Impact of great auricular nerve sacrifice on sensory disturbance after parotidectomy.

PURPOSE: To investigate the association between great auricular nerve (GAN) sacrifice during parotidectomy and postoperative sensory disturbance. MATERIALS AND METHODS: Patients who underwent parotidectomy between November 2016 and May 2020 at a single academic institution were included in this retrospective chart review. Operative notes were reviewed to determine incidence of GAN sacrifice. Prevalence of patient-reported sensory complaints in the GAN distribution and time to spontaneous resolution of symptoms were assessed. RESULTS: Of 305 parotidectomy patients, 111 (36.4%) endorsed complaints of postoperative sensory disturbances in the GAN distribution typically characterized by numbness or shooting pains. GAN sacrifice was present in 9 (8.1%) of 111 patients who experienced sensory disturbances compared to 9 (4.6%) who reported no sensory disturbances (p > 0.05). Twenty-five patients (32.5%) experienced spontaneous resolution of symptoms at their most recent follow-up at a mean of 6.2 months after onset of symptoms. Of those that experienced a sensory disturbance, GAN preservation was not significantly associated with likelihood of spontaneous recovery (p > 0.05). CONCLUSIONS: We report the largest series to date of post-operative sensory disturbance in parotidectomy patients as it relates to intraoperative GAN sacrifice. Although the relationship between GAN sacrifice and the incidence of postoperative sensory disturbance and its subsequent resolution were not significant, we continue to advocate for GAN preservation to reduce incidence of postoperative sensory disturbances.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

LEARNING OBJECTIVES: Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. STUDY OBJECTIVES: To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. DESIGN: Retrospective Chart Review Case Series. SETTING: Multicenter Tertiary Care. METHODS: A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. RESULTS: 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p = .003), type of flap (fibula p < .001), skin graft area (p = .006), tourniquet use (p = .003), DVT prophylaxis (p = .008) and casting (p = .003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. CONCLUSION: Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.

Tourniquet use and factors associated with hematoma formation in free tissue transfer.

PURPOSE: Our objective was to understand which variables are associated with hematoma formation at both the donor and recipient sites in head and neck free tissue transfer and if hematoma rates are affected by tourniquet use. METHODS: Patients were identified who underwent free tissue transfer at three institutions, specifically either a radial forearm free flap (RFFF) or a fibula free flap (FFF), between 2007 and 2017. Variables including use of tourniquet, anticoagulation, treatment factors, demographics, and post-operative factors were examined to see if they influenced hematoma formation at either the free tissue donor or recipient site. RESULTS: 1410 patients at three institutions were included in the analysis. There were 692 (49.1%) RFFF and 718 (50.9%) FFF. Tourniquets were used in 764 (54.1%) cases. There were 121 (8.5%) hematomas. Heparin drips (p < .001) and DVT prophylaxis (p = .03) were significantly associated with hematoma formation (OR 95% CI 12.23 (4.98-30.07), 3.46 (1.15-10.44) respectively) on multivariable analysis. CONCLUSIONS: Heparin Drips and DVT prophylaxis significantly increased hematoma rates in free flap patients while tourniquets did not affect rates of hematoma.

Management of Large Facial Defects.

There is considerable variation in the surgical management of patients with large facial defects after excision of skin malignancy. The surrounding facial subunits as well as local, regional, and distant soft-tissue flaps can be considered in more complicated facial defects. We place an emphasis on the versatility of adjacent tissue advancement and transposition flaps in the treatment of these defects. We also focus on the secondary reconstructive efforts necessary to achieve the best functional and aesthetic outcomes for patients.

Kinetic characterization of the inhibition of protein tyrosine phosphatase-1B by Vanadyl (VO2+) chelates.

