Impact of gender and sleep position on relationships between anthropometric parameters and obstructive sleep apnea syndrome.

OBJECTIVE: Considering the mechanisms by which obesity affects obstructive sleep apnea syndrome (OSAS) and the differences of fat distribution depending on gender, associations between anthropometric parameters, and OSAS may differ depending on gender or sleep position. We analyzed the impact of gender and sleep position on the relationship between fat distribution and development of OSAS. METHODS: One thousand thirty-two consecutive subjects were analyzed. Recorded anthropometric measurements and overnight polysomnographic data of the subjects were reviewed retrospectively. The presence of OSAS was defined by the respiratory disturbance index (RDI) ≥5 with documented symptoms of excessive daytime sleepiness. RESULTS: Eight hundred fifty-eight males and 174 females were included. Male subjects had significantly higher body mass index (BMI), larger waist circumference (WC), and lower percent of overall body fat (P < 0.0001, P < 0.0001, and P < 0.0001, respectively). The severity of OSAS was significantly higher in male subjects (RDI 26.9 ± 22.4 in males vs. 10.2 ± 13.8 in females, P < 0.0001). In male subjects, BMI, WC, and overall body fat were significantly associated with severity of OSAS and had larger impacts on supine RDI than lateral RDI. Overall body fat was not associated with severity of OSAS in female subjects, and there were no significant differences of the associations between all anthropometric parameters and RDIs depending on sleep position. CONCLUSIONS: Evaluation of the correlation of anthropometric data with severity of OSAS should consider sleep position as well as gender.

Long-term Recovery Patterns of Olfactory Function after Trans-sphenoidal Approach with Nasoseptal Flap Elevation.

Introduction Nasoseptal flap is widely used in reconstruction of the skull base to prevent cerebrospinal fluid leakage after surgery for skull base lesions. There has been a debate on whether more severe olfactory dysfunction occurs after nasoseptal flap elevation than the conventional trans-sphenoidal approach. Objective To compare the long-term recovery patterns associated with nasoseptal flap and the conventional trans-sphenoidal approach. Methods The subjects were divided into the conventional trans-sphenoidal approach group and the nasoseptal flap elevation group. We followed up self-reported olfactory score using the visual analogue scale and threshold discrimination identification (TDI) score of the Korean Version of the Sniffin Stick test II for 12 months, with olfactory training. Results The study included 31 patients who underwent the trans-sphenoidal approach. Compared with preoperative status, the mean visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group recovered 2 months postoperatively, while in the nasoseptal flap elevation group the visual analogue scale and TDI scores recovered 6 months and 3 months after surgery, respectively. Twelve months after surgery, the visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group were 9.3 ± 0.5 and 28.5 ± 4.3, while those from the nasoseptal flap elevation group were 8.9 ± 1.5 and 27.2 ± 4.7 ( p = 0.326; 0.473). Only one of the patients in the nasoseptal flap elevation group had permanent olfactory dysfunction. Conclusion The olfactory function recovered more gradually in the nasoseptal flap elevation group than in the conventional trans-sphenoidal approach group, but there was no difference between the two groups after 6 months.

Bilateral neck metastases in upper aero-digestive tract cancer: emphasis on the distribution of lymphatic metastases and prognostic implications.

BACKGROUND: Bilateral neck metastases (BNM) in patients with upper aero-digestive tract cancer (UADTC) indicate a poor prognosis. However, the prognostic significance of involved neck node levels has not been determined clearly. In this study, the distribution of neck nodal metastasis and its impact on prognosis were investigated. METHODS: Eighty-two previously untreated UADTC patients with BNM from 2000 to 2007 were included in these analyses. The pathology was mainly squamous cell carcinomas, including nasopharynx undifferentiated carcinoma and excluding salivary and thyroid carcinomas. The distribution and pattern of neck metastases and their prognostic significance were assessed, along with other clinical variables. RESULTS: BNM confined to the upper neck level (I-III) showed a lower rate of distant metastasis compared to BNM beyond I-III levels (13.6% vs. 47.4%, P = 0.001). There was a significant reduction in survival among patients with bilateral lower neck (IV-V) metastases on multivariate analysis (HR: 5.95, 95%CI: 1.51-23.43). However, multi-level involvement itself did not correlate with survival. Subgroup analysis (according to nasopharynx and non-nasopharynx cancer) also confirmed the strong trends of lower neck nodal involvement for poorer survival in both groups. CONCLUSION: BNM at lower neck nodes can be a significant prognostic factor for early systemic dissemination and worse prognosis in UADTC patients.

Endoscope-assisted intra-oral resection of the external thyroglossal duct cyst.

