First branchial cleft fistula (Work Type 2) with an internal opening to the Eustachian tube: Case report and review of literature.

First branchial cleft anomalies are rare congenital defects of the head and neck. This case report presents a 12-year-old patient with a draining cutaneous pit approximately 1-cm anterior and 5-mm inferior to the right angle of the mandible. Imaging revealed a fistula between the cutaneous pit and Eustachian tube. Further characterization with methylene blue injection into the cutaneous pit resulted in spillage through the right Eustachian tube. Surgical excision of the fistula revealed a cylindrical structure comprised of ectodermal and mesodermal features that most likely represented a Work Type 2 first branchial cleft fistula.

Double Barrel Nasal Trumpets to Prevent Upper Airway Obstruction after Nasal and Non-Nasal Surgery.

OBJECTIVES: During anesthesia emergence, patients are extubated and the upper airway can become vulnerable to obstruction. Nasal trumpets can help prevent obstruction. However, we have found no manuscript describing how to place nasal trumpets after nasal surgery (septoplasties or septorhinoplasties), likely because (1) the lack of space with nasal splints in place and (2) surgeons may fear that removing the trumpets could displace the splints. The objective of this manuscript is to describe how to place nasal trumpets even with nasal splints in place. MATERIALS AND METHODS: The authors describe techniques (Double Barrel Technique and Modified Double Barrel Technique) that were developed over three years ago and have been used in patients with obstructive sleep apnea (OSA) and other patients who had collapsible or narrow upper airways (i.e., morbidly obese patients). RESULTS: The technique described in the manuscript provides a method for placing one long and one short nasal trumpet in a manner that helps prevent postoperative upper airway obstruction. The modified version describes a method for placing nasal trumpets even when there are nasal splints in place. Over one-hundred patients have had nasal trumpets placed without postoperative oxygen desaturations. CONCLUSIONS: The Double Barrel Technique allows for a safe emergence from anesthesia in patients predisposed to upper airway obstruction (such as in obstructive sleep apnea and morbidly obese patients). To our knowledge, the Modified Double Barrel Technique is the first description for the use of nasal trumpets in patients who had nasal surgery and who have nasal splints in place.

The effect of tonsillectomy on obstructive sleep apnea: an overview of systematic reviews.

OBJECTIVE: Tonsillectomy with adenoidectomy is a combination surgery that has been used to treat pediatric obstructive sleep apnea (OSA). For adults, tonsillectomy has also been reported as a primary treatment modality when the tissue is hypertrophied. The objective of this study is to provide an overview of published systematic reviews and meta-analyses of tonsillectomy with or without adenoidectomy as used in the treatment of OSA in children and adults. DATA SOURCES: Nine databases, including PubMed/MEDLINE. REVIEW METHODS: Databases were searched from their inception through July 9, 2017. The PRISMA statement was followed. RESULTS: More than 20 recent systematic reviews and meta-analyses were identified regarding tonsillectomy as a treatment modality for OSA. There were four articles that addressed tonsillectomy's overall success, efficacy, and complications in otherwise healthy pediatric patients. Three studies evaluated tonsillectomy in obese children, and two specifically examined children with Down syndrome. Only one systematic review and meta-analysis discussed tonsillectomy as a treatment for OSA in the adult population. CONCLUSION: Tonsillectomy as an isolated treatment modality is rarely performed in pediatric patients with OSA; however, tonsillectomy is commonly performed in combination with adenoidectomy and the combination has demonstrated efficacy as the primary treatment option for most children. In the limited adult data, tonsillectomy alone for OSA has a surprising success rate; yet, more research is required to determine long-term improvement and need for further treatment.

Oropharyngeal and tongue exercises (myofunctional therapy) for snoring: a systematic review and meta-analysis.