Protein tyrosine phosphatases (PTPases) are a prominent focus of drug design studies because of their roles in homeostasis and disorders of metabolism. These studies have met with little success because (1) virtually all inhibitors hitherto exhibit only competitive behavior and (2) a consensus sequence H/V-C-X5-R-S/T characterizes the active sites of PTPases, leading to low specificity of active site directed inhibitors. With protein tyrosine phosphatase-1B (PTP1B) identifed as the target enzyme of the vanadyl (VO2+) chelate bis(acetylacetonato)oxidovanadium(IV) [VO(acac)2] in 3T3-L1 adipocytes [Ou et al. J Biol Inorg Chem 10: 874-886, 2005], we compared the inhibition of PTP1B by VO(acac)2 with other VO2+-chelates, namely, bis(2-ethyl-maltolato)oxidovanadium(IV) [VO(Et-malto)2] and bis(3-hydroxy-2-methyl-4(1H)pyridinonato)oxidovanadium(IV) [VO(mpp)2] under steady-state conditions, using the soluble portion of the recombinant human enzyme (residues 1-321). Our results differed from those of previous investigations because we compared inhibition in the presence of the nonspecific substrate p-nitrophenylphosphate and the phosphotyrosine-containing undecapeptide DADEpYLIPQQG mimicking residues 988-998 of the epidermal growth factor receptor, a relevant, natural substrate. While VO(Et-malto)2 acts only as a noncompetitive inhibitor in the presence of either subtrate, VO(acac)2 exhibits classical uncompetitive inhibition in the presence of DADEpYLIPQQG but only apparent competitive inhibition with p-nitrophenylphosphate as substrate. Because uncompetitive inhibitors are more potent pharmacologically than competitive inhibitors, structural characterization of the site of uncompetitive binding of VO(acac)2 may provide a new direction for design of inhibitors for therapeutic purposes. Our results suggest also that the true behavior of other inhibitors may have been masked when assayed with only p-nitrophenylphosphate as substrate.

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.

A Review of and Algorithmic Approach to Soft Palate Reconstruction.

IMPORTANCE: The soft palate contributes to deglutition, articulation, and respiration. Current reconstructive techniques focus on restoration of both form and function. The unique challenges of soft palate reconstruction include maintenance of complex upper aerodigestive tract function, with minimal local or donor site morbidity. OBJECTIVE: To review the literature on soft palate reconstruction and present an algorithm on how to approach soft palate defects based on this review. EVIDENCE REVIEW: A review of the literature for articles reporting studies on and that described concepts related to soft palate reconstruction was conducted in March 2017. In all, 1804 candidate titles and abstracts were independently reviewed. English-language articles that discussed acquired soft palate defect reconstruction were included. Non-English language studies without available translations, studies on primary soft palate defect reconstruction (ie, cleft palate repair) and primary cleft palate repair, studies in which the soft palate was not the focus of the article, and studies involving animals were excluded. FINDINGS: The following observations were made from the review of 92 included articles. Soft palate anatomy is a complex interplay of multiple structures working in a 3-dimensional area. Three of the authors created an initial algorithmic framework based on the selected studies. After this, a round table discussion among 3 authors considered experts was used to refine the algorithm based on their expert opinion. The 4 most important factors were determined to be defect size, defect extension to other subsites, defect thickness, and history of radiotherapy or planned radiotherapy. This algorithm includes both surgical and nonsurgical options. Defects in the soft palate not only affect the size and shape of the organ but, more critically, the function. The reconstructive ladder is used to help maximize the remaining soft palate functional tissue and minimize the effect of nonfunctional implanted tissue. Partial-thickness defects or defects less than one-fourth of the soft palate may not require locoregional tissue transfer. Patients with a history of radiotherapy or defects of up to 75% of the soft palate may require locoregional tissue transfer. Defects greater than 75% of the soft palate, defects that include exposure of the neck vasculature, or defects that include significant portions of the hard palate or adjacent oropharyngeal subsites may require free tissue transfer. Obturation should be considered a second-line option in most cases. CONCLUSIONS AND RELEVANCE: Ideal reconstruction of the soft palate relies on a comprehensive understanding of soft palate anatomy, a full consideration of the armamentarium of surgical techniques, consideration for adjacent subsite deficits, and a detailed knowledge of various intrinsic and extrinsic patient factors to optimize speech, swallowing, and airway outcomes. The included algorithm may serve as a useful starting point for the surgeon when considering reconstruction.

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.

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.

Taste disturbance following tongue base resection for OSA.