OBJECTIVE: Surgical removal of a thyroglossal duct cyst (TGDC) and its tract is usually accomplished through an external neck incision, including the removal of the middle part of hyoid bone and a block of tissues extending to the foramen cecum. However, this procedure inevitably results in neck scarring. We implemented a modified approach to TGDC removal in a 28-year-old woman through the floor of the mouth using an endoscope system. CASE REPORT: Here, we describe the detailed procedure of the endoscope-assisted intra-oral resection for TGDC. The total operative time was 130 minutes. The patient complained of swelling and pain in the floor of the mouth for 2 days, but did not require any intervention. Follow-up imaging studies confirmed no recurrence (18 months) without any sequelae, and the patient was satisfied with her surgical outcome. CONCLUSION: The intra-oral approach through the floor of the mouth is a technically feasible alternative surgical option that allows for complete removal of a TGDC without the neck scar.

Labeling of cervical lymph node levels during neck dissection: from ex vivo to in situ mapping.

OBJECTIVES: To analyze the error rate of ex vivo mapping and to evaluate in situ mapping of lymph node (LN) levels during neck dissection (ND) METHODS: We retrospectively reviewed the pathological data on metastatic LN levels in head and neck cancer patients that had ND and ex vivo mapping of LN levels. Among them, we included the data from 43 patients that had a high risk for metastatic nodes based on both the preoperative CT and PET/CT. We compared the metastatic node levels based on the radiological studies and surgical pathology. In addition, we prospectively evaluated the accuracy of in situ mapping (N = 20). RESULTS: With ex vivo mapping, the discrepancy between the radiological results and the pathological reports was 11.6% (5 out of 43); two side mismatches, two up down mismatches, and one faulty labeling, and in 7.0% (3 out of 43), the adjuvant treatment was redirected. However, in situ mapping of LN levels during ND resulted in no differences between the post-operative pathological and preoperative radiological findings. CONCLUSION: Ex vivo mapping of LN levels had an error rate of 11.6% in labeling of LN levels. In situ mapping of cervical LN levels during ND provided more accurate results about the status of LN metastasis.

Long-term Recovery Patterns of Olfactory Function after Trans-sphenoidal Approach with Nasoseptal Flap Elevation

Abstract Introduction Nasoseptal flap is widely used in reconstruction of the skull base to prevent cerebrospinal fluid leakage after surgery for skull base lesions. There has been a debate on whether more severe olfactory dysfunction occurs after nasoseptal flap elevation than the conventional trans-sphenoidal approach. Objective To compare the long-term recovery patterns associated with nasoseptal flap and the conventional trans-sphenoidal approach. Methods The subjects were divided into the conventional trans-sphenoidal approach group and the nasoseptal flap elevation group. We followed up self-reported olfactory score using the visual analogue scale and threshold discrimination identification (TDI) score of the Korean Version of the Sniffin Stick test II for 12 months, with olfactory training. Results The study included 31 patients who underwent the trans-sphenoidal approach. Compared with preoperative status, the mean visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group recovered 2 months postoperatively, while in the nasoseptal flap elevation group the visual analogue scale and TDI scores recovered 6 months and 3 months after surgery, respectively. Twelve months after surgery, the visual analogue scale and TDI scores in the conventional trans-sphenoidal approach group were 9.3 ± 0.5 and 28.5 ± 4.3, while those from the nasoseptal flap elevation group were 8.9 ± 1.5 and 27.2 ± 4.7 (p = 0.326; 0.473). Only one of the patients in the nasoseptal flap elevation group had permanent olfactory dysfunction. Conclusion The olfactory function recovered more gradually in the nasoseptal flap elevation group than in the conventional trans-sphenoidal approach group, but there was no difference between the two groups after 6 months.

Optimal cutoff values of allergen-specific immunoglobulin E to house dust mites and animal dander based on skin-prick test results: Analysis in 16,209 patients with allergic rhinitis.

