Obstructive Sleep Apnea is an Independent Risk Factor for Hospital Readmission.

STUDY OBJECTIVES: Hospital readmissions are an important metric of quality and safety. This study seeks to characterize the relationship between readmissions and obstructive sleep apnea (OSA). A better understanding of this relationship could be utilized to develop preventative measures and reduce readmission rates. METHODS: A retrospective review of patients discharged over a 24-month period to a Department of Defense hospital was conducted. Medical records review provided demographic data, presence of OSA and comorbid diseases, and whether readmission occurred within 30 days of discharge. Statistical analysis assessed risk factors for readmission, and multivariate analysis was performed. Next, 125 readmitted patients with OSA were randomly selected for detailed chart review and compared to a matched cohort that was not readmitted. RESULTS: Of 22,261 unique patients discharged, 1,899 (8.5%) were readmitted. Patients with OSA had a readmission rate of 11.4% versus 7.6% for patients without OSA (P < .00001). Multivariable analysis revealed an odds ratio of 1.46 for readmission in patients with OSA (P < .0001). For the detailed chart review of 250 patients, length of hospital stay differed for the readmitted and non-readmitted groups (5.1 versus 3.6 days; P = .007). Apnea-hypopnea index (24.1 versus 27.2 events/h; P = .48) was similar between the groups. Also, inpatient (27.2% versus 26.4%) and outpatient (38.4% versus 37.6%) positive airway pressure (PAP) treatment rates were not different. CONCLUSIONS: This study found OSA to be an independent risk factor for readmission within 30 days of discharge. PAP therapy appears to be underutilized in patients with known OSA. Additional studies are needed to define the relationship between OSA, PAP adherence, and hospital readmission.

Surgical relationship of the nasolacrimal system to the maxillary line: Performing safe mega antrostomy.

BACKGROUND: Endoscopic extended maxillary mega-antrostomy (EMMA) is a mucosal sparing technique that allows maxillary drainage by gravity, with a reported symptomatic nasolacrimal duct injury incidence of 0-4%, based on history alone. Injury to the nasolacrimal duct is known to cause epiphora, a complication that is rare but more often seen in this revision surgery. OBJECTIVE: The goal of this study was to determine the incidence of nasolacrimal system penetration during EMMA. We, in addition, sought to determine the minimal safe distance from the midpoint of the maxillary line (the "M" point) to the nasolacrimal system to avoid this injury. METHODS: Six cadaveric heads underwent bilateral Jones II test followed by EMMA. Measurements from the M point to the antrostomy were recorded. The Jones II test was then repeated to assess for penetration and/or injury of the nasolacrimal system. If no penetration occurred at the surgical limit of EMMA, then dissection was continued incrementally until penetration occurred. This measurement was recorded. RESULTS: Lacrimal duct violation was identified in 5 of 12 procedures (42%). Lacrimal duct penetration occurred at an average of 3.7 mm (range, 2-7 mm) posterior to the M point. CONCLUSION: Subclinical lacrimal system injury is likely to occur during EMMA. These findings would indicate that maintaining a distance of >7 mm from the maxillary line could avoid this injury.

The effect of tonsillectomy alone in adult obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). STUDY DESIGN: Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. SETTING: Tertiary care medical centers within the US Department of Defense. SUBJECTS AND METHODS: Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. RESULTS: A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate--with subjects achieving at least a 50% reduction of AHI to a value <15--was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. CONCLUSIONS: Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

An electrical cause of stridor: pediatric vagal nerve stimulators.

Vagal nerve stimulators (VNS) are surgically implantable medical devices which are approved by the food and drug administration (FDA) for treatment of medically refractory epilepsy in children. Two children with seizures disorders presented to the pediatric otolaryngology clinic with complaints of stridor and sleep apnea following implantation of VNS devices. Both children were evaluated with flexible laryngoscopy, direct laryngoscopy and bronchoscopy. The children were noted to have contraction of their vocal folds and supraglottis and the settings of their VNS were adjusted until no further contractions were noted. Each child had resolution of their symptoms following adjustment.

Correlation of otologic complaints in soldiers with speech disorders after traumatic brain injury.