OBJECTIVES/HYPOTHESIS: To investigate taste disturbance (TD) following endoscopic coblator open tongue base resection (Eco-TBR) for the treatment of obstructive sleep apnea (OSA)-hypopnea syndrome. STUDY DESIGN: A retrospective study in a tertiary academic medical center. METHODS: Eighty patients with OSA who failed continuous positive airway pressure therapy and underwent Eco-TBR for the tongue base obstruction were enrolled in this study. Taste changes and complications were examined before and after surgery. The standard three-drop-method gustatory function test was used to study taste status preoperatively and at 7 days, 1 month, and 3 months postoperatively. RESULTS: Six female and 74 male patients with OSA (mean age, 42.6 years; mean apnea-hypopnea index, 48.9/hour) had a minimum follow-up of 3 months and complete data available for analysis. One patient had postoperative oral bleeding. No long-term obvious dysphagia was encountered. Twelve patients had obvious TD in the four basic tastes (sweet, sour, salty, and bitter). At 3 months postoperative time, eight patients still had changes in taste sensation; however, the TD severity decreased and did not impact the patients' regular social life. The percentage of taste changes by time after Eco-TBR was between 13.8% and 17.5%. CONCLUSION: This study shows Eco-TBR may contribute to postoperative TD. The surgeons should clearly inform the OSA patient about the possibility of TDs after tongue base resection. LEVEL OF EVIDENCE: 4.

Isolated bilateral abducens nerve palsy due to an inflammatory process within the sella and parasellar regions.

Isolated bilateral abducens nerve palsy raises concern about a serious intracranial condition. Abducens nerve palsy is a common isolated palsy due to its susceptibility to injury along its long course. Non-traumatic isolated abducens nerve palsy is often caused by a mass that indirectly stretches and compresses the nerve. Pathological processes directly causing bilateral isolated involvement of the abducens nerve are rare. We describe a 24-year-old man who presented with isolated bilateral abducens nerve palsy. Radiological imaging and laboratory tests were consistent with an aggressive bacterial infectious process located in the sellar region with parasellar extension. If promptly addressed, sixth cranial nerve palsy appears to be reversible with aggressive medical therapy and endoscopic sinus surgery.

Provent therapy for obstructive sleep apnea: Impact of nasal obstruction.

OBJECTIVES/HYPOTHESIS: Determine the impact of nasal obstruction on efficacy, success, and adherence of Provent therapy in patients with obstructive sleep apnea (OSA). STUDY DESIGN: Prospective, two-arm, clinical pilot study at a single clinical site. METHODS: Patients with OSA who failed continuous positive airway pressure therapy were divided into two treatment arms: arm 1 were patients with no complaints of nasal obstruction and <50% nasal obstruction on exam, and arm 2 were patients with occasional complaints of nasal obstruction and 50% to 80% nasal obstruction on exam. Sleep testing at home was performed prior to the trial and on day 10 of the study with the use of Provent. RESULTS: Apnea-hypopnea index (AHI) decreased significantly from 20.5 ± 14.8 to 11.5 ± 16.6 (P < .001) in our total patient population. Patients in arm 1 had statistically significant improvement in their AHI (18.1 ± 13.0 to 7.4 ± 10.1, P < .001), oxygen desaturation index (ODI) (16.3 ± 10.8 to 8.2 ± 9.0, P < .001), and minimum oxygen saturation (81.3% ± 6.7% to 86.9% ± 5.6%, P = 0.008) from baseline sleep study to sleep study 2. Patients in arm 2 had improvements in their AHI (23.4 ± 16.6 to 16.5 ± 21.4), ODI (21.5 ± 14.8 to 17.0 ± 16.0) and minimum 02 %. However, none of these reached statistical significance. CONCLUSIONS: In this study, Provent therapy had a high failure rate. Patients without nasal obstruction showed greater improvements using Provent than patients with obstruction. Correction of nasal obstruction may be a useful prerequisite for treatment with Provent.

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.

Targeted hypoglossal nerve stimulation for the treatment of obstructive sleep apnea: Six-month results.

