Computational analysis of swallowing mechanics after surgery for obstructive sleep apnea.

Multilevel upper airway surgery for obstructive sleep apnea (OSA) has been shown to cause clinically significant dysphagia in some patients. We describe the cases of 2 adults with OSA who developed persistent dysphagia after multilevel upper airway surgery. Patient-specific computational analysis of swallowing mechanics (CASM) revealed absent pharyngeal shortening and aberrant tongue base retraction in both patients. These findings are consistent with the OSA surgical goal of enlarging the hypopharyngeal airway but likely contributed to our patients' dysphagia. Patient-specific CASM allows for sensitive identification of swallowing mechanical dysfunction that might otherwise be overlooked, and it may be utilized in future head and neck surgery patients to analyze swallowing dysfunction associated with treatment.

Effect of Chromoendoscopy Filters on Visualization of KTP Laser-Associated Tissue Changes: A Cadaveric Animal Model.

Standard KTP laser (potassium titanyl phosphate) wavelength-specific protective eyewear often impairs visualization of tissue changes during laser treatment. This sometimes necessitates eyewear removal to evaluate tissue effects, which wastes time and poses safety concerns. The objective was to determine if "virtual" or "electronic" chromoendoscopy filters, as found on some endoscopy platforms, could alleviate the restricted visualization inherent to protective eyewear. A KTP laser was applied to porcine laryngeal tissue and recorded via video laryngoscopy with 1 optical (Olympus Narrow Band Imaging) and 8 digital (Pentax Medical I-scan) chromoendoscopy filters. Videos were viewed by 11 otolaryngologists wearing protective eyewear. Using a discrete visual analog scale, they rated each filter on its ability to improve visualization,. No filter impaired visualization; 5 of 9 improved visualization. Based on statistical significance, the number of positive responses, and the lack of negative responses, narrow band imaging and the I-scan tone enhancement filter for leukoplakia performed best. These filters could shorten procedure time and improve safety; therefore, further clinical evaluation is warranted.

Prospective multi-institutional transnasal esophagoscopy: Predictors of a change in management.

OBJECTIVES/HYPOTHESIS: To evaluate clinical indications and endoscopic findings for patients undergoing transnasal esophagoscopy (TNE). STUDY DESIGN: Prospective, multi-institutional, observational cohort study at four tertiary centers. METHODS: Demographics, reflux finding score, reflux symptom index, Eating Assessment Tool (EAT-10) scores, clinical indications, and endoscopic findings were compared among patients whose TNE findings resulted in a changes in management (FCIM), defined as a referral, new medication, or surgery recommendation. RESULTS: Of the 329 patients who were enrolled nine (3%) were unable to complete the exam. In an adjusted regression model, male gender and elevated body mass index were significantly predictive of a positive TNE (P =.013-.045); 51% (n = 162/319) had TNE with FCIM. Common FCIM were esophageal stricture (7.5%), irregular Z-line (27.4%), reflux esophagitis (12.8%), and infectious esophagitis (6.3%) (P <.001-.010). Overall, the average EAT-10 was higher for patients with FCIM (9.7 vs. 5.4) than in those without it (P =.014). Patients with a history of head and neck cancer (HNCA) had FCIM 64% of the time, which rose to 81% if they had both HNCA and dysphagia. CONCLUSIONS: In treatment-seeking patients TNE is predictive of a change in management in males and obese patients. In patients with HNCA and dysphagia, TNE is likely to yield findings that cause a change in management. LEVEL OF EVIDENCE: 2b. Laryngoscope, 126:2667-2671, 2016.

Tracheal size variability is associated with sex: implications for endotracheal tube selection.

PURPOSE: Whereas selection of endotracheal tube (ETT) size in pediatric patients benefits from predictive nomograms, adult ETT sizing is relatively arbitrary. We sought to determine associations between cervical tracheal cross-sectional area (CTCSA) and clinical variables. METHODS: One hundred thirty-two consecutive patients undergoing noncontrasted chest computed tomography (CT) at a single tertiary care institution from January 2010 to June 2011 were reviewed. Patients with improper CT technique, endotracheal intubation, and pulmonary/tracheal pathology were excluded. Tracheal luminal diameters in anteroposterior (D1) and transverse (D2) were measured 2 cm inferior to the cricoid and used to determine CTCSA = π*D1*D2*». The demographic variables of age, height, weight, and body mass index (BMI) were tested for association with CTCSA by Spearman correlation. Wilcoxon rank-sum test was used to compare CTCSA by race and sex. Multivariate linear regression was performed including all clinical variables. RESULTS: There were 91 patients who met inclusion criteria. There was no correlation between age, weight, or BMI and CTCSA. There was a significant positive correlation between patient height and CTCSA (P = .001, R = 0.35); however, this was confounded by sex. Female patients had significantly smaller CTCSA (mean = 241 mm(2)) compared to male patients (mean = 349 mm(2), P < .001). Multivariate linear regression stratified by sex revealed that height is correlated with CTCSA only in males (P = .028). Males also had more variability in CTCSA (SD 118.6) compared to females (SD 65.5). CONCLUSION: Our data suggest that selection of ETT size in male patients should include height as a predictive factor. For female patients, it may be appropriate to select a uniformly smaller diameter ETT size.

Regulation and dysregulation of immunoglobulin E: a molecular and clinical perspective.

BACKGROUND: Altered levels of Immunoglobulin E (IgE) represent a dysregulation of IgE synthesis and may be seen in a variety of immunological disorders. The object of this review is to summarize the historical and molecular aspects of IgE synthesis and the disorders associated with dysregulation of IgE production. METHODS: Articles published in Medline/PubMed were searched with the keyword Immunoglobulin E and specific terms such as class switch recombination, deficiency and/or specific disease conditions (atopy, neoplasia, renal disease, myeloma, etc.). The selected papers included reviews, case reports, retrospective reviews and molecular mechanisms. Studies involving both sexes and all ages were included in the analysis. RESULTS: Both very low and elevated levels of IgE may be seen in clinical practice. Major advancements have been made in our understanding of the molecular basis of IgE class switching including roles for T cells, cytokines and T regulatory (or Treg) cells in this process. Dysregulation of this process may result in either elevated IgE levels or IgE deficiency. CONCLUSION: Evaluation of a patient with elevated IgE must involve a detailed differential diagnosis and consideration of various immunological and non-immunological disorders. The use of appropriate tests will allow the correct diagnosis to be made. This can often assist in the development of tailored treatments.