigation Outcomes.

OBJECTIVE: This study examined malpractice claims related to cleft lip and cleft palate surgery to identify common allegations and injuries and reviewed financial outcomes. DESIGN: The WestlawNext legal database was analyzed for all malpractice lawsuits and settlements related to the surgical repair of cleft lip and palate. MAIN OUTCOMES MEASURES: Inclusion criteria included patients undergoing surgical repair of a primary cleft lip or palate or revision for complications of previous surgery. Data evaluated included patient demographics, type of operation performed, plaintiff allegation, nature of injury, and litigation outcomes. RESULTS: A total of 36 cases were identified, with 12 unique cases from 1981 to 2006 meeting the inclusion criteria. Six cases (50%) were decided by a jury and six by settlement. Five cases involved complications related to the specific surgery, and the other seven were associated with any surgery and perioperative care of children and adults. Cleft palate repair (50%) was the most frequently litigated surgery. Postoperative negligent supervision was the most common allegation (42%) and resulted in a payout in each case (mean = $3,126,032). Death (42%) and brain injury (25%) were the most frequent injuries reported. Financial awards were made in nine cases (after adjusting for inflation, mean = $2,470,552, range = $0 to $7,704,585). The awards were significantly larger for brain injury than other outcomes ($4,675,395 versus $1,368,131 after adjusting for inflation, P = .0101). CONCLUSION: Malpractice litigation regarding cleft lip and palate surgery is uncommon. However, significant financial awards involving perioperative brain injury have been reported.

Systematic Review and Meta-analysis of the Change in Pharyngeal Bacterial Cultures After Pediatric Tonsillectomy.

OBJECTIVE: To review all available biomedical literature to assess published data regarding the effect of pediatric tonsillectomy on the culture results of potentially pathogenic respiratory pharyngeal bacteria before and after surgery. DATA SOURCES: Biomedical literature databases (PubMed, Embase, Web of Science) from January 1970 to December 2019. REVIEW METHODS: A systematic review of the literature was performed with the assistance of a medical librarian. Inclusion criteria consisted of pediatric patients and extractable data regarding respiratory bacteria culture data before and after tonsillectomy. Meta-analysis with random effects modeling was used on a limited basis. RESULTS: Only 5 studies met the inclusion criteria. The grand mean age was 5.9 years; the sample size range was 31 to 134; and the range of follow-up was 1 to 12 months. Group A beta hemolytic Streptococcus was generally the least commonly cultured pathogenic bacteria on preoperative cultures. Qualitative culture data generally showed an overall decrease in potentially pathogenic bacteria and some increase in nonpathologic respiratory flora after tonsillectomy. Meta-analysis showed significant reductions in postoperative culture rates for group A beta hemolytic Streptococcus (positive post- vs preoperative culture: risk ratio [RR], 0.144; 95% CI, 0-0.342), Haemophilus influenzae (RR, 0.437; 95% CI, 0.266-0.608), and Streptococcus pneumoniae (RR, 0.268; 95% CI, 0-0.567) and mixed results for Moraxella catarrhalis (0.736; 95% CI, 0.446-1.03) but no significant reduction for Staphylococcus aureus (RR, 0.774; 95% CI, 0.157-1.39). CONCLUSION: The majority of published evidence shows that pediatric tonsillectomy appears to reduce the quantity of most cultured potentially pathogenic respiratory bacteria in the pharynx after surgery. The implications and possible benefits of this favorable change in the microbiologic environment after surgery require further study.

Clinical Consensus Statement: Ankyloglossia in Children.