PURPOSE: Oropharyngeal and tongue exercises (myofunctional therapy) have been shown to improve obstructive sleep apnea. However, to our knowledge, a systematic review has not been performed for snoring. The study objective is to perform a systematic review, with a meta-analysis, dedicated to snoring outcomes after myofunctional therapy. METHODS: PubMed/MEDLINE and three other databases were searched through November 25, 2017. Two authors independently searched the literature. Eligibility (1) patients: children or adults with snoring, (2) intervention: oropharyngeal and/or tongue exercises, (3) comparison: pre and post-treatment data for snoring, (4) outcomes: snoring frequency and snoring intensity, (5) study design: publications of all study designs. RESULTS: A total of 483 articles were screened, 56 were downloaded in their full text form, and nine studies reported outcomes related to snoring. There were a total of 211 patients (all adults) in these studies. The snoring intensity was reduced by 51% in 80 patients from pre-therapy to post-therapy visual analog scale values of 8.2 ± 2.1 (95% CI 7.7, 8.7) to 4.0 ± 3.7 (95% CI 3.2, 4.8). Berlin questionnaire snoring intensity reduced by 36% in 34 patients from 2.5 ± 1.0 (95% CI 2.2, 2.8) to 1.6 ± 0.8 (95% CI 1.3, 1.9). Finally, time spent snoring during sleep was reduced by 31% in 60 patients from 26.3 ± 18.7% (95% CI 21.6, 31.0) to 18.1 ± 20.5% (95% CI 12.9, 23.3) of total sleep time. CONCLUSIONS: This systematic review demonstrated that myofunctional therapy has reduced snoring in adults based on both subjective questionnaires and objective sleep studies.

Flap Basics III: Interpolated Flaps.

Paramedian forehead and melolabial flaps are the most common examples of interpolated flaps used by facial plastic surgeons and are excellent options for reconstruction of the midface after Mohs surgery. They provide superior tissue match in terms of thickness, texture, and color, while leaving minimal defects at the tissue donor sites. The main advantage of interpolated flaps is the robust blood supply, which can be either axial of randomly based, and the maintenance of the integrity of facial landmarks. The main disadvantage is the frequent need for a multistage procedure, which eliminates some patients from consideration.

Tongue surgeries for pediatric obstructive sleep apnea: a systematic review and meta-analysis.

OBJECTIVES: To evaluate the international literature for studies reporting outcomes for obstructive sleep apnea (OSA) in children undergoing isolated tongue surgeries. METHODS: Two authors searched from inception through November 14, 2016 in four databases including PubMed/MEDLINE. RESULTS: 351 studies were screened. Eleven studies (116 children) met criteria. Most children were syndromic and had craniofacial disorders, co-morbidities, or other serious medical issues. Surgeries included base-of-tongue (BOT) reduction (n = 114), tongue suspension (n = 1), and hypoglossal nerve stimulation (n = 1). The pre- and post-BOT reduction surgeries decreased apnea-hypopnea index (AHI) from a mean (M) and standard deviation (SD) of 16.9 ± 12.2/h to 8.7 ± 10.6/h (48.5% reduction) in 114 patients. Random effects modeling (109 patients) demonstrated a standardized mean difference for AHI of -0.78 (large magnitude of effect) [95% CI -1.06, -0.51], p value <0.00001. For BOT surgery in 53 non-syndromic children, the AHI decreased 59.2% from 14.0 ± 11.4 to 5.7 ± 6.7/h, while in 55 syndromic children, the AHI decreased 40.0% from 20.5 ± 19.1 to 12.3 ± 18.2/h. BOT reduction improved lowest oxygen saturation from M ± SD of 84.7 ± 7.4-87.9 ± 6.5% in 113 patients. Hypoglossal nerve stimulation and tongue-base suspension are limited to case reports. CONCLUSIONS: Most children undergoing tongue surgeries in the literature were syndromic and had craniofacial disorders, co-morbidities, or other serious medical issues. Children with a body mass index <25 kg/m2 and non-syndromic children have had the most improvement in AHI. The specific type of surgery must be tailored to the patient. Patients with co-morbidities should undergo treatment in centers that are equipped to provide appropriate perioperative care.

Sleep surgery tool: A medical checklist to review prior to operating.

OBJECTIVE: The objective of this study was to systematically review the international literature for studies providing a preoperative checklist for medical disorders to be evaluated or treated before performing sleep surgery. If no checklist exists, then studies providing recommendations would be used to develop a checklist de novo. STUDY DESIGN: Systematic review combined with expert opinion. METHODS: Four databases, including PubMed/Medline were searched through August 10, 2016. RESULTS: 453 potentially relevant studies were screened, 32 were downloaded for full review. No study included a preoperative checklist. No study provided guidance for specific medical disorders to evaluate or screen for prior to sleep surgery. Therefore, we reviewed articles in adults that provided recommendations such as: (1) labs to review, (2) non-operative disorders to evaluate and treat, and (3) comorbidities to optimize prior to performing sleep surgery. These articles were utilized in conjunction with expert opinion to develop a preoperative checklist for surgical guidance. CONCLUSION: There are several items to review prior to performing sleep surgery on obstructive sleep apnea patients. This systematic review and expert opinion-based checklist provides over twenty items for reviewing prior to performing sleep surgery to reduce the chance of operating prematurely.