Obstructive Sleep Apnea Is Associated With Late-Onset Preeclampsia in Overweight Pregnant Women in Korea.

BACKGROUND: Obstructive sleep apnea (OSA) is closely related to maternal obesity in pregnant women, and the association increases with later pregnancy. Obesity and OSA are risk factors of pregnancy-related complications, including gestational hypertension, gestational diabetes mellitus (GDM), and fetal morbidities. We aimed to determine the prevalence of OSA and to assess the impact of OSA on pregnancy-related disorders in overweight pregnant women. METHODS: Eligible participants who were overweight [body mass index (BMI) ≥ 23 kg/m²] in gestational age 30 weeks or more, assessed OSA using a portable polysomnography at home. Clinical data were collected from pregnant women and their babies. RESULTS: The average age of 51 participants was 34.5 years (27-44 years). The number of primipara was 25 (49%) and that of multipara was 26 (51%). Eight cases of GDM (15.7%) and five cases of preeclampsia (9.8%) were reported, and six patients (11.8%) experienced preterm delivery. In results of polysomnography, 14 patients (27.5%) were diagnosed as OSA. Apnea-hypopnea index moderately correlated with BMI (r = 0.515, P < 0.001). The BMI (P < 0.005) and preeclampsia rate (P < 0.017) were higher in the OSA group compared to the control group. Odds ratios (ORs) adjusting age, BMI, parity, and abortion history were calculated. The presence of OSA increased OR of preeclampsia (OR, 13.1; 95% confidence interval, 1.1-171.3). The majority of preeclampsia patients (4/5, 80%) underwent preterm delivery. CONCLUSION: OSA is an important risk factor for preeclampsia, resulting in preterm delivery. For overweight pregnant women, an OSA evaluation should be mandatory.

The Mechanism of Action and Clinical Efficacy of Low-Dose Long-Term Macrolide Therapy in Chronic Rhinosinusitis.

Various chronic inflammatory airway diseases can be treated with low-dose, long-term (LDLT) macrolide therapy. LDLT macrolides can be one of the therapeutic options for chronic rhinosinusitis (CRS) due to their immunomodulatory and anti-inflammatory actions. Currently, various immunomodulatory mechanisms of the LDLT macrolide treatment have been reported, as well as their antimicrobial properties. Several mechanisms have already been identified in CRS, including reduced cytokines such as interleukin (IL)-8, IL-6, IL-1ß, tumor necrosis factor-α, transforming growth factor-ß, inhibition of neutrophil recruitment, decreased mucus secretion, and increased mucociliary transport. Although some evidence of effectiveness for CRS has been published, the efficacy of this therapy has been inconsistent across clinical studies. LDLT macrolides are generally believed to act on the non-type 2 inflammatory endotype of CRS. However, the effectiveness of LDLT macrolide treatment in CRS is still controversial. Here, we reviewed the immunological mechanisms related to CRS in LDLT macrolide therapy and the treatment effects according to the clinical situation of CRS.

Learning curve and technical nuances of endoscopic skull base reconstruction with nasoseptal flap to control high-flow cerebrospinal fluid leakage: reconstruction after endoscopic skull base surgery other than pituitary surgery.

PURPOSE: Although reconstruction techniques after endoscopic skull base surgery have been improved, there are difficulties in reconstructing the skull base with a nasoseptal flap (NSF), especially in the case of high-flow cerebrospinal fluid (CSF) leak. The aim of this study was to analyze risk factors for the development of postoperative CSF leaks in terms of less experienced surgeon practices. METHODS: Retrospective review of medical records was performed for 125 patients who underwent endoscopic skull base surgery for intradural pathology with intraoperative high-flow CSF leakage between Oct 2012 and Apr 2017. Basic demographic data were collected, including body mass index (BMI), tumor pathology, comorbidities, and outcomes. To assess the learning curve effect, patients were divided into early cohort (n = 30) and late cohort (n = 95) groups. RESULTS: Overall postoperative CSF leakage was 10.4% (13/125) in this series. There were no significant risk factors for postoperative CSF leakage among the demographic data including BMI, comorbidities, or radiation history. Postoperative CSF leakage was most prevalent in the transclival approach than in other approaches, but the difference was not statistically significant (20.8%, p = 0.351). When dividing the results by timetable, the patients who underwent skull base reconstruction in the early cohort experienced more postoperative CSF leakage (23.3%, 7 cases out of 30) than in the late cohort (6.3%, 6 cases out of 95, p = 0.014). The learning curve was steeper in the early cohort (30 early cases 23.3%, 31-60 10%, 61-90 6.7%, 91-125 2.9%). CONCLUSIONS: To improve the success rate of endoscopic skull base reconstruction, surgeons have to keep the basic technical details in mind to reduce the learning curve.

The Effect of a Horse-Riding Simulator with Virtual Reality on Gross Motor Function and Body Composition of Children with Cerebral Palsy: Preliminary Study.