BACKGROUND: The most common tests for allergen sensitization in patients with allergic rhinitis are the skin-prick test (SPT) and an in vitro test to detect serum specific immunoglobulin E (sIgE). However, in vitro allergen test results were interpreted dichotomically as positive or negative at a threshold of 0.35 kU/L of sIgE, regardless of the patient characteristics or antigen types. OBJECTIVE: The purpose of this study was to determine the cutoff value for sIgE in house-dust mites and animal dander, and to analyze differences in cutoff value according to age and gender. METHODS: A total of 16,209 patients with more than one allergic rhinitis symptom who underwent both SPT and serum sIgE testing were retrospectively evaluated between March 2008 and May 2012. There were 9374 male (57.8%) and 6835 female (42.2%) patients. The mean age was 31.8 years (range, 2-89 years). The criterion standard for allergen sensitization was defined as a wheal of >3 mm or an allergen-to-histamine ratio of ≥1 in SPT results. The Youden index was used to calculate the cutoff value of sIgE. RESULTS: Cutoff values of sIgE for Dermatophagoides pteronyssinus, Dermatophagoides farinae, cat, and dog were 0.69, 1.16, 0.13, and 0.45 kU/L, respectively. The cutoff value of sIgE changed according to age for D. pteronyssinus and D. farinae but not for cat and dog allergens. When categorizing according to age group, the cutoff values of sIgE for D. pteronyssinus and D. farinae had a tendency to decrease with age. There was no significant difference in cutoff value according to gender. CONCLUSION: The cutoff value for sIgE differed for each antigen and changed with age. Physicians should select the proper cutoff value for sIgE for appropriate criteria according to antigen and patient age rather than using a uniform cutoff value.

The first Korean case with Floating-Harbor syndrome with a novel SRCAP mutation diagnosed by targeted exome sequencing.

Floating-Harbor syndrome is a rare autosomal dominant genetic disorder associated with SRCAP mutation. To date, approximately 50 cases of Floating-Harbor syndrome have been reported, but none have been reported in Korea yet. Floating-Harbor syndrome is characterized by delayed bony maturation, unique facial features, and language impairment. Here, we present a 6-year-old boy with a triangular face, deep-set protruding eyes, low-set ears, wide nose with narrow nasal bridge, short philtrum, long thin lips, clinodactyly, and developmental delay that was transferred to our pediatric clinic for genetic evaluation. He showed progressive delay in the area of language and cognition-adaption as he grew. He had previously undergone chromosomal analysis at another hospital due to his language delay, but his karyotype was normal. We performed targeted exome sequencing, considering several syndromes with similar phenotypes. Library preparation was performed with the TruSight One sequencing panel, which enriches the sample for about 4,800 genes of clinical relevance. Massively parallel sequencing was conducted with NextSeq. An identified variant was confirmed by Sanger sequencing of the patient and his parents. Finally, the patient was confirmed as the first Korean case of Floating-Harbor syndrome with a novel SRCAP (Snf2 related CREBBP activator protein) mutation (c.7732dupT, p.Ser2578Phefs*6), resulting in early termination of the protein; it was not found in either of his healthy parents or a control population. To our knowledge, this is the first study to describe a boy with Floating-Harbor syndrome with a novel SRCAP mutation diagnosed by targeted exome sequencing in Korea.

Changes in the Reflux Symptom Index After Multilevel Surgery for Obstructive Sleep Apnea.

OBJECTIVES: This study evaluated whether the symptoms of laryngopharyngeal reflux (LPR) change after multilevel surgery for obstructive sleep apnea (OSA). METHODS: Patients who underwent multilevel surgery for OSA between April 2009 and September 2014 were enrolled in this study. All patients underwent preoperative polysomnography prior to surgery and were asked to complete the reflux symptom index (RSI) questionnaire before and after surgery. RESULTS: Of 73 enrolled patients, 24 (33%) reported an RSI score >13 and were thus classified as having reflux. The mean RSI score before surgery was 11.48±7.95; this number decreased to 4.95±6.19 after surgery (P<0.001). The rate of positive RSI responses was 33% before surgery and 9% after surgery. Each variable that comprised the RSI improved significantly after surgery, except for difficulty with swallowing. Regarding the degree of RSI improvement after surgery, there were no significant differences between subgroups according to sex, age, body mass index, OSA severity, or surgical outcome. CONCLUSION: LPR symptoms are prevalent in OSA patients. Treatment for OSA using multilevel surgery potentially reduces the symptoms of LPR.

Temporal differences in improvement of nasal obstruction between primary and revision septoplasty.

BACKGROUND: Septoplasty is one of most frequently performed surgeries in otorhinolaryngologic clinics to improve nasal obstruction by correcting nasal septal deformities. Many patients require revision surgery for persistent nasal obstruction. However, the outcomes and sources of revision septoplasty are unclear. OBJECTIVE: We investigated the discrepancy between patient's subjective and objective improvements after septoplasty by comparing primary and revision procedures. METHODS: Patients who underwent septoplasty from January 2012 to December 2014 were enrolled. All the subjects were questioned regarding subjective nasal symptoms before surgery and 1 month and every 3 months after surgery, with responses rated on a 7-point Likert scale. Nasal endoscopic evaluation and acoustic rhinometry were also performed with the same schedule. RESULTS: One hundred seventy-nine patients were analyzed. Subjective nasal obstruction scores of both the primary (n = 161) and revision (n = 18) groups were significantly improved at 1 month after surgery and showed no difference between the two groups. However, this improvement was sustained to the last follow-up only in the primary group. The symptom improvement rate of the primary group (85.5% [n = 109]) was significantly higher than that of the revision group (58.8% [n = 10]) at the last follow-up. There was no difference in the degree of improvement in objective findings between the two groups, including the difference and the ratio of the minimal cross-sectional area between the wider and narrower sides, and in endoscopic findings, even at the last follow-up. CONCLUSION: Compared with primary septoplasty, the long-term efficacy of revision septoplasty may not be clear, and there are discrepancies between the subjective and objective outcomes.