OBJECTIVE: To identify and seek consensus on issues and controversies related to ankyloglossia and upper lip tie in children by using established methodology for American Academy of Otolaryngology-Head and Neck Surgery clinical consensus statements. METHODS: An expert panel of pediatric otolaryngologists was assembled with nominated representatives of otolaryngology organizations. The target population was children aged 0 to 18 years, including breastfeeding infants. A modified Delphi method was used to distill expert opinion into clinical statements that met a standardized definition of consensus, per established methodology published by the American Academy of Otolaryngology-Head and Neck Surgery. RESULTS: After 3 iterative Delphi method surveys of 89 total statements, 41 met the predefined criteria for consensus, 17 were near consensus, and 28 did not reach consensus. The clinical statements were grouped into several categories for the purposes of presentation and discussion: ankyloglossia (general), buccal tie, ankyloglossia and sleep apnea, ankyloglossia and breastfeeding, frenotomy indications and informed consent, frenotomy procedure, ankyloglossia in older children, and maxillary labial frenulum. CONCLUSION: This expert panel reached consensus on several statements that clarify the diagnosis, management, and treatment of ankyloglossia in children 0 to 18 years of age. Lack of consensus on other statements likely reflects knowledge gaps and lack of evidence regarding the diagnosis, management, and treatment of ankyloglossia. Expert panel consensus may provide helpful information for otolaryngologists treating patients with ankyloglossia.

Electrocautery adenoidectomy outcomes: a meta-analysis.

OBJECTIVE: Review the published literature regarding clinical outcomes of suction electrocautery adenoidectomy (ECA) in pediatric patients. DATA SOURCE: The MEDLINE database was systematically reviewed for articles reporting on the use of ECA. REVIEW METHODS: Each study was independently reviewed by each investigator. Inclusion criteria included English language, sample size greater than five, and presentation of extractable data regarding outcomes with ECA. Random-effects modeling was used to estimate summary outcomes. RESULTS: Nine studies met the inclusion criteria. The mean sample size was 276 patients with a grand mean age of 6.0 years. Random-effects modeling of intraoperative hemorrhage (4.1 cc vs 24.0 cc, 95 percent CI of difference = 16.5-23.1, P < 0.001) and operative time (10.0 minutes vs 18.4 minutes, 95 percent CI of difference = 0.82-2.90, P < 0.001) favored ECA vs curette adenoidectomy. Subjective success was reported in 95.0 percent (95% CI = 92.7%-97.3%, P < 0.001) of ECA patients with a grand mean of 5.8 months of follow-up. Adenoid regrowth was evaluated objectively (endoscopy or x ray) in only 116 of 2132 patients (5.4%), with an observed regrowth rate of 2.8 percent that (95% CI = 0%-5.5%, P = 0.052). CONCLUSIONS: The preponderance of available evidence favors ECA vs curette adenoidectomy in terms of decreased intraoperative hemorrhage and operative time. Long-term outcome data for ECA are scarce but suggest a low regrowth and complication rate.

Pediatric tonsil size: objective vs subjective measurements correlated to overnight polysomnogram.

OBJECTIVE: To compare subjective and objective tonsil size measurements (weight, volume, intertonsillar distance) along with simple pharyngeal measurements in the prediction of pediatric obstructive sleep apnea hypopnea syndrome (OSAHS) severity. STUDY DESIGN: Prospective case series. SUBJECTS AND METHODS: Tonsil size (0-4+) and Mallampati/Friedman palate position were subjectively measured. During adenotonsillectomy, tonsil size was objectively measured along with simple pharyngeal dimensions. Spearman rank correlation coefficients were calculated and forward and reverse stepwise multivariate regression modeling was used to assess the prediction of preoperative OSAHS severity as determined by polysomnogram (PSG). Evaluation of possible outlier influence was also performed. RESULTS: Thirty-four pediatric patients (median age, 4; range, 2-9) were included. Objective tonsil weight (Spearman's rho = 0.6143, P = 0.0002), tonsil volume (rho = 0.4960, P = 0.0039), and intertonsillar distance (rho = -0.7559, P < 0.0001) were strongly correlated with subjective tonsil size but not with age, body mass index (BMI), or preoperative apnea-hypopnea index (AHI). Regression modeling demonstrated that only measured tonsil weight (beta = 1.43, P = 0.003), age (beta = -3.21, P = 0.001), and hard palate length (beta = 0.979, P = 0.003) were significant predictors of the preoperative AHI (R(2) = 0.5358). Evaluation of possible outliers indicated tonsil weight was the most robust predictor of preoperative AHI. CONCLUSION: Subjective tonsil size measurements correlate well with objective tonsil volume measurements. However, only objective tonsil measurements were significantly predictive of objective PSG-measured OSAHS severity.