This study aimed to evaluate the effect of a horse-riding simulator (HRS) with virtual reality (VR) on gross motor function, balance control, and body composition in children with spastic cerebral palsy (CP). Seventeen preschool and school-aged children with spastic CP were included; 10 children in the intervention group (HRS group) received 30 min of HRS with VR training twice a week for a total of 16 sessions in addition to conventional physiotherapy. Seven children in the control group were instructed to perform home-based aerobic exercises twice a week for 8 weeks in addition to conventional physiotherapy. Gross motor function measure (GMFM) and body composition were evaluated before the first session and after the last session. Before and after the 2-month intervention, Pediatric Balance Scale and Timed Up and Go test were evaluated for the HRS group. GMFM scores and body composition changed significantly in the HRS group (p < 0.05). However, no significant differences were observed in the control group. Changes in the GMFM total scores, GMFM dimension D scores, and skeletal muscle mass significantly differed between the HRS and control groups (p < 0.05). HRS with VR may be an effective adjunctive therapeutic approach for the rehabilitation of children with CP.

Virtual Reality-Incorporated Horse Riding Simulator to Improve Motor Function and Balance in Children with Cerebral Palsy: A Pilot Study.

The horse riding simulator (HRS) reportedly has a beneficial effect on motor function and balance in children with cerebral palsy (CP). However, by itself, the HRS is not a sufficient source of challenge and motivation for children. To address this issue, we combined the HRS with virtual reality (VR) to promote somatosensory stimulation and motivation. Sixteen children (ages: 5-17 years) with CP and presenting Gross Motor Function Classification System (GMFCS) levels I-IV were enrolled in the study. Using a head-mounted display and controllers, interventions were carried out over 30-min periods (two rides lasting 12 min each, along with a six-min rest period) twice a week over a period of eight weeks (16 sessions in aggregate). The Pediatric Balance Scale (PBS), Gross Motor Function measure (GMFM)-88, and GMFM-66 scores of each participant were measured before and after the interventions. Statistically significant improvements were observed in the PBS, GMFM-66, the total GMFM-88 scores, and those corresponding to dimensions D and E of GMFM-88 after the intervention (p < 0.05). This study demonstrates that VR-incorporated HRS is effective in improving motor function and balance in children with CP and that its incorporation in conventional PT programs could yield beneficial results.

Clinically Node-Negative Parotid Gland Cancers: Prognostic Factors of Survival and Surgical Extent.

OBJECTIVE: Conservative parotidectomy is known to reduce morbidity, but has been rarely examined in patients with clinically node-negative (cN0) parotid cancers. We evaluated the clinicopathological variables influencing the outcomes of these patients and the efficacy of conservative parotidectomy. METHODS: We reviewed the clinical and pathological data of 256 patients with cN0 parotid carcinomas who underwent curative surgery at our institution. Of these, 110 and 146 underwent conservative and total parotidectomy, respectively, with 83 undergoing elective neck dissection and 135 receiving postoperative radiotherapy. Univariate and multivariate analyses of variables predicting recurrence-free survival (RFS) and overall survival (OS) were performed. Morbidity, survival, and recurrence rates were compared between the conservative and total parotidectomy groups. RESULTS: The 5-year RFS and OS rates in all patients were 85.7 and 91.4%, respectively. Multivariate analysis showed that advanced T classification, positive resection margin, and high-histologic grade were independent prognostic factors for both RFS and OS. Among the 201 patients with low- or intermediate-grade parotid cancers, those who underwent total parotidectomy had a greater chance of facial nerve paralysis than those who underwent conservative parotidectomy (p < 0.001). The 5-year RFS and OS after conservative parotidectomy (93.7 and 100%, respectively) were not worse than those after total parotidectomy (85.5 and 90.9%, respectively). CONCLUSION: Patients with cN0 parotid cancers may be stratified by histological grade and T classification. Conservative parotidectomy may be suitable for early T1-2 low- or intermediate-grade tumors if a resection margin is secured.

Survival Outcome of Intermediate-Grade Salivary Gland Carcinoma.

OBJECTIVE: Histological grade is the most important factor for defining treatment strategies and predicting prognosis for salivary gland carcinoma (SGC). We examined factors affecting long-term recurrence and survival among intermediate-grade SGC (IGSGC) patients to define optimal treatment modalities and outcomes. METHODS: We reviewed the clinical and pathological data on 108 IGSGC patients who underwent definitive surgery with or without postoperative radiotherapy. We compared treatment outcomes by treatment strategies such as surgical extent for the primary tumor, neck dissection, or postoperative radiotherapy. RESULTS: During a 103-month median follow-up, local, regional, and distant recurrences were detected in 14 (13.0%), 3 (2.8%), and 21 (19.4%) patients, respectively. The 10-year locoregional control (LRC), distant metastasis-free survival (DMFS), and overall survival (OS) rates were 83.1, 76.0, and 80.1%, respectively. Multivariate analyses identified a nonparotid primary site as an independent prognostic factor for LRC (p = 0.018). Adenoid cystic carcinoma and a positive pN classification were significantly unfavorable prognostic factors for DMFS (p = 0.025 and p = 0.030, respectively); overall advanced stage was an independent prognostic factor for OS (p = 0.020). Surgical extent, elective neck dissection, and postoperative adjuvant radiotherapy did not significantly affect treatment outcomes. CONCLUSION: Patients with early-stage IGSGC of parotid origin can achieve favorable treatment outcomes with conservative surgery alone.