Upper Airway Variation and Frequent Alcohol Consumption Can Affect Compliance With Continuous Positive Airway Pressure.

OBJECTIVES: Compliance with continuous positive airway pressure (CPAP) treatment remains a primary concern for improving treatment outcomes of obstructive sleep apnea. There are few studies that have considered the role of upper airway anatomy on the compliance with CPAP. We hypothesized that upper airway anatomy would influence the compliance with CPAP. METHODS: One hundred out of 161 consecutive patients were enrolled in this study. The following possible determinants were tested against CPAP use: demographic and anthropometric data, minimal cross-sectional area on acoustic rhinometry, cephalometric and polysomnographic data, questionnaires of Epworth sleepiness scale and Beck depression index, and histories of previous upper airway surgery, degree of nasal obstruction, daily cigarette consumption, and weekly frequency of alcohol intake. RESULTS: Univariate analysis showed that histories of previous upper airway surgery and less frequent alcohol consumption, and longer mandibular plane-hyoid length (MP-H) on cephalometry were associated with longer average daily CPAP use. After adjustment for the confounding factors with multiple linear regression analysis, alcohol consumption and MP-H were still associated with the compliance with CPAP significantly. CONCLUSION: To improve compliance with CPAP, careful evaluations of upper airway problems and life style are important before initiating CPAP.

Nasal obstruction and palate-tongue position on sleep-disordered breathing.

OBJECTIVES: We wanted to evaluate whether the presence of nasal obstruction makes a change on the association between the modified Mallampati score and the severity of sleep-disordered breathing (SDB) and the sleep quality. METHODS: Polysomnography (PSG), the modified Mallampati score (MMS), the body-mass index, and a questionnaire about nasal obstruction were acquired from 275 suspected SDB patients. The subjects were divided into two groups according to the presence of nasal obstruction. The clinical differences between the two groups were evaluated and the associations between the MMS and PSG variables in each group were also assessed. RESULTS: Significant correlations were found between the MMS and many PSG variables, including the apnea-hypopnea index, the arousal index and the proportion of deep sleep, for the patients with nasal obstruction, although this was not valid for the total patients or the patients without nasal obstruction. CONCLUSION: The severity of SDB and the quality of sleep are well correlated with the MMS, and especially for the patients with nasal obstruction. The MMS can give more valuable information about the severity of SDB when combined with simple questions about nasal obstruction.

Preservation of the external jugular venous drainage system in neck dissection.

OBJECTIVE: To investigate whether preserving the external jugular vein (EJV) in neck dissection reduces postoperative edema of the face and neck. STUDY DESIGN: A prospective, randomized controlled trial. SETTING: A tertiary hospital. SUBJECTS AND METHODS: Thirty-eight subjects were randomly assigned to two groups: EJV preservation versus sacrifice during neck dissection after stratification according to the neck dissection extent and type, the previous treatment, the primary site, and the reconstruction type. The relative soft-tissue thickness was evaluated by follow-up computed tomography (CT) scans at one week and four to five weeks postoperatively and compared with preoperative findings. The preserved EJV patency was also determined by contrast enhancement of EJV on follow-up CT scans. In addition, the scores for pain/discomfort on the upper neck/face and laryngeal edema were recorded at each time point. RESULTS: Relative soft-tissue thickness reached up to 160 percent of preoperative status at the hyoid and cricoid levels at one week postoperatively but resolved at four to five weeks. EJV preservation reduced the soft-tissue thickness significantly compared with EJV sacrifice (P < 0.05) at one week postoperatively, particularly at the mandible and hyoid level. All preserved EJVs remained patent at one week, and 18 of 19 remained patent at four to five weeks. In addition, EJV preservation diminished the discomfort/pain of the upper neck/face compared with EJV sacrifice at one week (P = 0.036). The extent of laryngeal edema did not differ between the two groups. CONCLUSION: EJV preservation may reduce immediate postoperative neck edema and pain/discomfort related to neck dissection.