Cost Benefit and Utility Decision Analysis of Turbinoplasty with Adenotonsillectomy for Pediatric Sleep-Disordered Breathing.

OBJECTIVES: Use decision analysis techniques to assess the potential utility gains/losses and costs of adding bilateral inferior turbinoplasty to tonsillectomy/adenoidectomy (T/A) for the treatment of obstructive sleep-disordered breathing (oSDB) in children. Use sensitivity analysis to explore the key variables in the scenario. STUDY DESIGN: Cost-utility decision analysis model. SETTING: Hypothetical cohort. SUBJECTS AND METHODS: Computer software (TreeAge Software, Williamstown, Massachusetts) was used to construct a decision analysis model. The model included the possibility of postoperative complications and persistent oSDB after surgery. Baseline clinical and quality-adjusted life year (QALY) parameters were estimated using published data. Cost data were estimated from Centers for Medicare and Medicaid 2018 databases ( www.cms.gov ). Sensitivity analyses were completed to assess for key model parameters. RESULTS: The utility analysis of the baseline model favored the addition of turbinoplasty (0.8890 vs 0.8875 overall utility) assuming turbinate hypertrophy was present. Sensitivity analysis indicated the treatment success increase (%) provided by concurrent turbinoplasty was the key parameter in the model. A treatment success increase of 3% of turbinoplasty was the threshold where concurrent turbinoplasty was favored over T/A alone. The incremental cost-effectiveness ratio (ICER) of $27,333/QALY for the baseline model was favorable to the willingness-to-pay threshold of $50,000 to $100,000/QALY for industrialized nations. CONCLUSIONS: The addition of turbinoplasty for children with turbinate hypertrophy to T/A for the treatment of pediatric oSDB is beneficial from both a utility and cost-benefit analysis standpoint even if the benefits of turbinoplasty are relatively modest.

Injection laryngoplasty in neonates and young children with unilateral vocal fold immobility.

INTRODUCTION: Although injection laryngoplasty (IL) is a well-accepted treatment strategy in older children and adults with unilateral vocal fold immobility (UVFI), its efficacy and safety have not been well studied in neonates and young children. OBJECTIVES: The main objective of this study was to evaluate the clinical and radiographic effects of IL on aspiration & dysphagia in neonates and young children with UVFI. METHODS: This was a retrospective chart review of infants and children who underwent IL at a tertiary children's hospital. The primary endpoints were improved aspiration and avoidance of gastrostomy tube placement. Additional endpoints included adverse airway and swallowing effects of IL. RESULTS: Eight patients were included in this case series. A total of 10 injection laryngoplasties were performed. Average corrected age of patients undergoing IL was 1.22 years(range 0.5-3.6 y). Seven out of 8 patients had preoperative modified barium swallow (MBS). Five out of seven showed improvement in aspiration. Three out of six (50%) patients who did not have gastrostomy tube preoperatively, were able to avoid gastrostomy tube. No adverse effects were noted following IL. One patient with severe tracheomalacia ultimately required tracheostomy 5 months after IL. CONCLUSION: Injection laryngoplasty appears to be a safe and effective therapeutic option in neonates and young children with unilateral vocal cord immobility and associated aspiration. It may be an effective treatment to improve aspiration and avoid gastrostomy tube placement. Further investigation is warranted. LEVEL OF EVIDENCE: 4.

Mitomycin C and airway surgery: how well does it work?