OBJECTIVES/HYPOTHESIS: This feasibility study was designed to show the preliminary safety and efficacy of targeted hypoglossal neurostimulation (THN), and to identify baseline predictors of successful therapy. STUDY DESIGN: Open-label, prospective, multicenter, single-arm cohort study, conducted at seven centers in the U.S.A. and Europe. METHODS: Forty-six participants with moderate to severe obstructive sleep apnea (OSA), failing or intolerant of continuous positive airway pressure, were implanted. Primary (Apnea-Hypopnea Index [AHI], Oxygen Desaturation Index [ODI]) and secondary (Arousal Index, Epworth Sleepiness Scale Index, Sleep Apnea Quality of Life Index) outcomes were measured at baseline and compared at 6 months. Data were analyzed to identify participant characteristics that would predict success with therapy. RESULTS: Sixty-seven adverse events (AEs) were observed among 36 participants; most of the AEs were related to the implant procedure and resolved without sequelae; one device replacement was necessary. Forty-three participants showed significant (P < .01) decreases in both AHI and ODI at 6 months; 35% (15 of 43) met criteria for AHI responders and 40% (17 of 43) for ODI responders. Significant improvement was observed in all the secondary endpoints. Predictors-of-success selection criteria were identified as baseline AHI < 65/hr, baseline apnea index ≤ 30, baseline body mass index < 35, and <15 events/hr of SpO2 decrease > 10%. Seven participants met these criteria; 86% (6 of 7) were AHI responders and 86% (6 of 7) were ODI responders, indicating that THN therapy can be efficacious in a carefully selected population of OSA patients. CONCLUSIONS: This feasibility study suggests that THN therapy is likely to be safe and effective in selected patients. LEVEL OF EVIDENCE: 2b Laryngoscope, 126:2618-2623, 2016.

Association Between Obstructive Sleep Apnea and Spontaneous Cerebrospinal Fluid Leaks: A Systematic Review and Meta-analysis.

IMPORTANCE: Spontaneous cerebrospinal fluid (CSF) leaks are a morbid condition associated with operative intervention for treatment. Understanding associations are key to diagnosis, treatment, and possible early detection. OBJECTIVE: To determine the clinical association and odds of having obstructive sleep apnea (OSA) and spontaneous CSF leaks. DATA SOURCES: A comprehensive search of the literature was conducted using PubMed (MEDLINE), Cochrane Library, and relevant article bibliographies. STUDY SELECTION: Systematic review and meta-analysis of studies from 2005 to 2015 investigating spontaneous CSF leaks in patients with OSA. The CSF leaks were considered spontaneous when they occurred in the absence of trauma, surgery, infection, and neoplasm. Included studies provided the number of patients diagnosed as having OSA and spontaneous CSF leaks. DATA EXTRACTION AND SYNTHESIS: Two independent investigators reviewed all studies for inclusion. The numbers of patients with OSA were systematically extracted from each study. Studies that compared the prevalence of OSA with spontaneous CSF leaks against their control cohort were pooled in the meta-analysis using a random-effects model. MAIN OUTCOME AND MEASURE: To determine whether there was increased incidence of OSA in patients with spontaneous CSF leaks. This hypothesis was formulated prior to data collection. RESULTS: The search criteria yielded 384 abstracts, and 6 clinical studies involving OSA and CSF leaks met the inclusion and exclusion criteria. They were all retrospective in nature and included 3 comparative (case-control) studies, 2 case series, and 1 case report. The cumulative reported prevalence of having OSA and spontaneous CSF leaks is 16.9% (232 of 1376 patients). Three of the studies were eligible for the meta-analysis. The odds of having OSA with a spontaneous CSF leak were 4.73 times more likely than in control cohorts (95% CI, 1.56-14.31; P = .006; I² = 35%). In a subgroup analysis of studies including nonspontaneous CSF leaks as their control cohort, the odds of having OSA with a spontaneous CSF leak were 2.85 times more likely than OSA with a nonspontaneous CSF leak (95% CI, 1.22-6.63; P = .02; I² = 0%). There was a notable difference in the age, BMI, or patients with hypertension in the comparative studies. CONCLUSIONS AND RELEVANCE: The association between OSA and spontaneous CSF leaks as demonstrated by retrospective studies is confounded by heterogeneous patient characteristics. Large prospective controlled studies using polysomnography and elevated intracranial pressure measurements are required to further evaluate the relationship between OSA and spontaneous CSF leaks.

Tonsillar Helicobacter pylori colonization in chronic tonsillitis: systematic review and meta-analysis.