OBJECTIVES/HYPOTHESIS: To determine the prevalence of otologic complaints in subjects with dysphonia and traumatic brain injury (TBI) in a sample population of the US Army. STUDY DESIGN: Cross-sectional study. METHODS: A total of 292 subjects were identified with a new diagnosis of voice disorder during a 3.5-year period at three large military medical centers. Of them, 70 subjects were also identified with TBI and had no history of dysphonia before this time period. In those with voice disorders and TBI, documentation of hearing complaints, hearing loss, tinnitus, or vertigo was recorded. Time to visit an otolaryngologist and audiologist were also recorded. RESULTS: A total of 70 soldiers were identified with a diagnosis of a voice disorder and TBI. Of these soldiers, 83% had at least one otologic complaint and 50% had more than one. Approximately 60%, 39%, and 44% of the subjects reported tinnitus, hearing loss, or vertigo, respectively. A total of 62% of the subjects with otologic complaints, TBI, and dysphonia were seen by an otolaryngologist. Time until an otolaryngologist evaluated these soldiers varied widely, with an average of 17 months and standard deviation of 12.5 months. CONCLUSIONS: Otologic manifestations are common in soldiers with dysphonia and TBI. Careful consideration of communication impairment from otologic dysfunction in those with speech disorders after TBI is warranted.

Characterization of voice disorders in deployed and nondeployed US army soldiers.

OBJECTIVES/HYPOTHESIS: To evaluate voice disorder differences between deployed and nondeployed US army soldiers. STUDY DESIGN: Cross-sectional study. METHODS: More than 1.3 million health records of active duty US army soldiers with no history of dysphonia were queried for voice disorder diagnoses over a 3.5-year period. A sample of 292 soldiers was further evaluated for known factors linked to dysphonia. RESULTS: US army soldiers were 1.13 times more likely to have a diagnosis of dysphonia if they were deployed. Risk factors and exposures common to patients with dysphonia were not statistically different between deployed and nondeployed soldiers. Additionally, the type of dysphonia diagnosis was not significantly different between deployed and nondeployed soldiers. CONCLUSIONS: US army soldiers deployed to war zones are more likely to be diagnosed with dysphonia. None of the reviewed parameters accounted for the difference in dysphonia rate between deployed and nondeployed soldiers, suggesting that occupational exposures of deployed soldiers account for the increase in the diagnoses of dysphonia.

Use of portable sleep monitors to diagnose sleep apnea during predeployment assessment.

INTRODUCTION: Portable sleep monitors (PMs) may be more expeditious and convenient than in-laboratory sleep studies in diagnosing obstructive sleep apnea (OSA). We report for the first time the use of PMs in a military population to demonstrate feasibility in predeployment assessments. METHODS: A nested, descriptive study was undertaken at 7 military medical facilities as part of a larger clinical trial. Subjects answered two questionnaires to identify OSA symptoms and used an ApneaLink Plus portable monitor to test for OSA. Descriptive statistics were used to characterize the subjects and to report results of PM use. RESULTS: 101 subjects were enrolled, and 77 subjects completed the study. 4.0% of subjects did not tolerate PM use. We found 15 subjects with OSA, with mean age of 31.4 +/- 12.8 years, mean body mass index of 33.0 +/- 7.4 kg/m2, and mean apnea-hypopnea index of 19.6 +/- 13.9 per hour. Subjects with OSA were more likely to have high pretest probability of disease than those without OSA. CONCLUSION: We demonstrate that PMs are well-tolerated and can successfully identify OSA in those with high pretest probability. We propose a method to implement PM use during predeployment assessments.

Reconstruction of airway soft tissues in obstructive sleep apnea.

Surgery for obstructive sleep apnea is multimodal. Procedures and aims of treatment vary. Surgery, medical devices, and medical therapy each may contribute to individualized patient care. There is no single procedure or intervention that "cures" upper airway obstruction. Treatment varies as the disease varies. In addition, surgical treatment varies because the level of obstruction and influence on air flow occurs at multiple levels and from many structures. This article is not intended as a critical assessment of surgical outcomes but rather focuses on airway structures and the nature of the procedures applied to influence them.