OBJECTIVE: Systematically review and critically evaluate all available published data on the use of topical mitomycin C (MMC) as an adjunctive in airway surgery. DATA SOURCES: Published studies indexed in MEDLINE, EMBASE, or Cochrane databases. Inclusion criteria were English language, sample size greater than five, and publication of data applicable to the analysis of topical MMC and airway surgery outcomes. REVIEW METHODS: Evidence tables were compiled to include sample size, study design, and evidence level. Summary statistics, random-effects modeling, and subgroup analysis were performed. RESULTS: Twenty manuscripts (eight human, 12 animal) met the inclusion criteria. Seven of eight (87.5%) of the human studies and eight of 12 (66%) animal studies concluded topical MMC was beneficial to airway surgical outcomes. Eleven of twelve animal studies included randomization and a control group, compared with only two of eight human studies. Random-effects modeling of human studies (k=7) indicated that 81.4 percent (95% CI, 72.0%-90.9%; P < 0.001) of patients had improved outcomes attributable to MMC. Random-effects modeling of animal data included modeling of change in airway diameter (Hedge's G = -0.03; 95% CI, -0.66-0.60; P = 0.924) and the change in histologic measures (Hedge's G = 1.26; 95% CI, 0.596-1.92; P < 0.001) in MMC-treated animals vs controls. CONCLUSION: The majority of the published literature individually suggests the use of topical MMC improves airway surgery outcomes. However, heterogeneity within the clinical studies, the lack of controlled data, and the lack of significance in the pooled animal data (other than histologic outcomes) suggest that the utility of MMC is still undetermined.

Nonsurgical therapies for lymphangiomas: a systematic review.

OBJECTIVE: Systematically review the published literature regarding the efficacy of nonsurgical therapies in the treatment of head and neck (H&N) lymphatic malformations (LM) in children. DATA SOURCE: MEDLINE. REVIEW METHODS: MEDLINE was searched for literature relating to nonsurgical treatments for H&N LM. RESULTS: The initial search returned 1876 articles, with 22 meeting criteria. The majority (20) were case series. All therapies were percutaneous, with OK-432 or bleomycin sclerotherapy being most common. Random-effects modeling revealed 43% (CI = 28.9%-57%) of patients undergoing OK-432 for LM achieved a complete/excellent response, 23.5% (CI = 5.8%-41.3%) achieved a good response, 16.9% (CI = 10.3%-23.4%) achieved a fair/poor response, and 15.4% (CI = 8.6%-22.2%) observed no response. In the bleomycin group, the results were: 35.2% (CI = 15.7%-54.6%) excellent, 37.1% (CI = 22%-52.3%) good, 18.4% (CI = 2.7%-34.2%) fair/poor, and 11.6% (CI = 3.5%-19.6%) no response. Seven major complications were noted out of the 289 patients in the series, including two mortalities. CONCLUSIONS: The literature indicates that sclerotherapy for H&N LM achieves excellent/good clinical response in a majority of patients, with few complications, and anecdotally does not complicate future surgery.

Adenoidectomy outcomes in pediatric rhinosinusitis: a meta-analysis.

OBJECTIVE: To evaluate the currently available literature regarding the reported effectiveness of adenoidectomy alone in the management of medically refractory pediatric chronic rhinosinusitis. METHODS: The MEDLINE and EMBASE databases were systematically searched for English language manuscripts reporting on effectiveness of adenoidectomy alone in management of medically refractory pediatric rhinosinusitis. Additional manuscripts were identified by manual searching. Random effects modeling was performed to produce summary estimates of adenoidectomy effectiveness. RESULTS: Nine studies met the inclusion criteria. Six were cohort studies (level 2b) and four were case series (level 4). Mean sample size was 46 subjects (range = 10-121) with grand mean age of 5.8 years (range 4.4-6.9 years). All studies showed that sinusitis symptoms or outcomes improved in half or more patients after adenoidectomy. Eight studies were sufficiently similar to undergo meta-analysis. The summary estimate of the proportion of patients who significantly improved after adenoidectomy was 69.3% (95% CI = 56.8-81.7%, p < 0.001). The possibility of author bias was explored as one author group contributed a large proportion of patients to the study group. CONCLUSION: Adenoidectomy reduces caregiver reported symptoms of chronic rhinosinusitis in a majority of pediatric patients. Given its simplicity, low risk profile, and apparent effectiveness, adenoidectomy should be considered first line therapy for medically refractory, uncomplicated pediatric rhinosinusitis.