IMPORTANCE: Helicobacter pylori colonization contributes significantly to multiple disease states, but its role in the development of tonsillar infection is unclear. Understanding the causes of chronic tonsillitis is important in clinical decision making of this commonly treated disease. OBJECTIVE: To assess the correlation between H pylori colonization of tonsillar tissue in chronic tonsillitis and in noninfectious hyperplastic tonsils. DATA SOURCES: We searched PubMed, MEDLINE, the Cochrane Trial Registry (through June 2014) and relevant article bibliographies. STUDY SELECTION: Systematic review and meta-analysis of studies assessing the correlation between H pylori colonization in tonsillar tissues of patients undergoing tonsillectomy for either chronic tonsillitis or noninfectious causes. Included studies hypothesized that H pylori played a role in the development of chronic tonsillitis. All included studies investigated the presence of H pylori in tonsillar tissue removed for various indications. Included studies must have used an accepted method of testing for H pylori. DATA EXTRACTION AND ANALYSIS: Studies were systematically reviewed by 2 independent reviewers for inclusion. Reported results of H pylori testing between tissues removed for infectious or noninfectious causes were systematically reviewed. The odds ratio of Hpylori colonization in tissue removed for chronic tonsillitis compared with tissue removed for noninfectious causes was calculated using a random-effects model. RESULTS: Six studies met inclusion criteria and had suitable data for pooling (n = 436). Of these, 2 studies measured H pylori colonization of tonsillar tissue in pediatric populations. One study analyzed tissue in both adult and pediatric populations. Noninfectious indications for tonsillectomy included sleep apnea or sleep-related breathing disorder, obstruction, carcinoma, and tonsillar hypertrophy. Overall, tonsillar H pylori colonization was found not to be significantly present more often in tissue samples removed secondary to recurrent infection rather than to noninfectious indications. The odds ratio of H pylori colonization in the tonsils of patients with chronic tonsillitis was 1.993 (95% CI, 0.909-4.371) (P = .09). CONCLUSIONS AND RELEVANCE: Helicobacter pylori colonization was not found to be more prevalent on tonsillar tissue with chronic or recurrent infections. The reviewed studies provide no evidence that H pylori infection plays a role in the pathogenesis or development of chronic tonsillitis.

A standardized lingual tonsil grading system: interexaminer agreement.

OBJECTIVE: Comparisons among studies involving the tongue base are limited by lack of a universal system for grading lingual tonsils. The authors propose a new standardized clinical grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study. STUDY DESIGN: Kappa interrater agreement study. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Video assessment: The proposed grading system consists of a 0-to-4 scale: 0 = complete absence of lymphoid tissue; 1 = lymphoid tissue scattered over tongue base; 2 = lymphoid tissue covering entirety of tongue base with limited vertical thickness; 3 = significantly raised lymphoid tissue covering entirety of the tongue base, approximately 5 to 10 mm in thickness; 4 = lymphoid tissue rising above the tip of the epiglottis, ≥1 cm in thickness. The vertical height of the tonsils is a clinical approximate. A teaching video demonstrated identification of this grading system. Fourteen trained otolaryngologists graded 20 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy. RESULTS: Video assessment: The overall Fleiss kappa statistic was 0.775 (P < .0001). This denotes substantial agreement. Live assessment: The overall kappa for nominal data was 0.8665 (P < .0001). This denotes near perfect agreement. CONCLUSION: The substantial interexaminer correlation demonstrated during video assessment and perfect interexaminer correlation in live assessment indicate that the proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

Factors associated with hypertrophy of the lingual tonsils.

