Clinical outcomes of expansion sphincter pharyngoplasty-a 17-year systematic review.

OBJECTIVES: To systematically review long-term (> 5 years) outcomes of ESP surgery for OSA treatment over 17 years. METHODS: Systemic review of MEDLINE, Google Scholar, Cochrane Library and Evidence Based Medicine Reviews to identify publications relevant to OSA and Expansion Pharyngoplasty and its variants. All relevant studies published between January 2007 and June 2023 were included. RESULTS: Twelve studies were included in this systematic review with a combined total of 1373 patients who had the ESP procedure were included. The clinical outcomes included encouraging long-term success rate, reductions in Epworth sleepiness scale, good mean disease alleviation, anatomical structural area and volume improvements, blood pressure reductions, biochemical improvements in acute phase reactants after ESP surgery, reductions in intra-ocular pressures, and post-operative reduction of sympathetic overdrive. CONCLUSIONS: Seventeen years on, the expansion sphincter pharyngoplasty has demonstrated not only increase in anatomical area and volume but significant desired improvements in polysomnographic, clinical and biochemical parameters post-surgery.

A prelacrimal approach technique to overcome the limitation of the narrow lacrimal recess.

PURPOSE: The distance between the anterior wall of the maxillary sinus and the nasolacrimal duct has been classified into three types by Simmen, in which type I (< 3 mm) is the least feasible for a prelacrimal approach. The aim of our study is to present a surgical technique which overcomes the anatomical limitation of the narrow lacrimal recess (type I) in the management of inverted papilloma in the maxillary sinus. METHODS: Case series. RESULTS: Eight patients with type I lacrimal recess underwent surgical resection for inverted papilloma in the maxillary sinus via a prelacrimal approach. The technique is described in detail in the article and essentially involves exposure of the nasolacrimal duct using a diamond burr. Complete tumor excision was achieved in all cases through this access, with no significant intra-operative complications. CONCLUSIONS: This prelacrimal approach technique is safe and effective for the management of inverted papilloma in maxillary sinuses with a type I lacrimal recess configuration.

Anterior maxillary wall and lacrimal duct relationship in Orientals: CT analysis for prelacrimal access to the maxillary sinus.

BACKGROUND: The pre-lacrimal window approach (PLWA) is a promising technique in approaching lesions of the anterior wall and floor of the maxillary sinus. Simmen et al. previously reported that this approach is feasible in only 2/3 of their patients. This percentage appears to be lower than that of our local (mainly Chinese) population based on our clinical experience. Our study aims to measure the distance between the anterior maxillary wall and lacrimal duct in ethnic Chinese. A higher incidence of sphenoid-ethmoidal cells has been reported in Orientals. We postulate that there is also a higher incidence of wider pre-lacrimal recesses in Orientals thus making the PLWA more feasible to perform in Orientals. METHODS: 100 consecutive sinus CT scans of adult patients with various rhinologic diseases that did not distort the bony anatomy of the maxilla were reviewed (2 sides each). The distance between the anterior maxillary wall and the anterior border of the lacrimal duct was measured in 200 sides. We have adopted the methodology of measurements previously published by Simmen et al.  This is so that we could compare between Oriental and Occidental paranasal sinuses. RESULTS: A distance of more than 7 mm was found in 39.5% of our subjects and a distance of > 3-7 mm was seen in 53.5%. In 6.5% of our subjects we found a prelacrimal recess < 3 mm. CONCLUSION: The PLWA could have been performed without removal of the bony lacrimal canal in 39.5% of our subjects ( > 7 mm). Good access to the anterior maxilla wall could also have been possible for 53.5% with sub-periosteal removal of the bony lacrimal canal and medial maxillary wall. Thus, the PLWA would have been feasible for 93% of our subjects. These percentages are significantly higher than Simmen's study of 68.5% in an Occidental population.

Indications for Eustachian tube dilation.

PURPOSE OF REVIEW: Eustachian tube dilation is a controversial surgical procedure because the intended problem for which it is meant to address, obstructive Eustachian tube dysfunction, is a clinical diagnosis without a reliable diagnostic tool to test.In the past 10 years, balloon dilation Eustachian tuboplasty (BDET) has been the most commonly performed Eustachian tube dilation procedure. The present review seeks to identify the patients who may benefit from this procedure and thus propose the indications. RECENT FINDINGS: Two randomized controlled trials for BDET published in the past 2 years showed statistically significant improvement in terms of symptomatic relief based on the ETDQ-7 scores and conversion of abnormal tympanograms (type B and type C) to normal tympanograms (type A). SUMMARY: Based on the review of the evidence available so far, the proposed indication for Eustachian tube dilation using BDET is for a patient with ALL of the following: aural fullness greater than 12 weeks; type B or C tympanogram; ETDQ-7 mean score more than 2; and failed medical management including Valsalva maneuver and either 4 weeks of nasal steroids or 1 week of oral steroids.

Educational utility of advanced three-dimensional virtual imaging in evaluating the anatomical configuration of the frontal recess.