Comparison of Pediatric Intracapsular Tonsillectomy and Extracapsular Tonsillectomy: A Cost and Utility Decision Analysis.

Objectives To use decision analysis modeling to compare utility and cost outcomes of intracapsular tonsillectomy (ICT) and extracapsular tonsillectomy (ECT). To use sensitivity analysis to determine the most important factors influencing outcomes favoring one surgical method versus another. Study Design Decision analysis model. Setting Hypothetical cohort. Subjects and Methods A decision analysis model was created with computer software comparing the results of ICT and ECT. The model featured complications with completion tonsillectomy, such as postsurgical bleed, dehydration, and tonsillar regrowth. Outcomes were quantified with a utility scale ranging from 0.95 (1 surgical procedure without complications) to 0.55 (ICT, regrowth requiring completion ECT, post-ECT bleeding). Costs measured out-of-pocket costs for an insured patient and factored in different recovery times for ECT versus ICT. Results Based on baseline parameters, ECT had higher cumulative utility than ICT. Utility model results were highly dependent on the value of having a single uncomplicated surgery, as well as on the tonsillar regrowth rate. Utility was equal at a regrowth rate of 1.64%; rates above this value favored ECT. The base cost model showed that ICT ($4177.92) was less expensive than ECT ($4546.91), although ICT with regrowth had the highest outcome cost ($8393.91). ECT and ICT costs were equal at a tonsil regrowth rate of 17.8% and at a recovery period of 7.4 days. Conclusion Utility decision modeling based on best estimates for baseline parameters suggests that ECT may be slightly superior to ICT, but cost analysis suggests the opposite. However, the comparative results are highly dependent on subtle changes in the tonsil regrowth rate and the potential difference in recovery time.

Pulse transit time as a screening test for pediatric sleep-related breathing disorders.

OBJECTIVES: To evaluate a noninvasive measure of arousal, the pulse transit time (PTT), as a screening tool for obstructive sleep apnea/hypopnea syndrome (OSAHS) in an unselected population of symptomatic children, compared with overnight polysomnography (PSG). A secondary objective included comparing the diagnostic performance of PTT with continuous pulse oximetry recorded during PSG. DESIGN: Prospective, blinded diagnostic comparison study using the gold standard of overnight PSG. SETTING: Tertiary-care children's hospital sleep laboratory. PATIENTS: An unselected, volunteer sample of 59 patients (mean age, 7.8 years) with and without adenotonsillar tissue undergoing PSG and simultaneous PTT, including patients with obesity and craniofacial syndromes. MAIN OUTCOME MEASURES: The relationship between the PTT and polysomnographic measures of OSAHS to include pulse oximetry using correlation coefficients and receiver operating characteristic curve analysis. RESULTS: The correlation coefficient between the PTT arousal index and PSG apnea-hypopnea index (AHI) was 0.70 (P<.001). Linear regression resulted in a good fit (R2=0.73) between PTT arousal index and AHI. With the use of an AHI of 1 or greater (35.6% prevalence of OSAHS) as a criteria for OSAHS, the area under the receiver operating characteristic curve was 0.86 (95% confidence interval, 0.76-0.96). The optimal PTT arousal index threshold was 5.4 events per hour, which translated into a sensitivity of 81% and a specificity of 76%. CONCLUSIONS: The PTT arousal index is highly correlated with the PSG-derived AHI and demonstrated excellent diagnostic utility for moderate and severe OSAHS. However, for mild OSAHS, PTT was barely adequate and did not significantly outperform pulse oximetry. Pulse transit time may be a useful tool to evaluate moderate to severe sleep-related breathing disorders in children.

Acoustical analysis of pediatric snoring: what can we learn?