OBJECTIVE: To identify factors that may be associated with lingual tonsil hypertrophy (LTH). STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Retrospective chart review identified 380 patients from August 2013 to April 2014 with graded lingual tonsils, documented during routine flexible laryngoscopy. Lingual tonsils were graded using a 0 to 4 scale: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covers entirety of tongue base with limited thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (rising above the tip of epiglottis). Reflux symptom index (RSI collected during patient intake), presence of obstructive sleep apnea hypopnea syndrome (OSAHS; confirmed by polysomnogram), smoking habits, and basic demographics were gathered. Chi-square and linear multivariate regression analyses were used to identify significant relationships with LTH levels. RESULTS: Overall, 59.8% were male with a mean age of 50.2 ± 16.5 years and BMI of 30.1 ± 18.0. Chi-square analysis revealed no significant relationship between OSAHS and LTH (P = .059). When RSI was stratified to ≥ 10 or < 10, a Cochran-Armitage test supported the trend hypothesis that as RSI increases, lingual tonsil grading increases. Significant univariate correlates included younger age (r = -0.307, P < .001) and smoking (r = 0.186, P = .002). Multivariate regression revealed the combination of younger age, increasing RSI, and smoking (r = -0.297, P < .001) to be a significant correlate. CONCLUSION: LTH does not seem to be associated with OSAHS or BMI in this group of patients. High RSI, younger age, and gender may be factors associated with increased lingual tonsil thickness.

Impact of mandibular advancement devices on C-reactive protein levels in patients with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To determine the effect of treatment of obstructive sleep apnea (OSA) with custom-made mandibular advancement devices (MADs) on C-reactive protein (CRP) levels in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Case series with chart review. METHODS: Charts of consecutive patients fitted with custom-made mandibular advancement devices for treatment of OSAHS between December 2011 and November 2012 were reviewed. Demographics such as age, sex, and body mass index (BMI) were collected. Prefitting and postfitting polysomnograms were reviewed. Pre- and posttreatment apnea-hypopnea index (AHI) and average O2 saturation were compared. Only patients with documented CRP levels determined prior to mandibular advancement device fitting and again after improvement of OSAHS symptoms were included. RESULTS: Forty-nine patients (77.6% male, age 47.4 ± 11.7 years, BMI 29.6 ± 5.0 kg/m(2)) were included in this study. Patients initially had elevated CRP levels (2.5 ± 1.8 mg/dl), which decreased significantly following use of their custom-made mandibular advancement device (1.9 ± 1.3 mg/dl, P = 0.006) by approximately 24%. AHI decreased significantly from 33.3 ± 21.7 pretreatment to 12.1 ± 22.3 posttreatment (P < 0.001). Treatment with MADs reduced AHI by approximately 69.3%. Minimum oxygen saturation significantly improved from 85.1% ± 5.9 pretreatment to 90.7% ± 3.6 posttreatment (P < 0.001). CONCLUSION: Treatment with custom-made mandibular advancement devices significantly reduced elevated CRP levels in patients with mild to severe OSAHS. Therapy achieves reasonable response and cure rates in the observed patients with a significant reduction in AHI.

Clinical predictors of effective continuous positive airway pressure in patients with obstructive sleep apnea/hypopnea syndrome.

OBJECTIVES/HYPOTHESIS: To identify standard clinical parameters that may predict the optimal level of continuous positive airway pressure (CPAP) in adult patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: This is a retrospective study in a tertiary academic medical center that included 129 adult patients (117 males and 12 females) with OSAHS confirmed by diagnostic polysomnography (PSG). METHODS: All OSAHS patients underwent successful full-night manual titration to determine the optimal CPAP pressure level for OSAHS treatment. The PSG parameters and completed physical examination, including body mass index, tonsil size grading, modified Mallampati grade (also known as updated Friedman's tongue position [uFTP]), uvular length, neck circumference, waist circumference, hip circumference, thyroid-mental distance, and hyoid-mental distance (HMD) were recorded. RESULTS: When the physical examination variables and OSAHS disease were correlated singly with the optimal CPAP pressure, we found that uFTP, HMD, and apnea/hypopnea index (AHI) were reliable predictors of CPAP pressures (P = .013, P = .002, and P < .001, respectively, by multiple regression). When all important factors were considered in a stepwise multiple linear regression analysis, a significant correlation with optimal CPAP pressure was formulated by factoring the uFTP, HMD, and AHI (optimal CPAP pressure = 1.01 uFTP + 0.74 HMD + 0.059 AHI - 1.603). CONCLUSIONS: This study distinguished the correlation between uFTP, HMD, and AHI with the optimal CPAP pressure. The structure of the upper airway (especially tongue base obstruction) and disease severity may predict the effective level of CPAP pressure. LEVEL OF EVIDENCE: 4.