BACKGROUND: Endoscopic sinus surgery represents a cornerstone in the professional development of otorhinolaryngology trainees. Mastery of these surgical skills requires an understanding of paranasal sinus and skull-base anatomy. The frontal sinus is associated with a wide range of variation and complex anatomical configuration, and thus represents an important challenge for all trainees performing endoscopic sinus surgery. METHODS: Forty-five otorhinolaryngology trainees and 20 medical school students from 5 academic institutions were enrolled and randomized into 1 of 2 groups. Each subject underwent learning of frontal recess anatomy with both traditional 2-dimensional (2D) learning methods using a standard Digital Imaging and Communications in Medicine (DICOM) viewing software (RadiAnt Dicom Viewer Version 1.9.16) and 3-dimensional (3D) learning utilizing a novel preoperative virtual planning software (Scopis Building Blocks), with one half learning with the 2D method first and the other half learning with the 3D method first. Four questionnaires that included a total of 20 items were scored for subjects' self-assessment on knowledge of frontal recess and frontal sinus drainage pathway anatomy following each learned modality. A 2-sample Wilcoxon rank-sum test was used in the statistical analysis comparing the 2 groups. RESULTS: Most trainees (89%) believed that the virtual 3D planning software significantly improved their understanding of the spatial orientation of the frontal sinus drainage pathway. CONCLUSION: Incorporation of virtual 3D planning surgical software may help augment trainees' understanding and spatial orientation of the frontal recess and sinus anatomy. The potential increase in trainee proficiency and comprehension theoretically may translate to improved surgical skill and patient outcomes and in reduced surgical time.

The International Classification of the radiological Complexity (ICC) of frontal recess and frontal sinus.

BACKGROUND: The frontal sinus is considered the most challenging sinus to address surgically. There are no current classifications of the degree of surgical complexity of different frontal sinus configurations. The aim of this study is to develop a classification system of the degree of complexity of frontal recess surgery based on preoperative computed tomography (CT) scans. METHODS: Authors were asked to submit a classification system. These were circulated to all authors. Selection of the final 3 classifications was based on a majority consensus. These classifications were compared further for time-taken, ease-of-use, and interrater agreement. These were assessed by the authors on 10 CT scans representing a range of anticipated surgical difficulty. RESULTS: Out of 3 compared classifications, classification A was the quickest to score (1.44 minutes vs 1.57 minutes and 2.25 minutes), subjectively easiest (3.23 vs 4.07 and 5 on a visual analogue scale [VAS]), and had a moderate interrater agreement (0.52 vs 0.42 and 0.79). In addition, the grading of complexity was as good whether measurements were taken on the CT scans or whether size of the frontal ostium was visually estimated. CONCLUSION: We propose a fast, easy classification to anticipate the complexity of surgery in the frontal sinus and recess, for patients undergoing primary surgery.

The International Frontal Sinus Anatomy Classification (IFAC) and Classification of the Extent of Endoscopic Frontal Sinus Surgery (EFSS).

The frontal recess and frontal sinus anatomy can vary from simple to complex. The variations in the anatomy of the frontal recess and frontal sinus are considerable but almost all variations can be classified if the various cell patterns are analyzed. This consensus document was developed to improve the ability of the surgeon to understand these possible variations, plan the surgery, and communicate these complexities when teaching or reporting outcomes. Once the surgeon understands the anatomical pattern of the frontal sinus and recess cells, the extent of surgery can be planned. This document presents a classification of the extent of surgery based on the anatomical classification.

Retropharyngeal pseudoabscess manifesting in nephrotic syndrome.

We describe a case of nephrotic syndrome that manifested as a retropharyngeal pseudoabscess. The patient was a 32-year-old man who presented with a short history of throat discomfort and a choking sensation. Laryngoscopy identified bulging of the posterior pharyngeal wall that partially occluded the laryngeal inlet. A lateral neck x-ray revealed that the prevertebral space was widened, and computed tomography detected fluid in the retropharyngeal and parapharyngeal spaces. Neck exploration revealed that the edema had been caused by nonsuppurative fluid. Biochemical analyses revealed marked hypoalbuminemia and heavy proteinuria suggestive of nephrotic syndrome. Following surgery, the patient's symptoms resolved. Aseptic effusion into the retropharyngeal space is rare; reported etiologies include internal jugular vein thrombosis, neoplasia, radiation therapy, trauma, acute calcific tendinitis, hereditary angioedema, and myxedema of hypothyroidism. To the best of our knowledge, this is the first case of nephrotic syndrome initially manifesting as retropharyngeal pseudoabscess to be reported in the literature. Thrombotic occlusion of the pharyngeal venous plexus secondary to hypercoagulability is a plausible explanation for such isolated retropharyngeal effusion.

Safety of multilevel surgery in obstructive sleep apnea: a review of 487 cases.

OBJECTIVE: To review the safety of multilevel surgery in patients with obstructive sleep apnea (OSA). DESIGN: Retrospective review. PATIENTS: A total of 487 consecutive patients with OSA and 1698 surgical procedures from January 2007 to May 2010. INTERVENTIONS: Multilevel OSA surgery comprising nasal surgery (endoscopic sinus surgery, septoplasty, and inferior turbinate reduction), palate surgery (traditional uvulopalatopharyngoplasty, expansion sphincter pharyngoplasty and anterior palatoplasty), and tongue surgery (hyoid suspension, radiofrequency tongue base, and tongue suspension suture). MAIN OUTCOME MEASURES: Surgical complications. RESULTS: The overall complication rate was 7.1%, with 1 patient having an upper airway obstruction. Complications were as follows: (1) 6 patients had postoperative oxygen desaturation within 3 hours after extubation (these patients had severe OSA [apnea-hypopnea index > 60 and lowest oxygen saturation level <80%]), (2) 15 patients had persistent hypertension (these patients had a history of hypertension), (3) 15 patients had secondary hemorrhage (7-12 days postoperatively), (4) there were 2 cases of negative pressure pulmonary edema, (5) 9 patients had tongue edema (following tongue surgery), and (6) 1 patient had upper airway obstruction requiring reintubation. Patients who had undergone tongue surgery were admitted routinely to the high-dependency unit (step-down care from the intensive care unit) overnight. CONCLUSIONS: Routine postoperative admission to the intensive care unit for all patients with OSA is unnecessary. These patients should be closely monitored in the postanesthesia care unit area after surgery, and based on the outcome of this period, they can be observed overnight in either the high-dependency unit or the general ward.