OBJECTIVE: Evaluate a database of pediatric patients who underwent snoring acoustical analysis for associations between snoring measurements, demographics, and obstructive sleep apnea/hypopnea syndrome (OSAHS) severity. STUDY DESIGN AND SETTING: A database of pediatric patients who underwent home testing with a polysomnogram device (SNAP Test, Glenview, IL) that includes acoustical snoring analysis was reviewed. RESULTS: Four hundred fifty-six patients were included (mean age, 6.87 years). Four hundred twenty-nine (94.1%) patients had measurable snoring. Snoring index (events/hr) (r = 0.2073; P < 0.0001) and maximal loudness (dB) (r = 0.2218; P < 0.0001) were directly proportional to the apnea/hypopnea index. Among patients without OSAHS (apnea index <1), increasing snoring index (r = -0.2102; P < 0.0001) and volume (P < 0.005 ANOVA) were associated with increasing oximetry desaturation events. CONCLUSION: The majority of children evaluated had objective snoring. Increasing snoring index and loudness are associated with increased severity of OSAHS. In the absence of OSAHS, increasing snoring is associated with oxygen desaturations. SIGNIFICANCE: Pediatric snoring is objectively related to OSAHS severity.

Polysomnography results versus clinical factors to predict post-operative respiratory complications following pediatric adenotonsillectomy.

OBJECTIVE: Systematically review the published literature comparing the presence of clinical features (age, BMI, co-morbidities, etc.) versus polysomnogram (PSG) results in the prediction of major post-operative respiratory complications following pediatric adenotonsillectomy (T/A) for the treatment of Obstructive Sleep Apnea Syndrome (OSAS). METHODS: A systematic review of the PUBMED and EMBASE databases was performed to identify studies containing both clinical and PSG data predicting major post-operative respiratory complications following T/A. Inclusion criteria included English language and extractable data. Major respiratory complications were defined as events that required significant intervention (intubation, CPAP,etc.) and/or altered patient disposition. Random effect modeling was performed and study quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies met the inclusion criteria with a median sample size of 157 (range 26-1735) and published between 1992 and 2015. The most common study design was a case series. Most studies included multiple patients at high risk for respiratory complications (Syndromic, obese, etc.). The summary estimate of the major respiratory complication rate following T/A was only 5.8% (95% CI = 4.2-7.4%, p < 0.001, I2 = 99%). For studies with extractable data, 102 of 112 patients (91.1%) with a post-operative respiratory complication had a clearly identifiable clinical risk factor, the remainder (8.9%) had only moderate or severe OSAS on PSG and no other predictor. CONCLUSION: The major respiratory complication rate following pediatric T/A for OSAS is low even amongst series of high risk patients. The majority of the published literature report that readily identified clinical factors predict the large majority of post-operative respiratory complications following T/A.

National Database Analysis of Single-Level versus Multilevel Sleep Surgery.

Objective Recent evidence suggests that multilevel sleep surgery improves outcomes when compared with palate surgery alone for most patients. The study objective was to compare demographic and outcomes data for palate surgery (uvulopalatopharyngoplasty [UPPP]) alone versus multilevel surgery through a national insurance claims database. Study Design Retrospective cohort study. Setting National insurance claims database. Subjects and Methods An adult cohort undergoing single-level UPPP versus UPPP with nasal and/or tongue/hypopharyngeal surgery was identified in the Truven Health Analytics MarketScan Research Databases for the years 2010 through 2012. Demographic and outcomes data were assessed at short-term (≤14 days), intermediate (15-60 days), and long-term (61-183 days) intervals via a multivariate regression model adjusted for age, sex, geographic region, insurance type, and the Charlson-Deyo comorbidity score. The primary long-term complication considered was positive airway pressure (PAP) equipment supply, implying possible treatment failure. Results The cohort included 14,633 patients: 7559 (51.6%), UPPP alone; 5219 (35.7%), UPPP + nasal surgery; 1164 (7.95%), UPPP + tongue/hypopharyngeal surgery; and 691 (4.7%), UPPP + nasal + tongue/hypopharyngeal surgery. Demographic data were similar among the groups. UPPP alone had lower rates of postoperative bleeding than UPPP + tongue/hypopharyngeal surgery (4.31% vs 6.19%, P = .004). Multivariate modeling indicated that the addition of either nasal surgery (odds ratio = 1.21, 95% CI = 1.10-1.34, P < .001) or tongue/hypopharyngeal surgery (odds ratio = 1.15, 95% CI = 1.00-1.32, P = .048) to UPPP was associated with increased odds of postoperative continuous positive airway pressure. Conclusions UPPP alone is currently the predominant form of sleep surgery in the United States. Multilevel surgery had greater odds of postoperative bleeding and positive airway pressure equipment supply than UPPP alone. Dedicated studies formally evaluating single- versus multilevel sleep surgery and the impact of possible surgeon/patient selection bias should be a priority.

Outpatient tonsillectomy in children: a systematic review.

OBJECTIVE: To evaluate the level of evidence regarding the safety of outpatient pediatric tonsillectomy. STUDY DESIGN AND SETTING: The medical literature addressing outpatient pediatric tonsillectomy was systematically reviewed. The level of evidence was assessed, and data were pooled. RESULTS: Seventeen articles met inclusion criteria. Each article suggested that outpatient tonsillectomy was safe. The overall level of evidence was fair (grade B-). Pooled data analysis in the perioperative period showed a complication rate estimate of 8.8% (95% confidence interval [CI], 5.5%-12.1%; P < or = 0.001) and an unplanned admission rate estimate of 8.0% (95% CI, 5.3%-10.7%; P < or = 0.001). Subgroup analysis suggests that children under age 4 are at a higher risk of complications in the perioperative period with an odds ratio of 1.64 (95% CI, 1.16-2.31). CONCLUSION: The level of evidence supporting the safety of outpatient pediatric tonsillectomy is fair. The analyzed data show a higher rate of early complications and unplanned admissions in children under age 4. SIGNIFICANCE: The current evidence supports the practice of outpatient tonsillectomy in properly selected children. EBM RATING: A-1a.

Acoustical analysis of snoring: can the probability of success be predicted?

PURPOSE: Palatal flutter snoring is the most common form of snoring. However, other types of snoring do exist. Does identifying palatal snoring beforehand translate into improved subjective treatment success with palatal stiffening procedures? METHODS: Fifty-three patients presenting with snoring were evaluated with a commercially available device. The proportion (%) and magnitude of palatal flutter (dB) were quantified. Patients then underwent a palatal stiffening procedure and subjective success/failure was assessed. RESULTS: Overall subjective treatment success was 85% (45 of 53). The percent palatal flutter was the most predictive of success (area under ROC = 0.8556, 95% CI = .7428-.9683). Patients exceeding 68% palatal flutter had a 95% (39 of 41) success rate (P = 0.001, Fisher's exact) and an adjusted odds ratio of treatment success of 25.2 (95% CI = 3.22-196, P = 0.002). CONCLUSION: Palatal stiffening treatments are successful in the majority of patients. However, identifying patients with predominant palatal flutter snoring significantly increases the probability of subjective treatment success. EBM RATING: B-2b.

The effectiveness of tonsillectomy and adenoidectomy in the treatment of pediatric obstructive sleep apnea/hypopnea syndrome: a meta-analysis.

OBJECTIVE: Present and evaluate the currently available literature reporting on the effectiveness of adenotonsillectomy (T/A) in treating obstructive sleep apnea/hypopnea syndrome (OSAHS) in uncomplicated pediatric patients. STUDY DESIGN AND SETTING: Systematic review of the literature and meta-analysis of the reduction of the polysomnogram (PSG)-measured Apnea Hypopnea Index (AHI events/hour) resulting from T/A and the overall success rate of T/A in normalizing PSG measurements (%). RESULTS: Fourteen studies met the inclusion criteria. Mean sample size was 28. All were case series (level 4 evidence). The summary change in AHI was a reduction of 13.92 events per hour (random effects model 95% CI 10.05-17.79, P < 0.001) from T/A. The summary success rate of T/A in normalizing PSG was 82.9% (random effects model 95% CI 76.2%-89.5%, P < 0.001). CONCLUSION/SIGNIFICANCE: T/A is effective in the treatment of OSAHS. However, success rates are far below 100%, which could have far-reaching pediatric public health consequences. EBM RATING: B-2a.