Management of chronic rhinosinusitis with nasal polyps in the Asia-Pacific region and Russia: Recommendations from an expert working group.

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a chronic inflammatory condition of the nasal and paranasal tissues, characterized by the presence of bilateral nasal polyps. An expert panel of specialists from the Asian-Pacific region and Russia was convened to develop regional guidance on the management of CRSwNP through a consensus approach. The present article presents the chief observations and recommendations from this panel to provide guidance for clinicians in these areas. Etiology and pathogenetic mechanisms in CRSwNP are heterogeneous and complex. In many patients, CRSwNP is primarily driven by type 2 inflammation, although this may be less important in Asian populations. Frequent comorbidities include asthma and other inflammatory diseases such as non-steroidal anti-inflammatory drug (NSAID)/aspirin-exacerbated respiratory disease or atopic dermatitis. Clinical management of CRSwNP is challenging, and a multidisciplinary approach to evaluation and treatment is recommended. While many patients respond to medical treatment (topical irrigation and intranasal corticosteroids, and adjunctive short-term use of systemic corticosteroids), those with more severe/uncontrolled disease usually require endoscopic sinus surgery (ESS), although outcomes can be unsatisfactory, requiring revision surgery. Biological therapies targeting underlying type 2 inflammation offer additional, effective treatment options in uncontrolled disease, either as an alternative to ESS or for those patients with persistent symptoms despite ESS.

Differences in Nasal Shapes and the Degree of Changes Over a Decade or More: A Paired Analysis.

OBJECTIVES: This study investigated age-related differences in nasal morphometry and the degree of changes within an individual over at least a 10-year period by pairing previous and recent three-dimensional reconstructed computed tomography (CT) images. METHODS: Forty-eight adult Korean patients who underwent at least two CT scans of the nasal region with an interval of at least 10 years were selected. Patients were categorized into six subgroups according to sex and age (20-39 years, 40-49 years, and ≥50 years) at the time of initial imaging. Eight nasal parameters were measured on the initial and recent images, and paired comparisons between the two images were performed based on the data. The differences in the degree of change by age were also analyzed. RESULTS: Over an average image interval of 12 years, men exhibited an increase in the nasofrontal angle (3.2°±5.4°, P=0.041), profile nasal length (1.7±1.7 mm, P=0.002), and nasal bridge height (1.2±1.6 mm, P=0.002). Conversely, they showed a decrease in the nasofacial angle (-2.3°±2.9°, P=0.010). Women also demonstrated an increase in the nasofrontal angle (2.5°±5.2°, P=0.010), profile nasal length (1.4±1.9 mm, P<0.001), and nasal bridge height (1.3±1.6 mm, P<0.001). However, they exhibited a decrease in the nasofacial angle (-2.0°±2.1°, P<0.001), glabella angle (-9.1°±9.8°, P<0.001), and pyriform angle (-8.5°±10.1°, P<0.001). With the exception of the nasal bridge height (P=0.036) and pyriform angle (P=0.022), the degree of changes in most parameters did not show significant differences across age groups. CONCLUSION: Our findings indicate that the aging nose exhibits a greater nasal length with inferior angulation of the nasal tip, with an increase in the nasofrontal angle, profile nasal length, and nasal bridge height, along with a decrease in the nasofacial angle. The degree of most nasal morphologic changes demonstrated no significant differences by specific age group.

Enhanced artificial intelligence-based diagnosis using CBCT with internal denoising: Clinical validation for discrimination of fungal ball, sinusitis, and normal cases in the maxillary sinus.

BACKGROUND AND OBJECTIVE: The cone-beam computed tomography (CBCT) provides three-dimensional volumetric imaging of a target with low radiation dose and cost compared with conventional computed tomography, and it is widely used in the detection of paranasal sinus disease. However, it lacks the sensitivity to detect soft tissue lesions owing to reconstruction constraints. Consequently, only physicians with expertise in CBCT reading can distinguish between inherent artifacts or noise and diseases, restricting the use of this imaging modality. The development of artificial intelligence (AI)-based computer-aided diagnosis methods for CBCT to overcome the shortage of experienced physicians has attracted substantial attention. However, advanced AI-based diagnosis addressing intrinsic noise in CBCT has not been devised, discouraging the practical use of AI solutions for CBCT. We introduce the development of AI-based computer-aided diagnosis for CBCT considering the intrinsic imaging noise and evaluate its efficacy and implications. METHODS: We propose an AI-based computer-aided diagnosis method using CBCT with a denoising module. This module is implemented before diagnosis to reconstruct the internal ground-truth full-dose scan corresponding to an input CBCT image and thereby improve the diagnostic performance. The proposed method is model agnostic and compatible with various existing and future AI-based denoising or diagnosis models. RESULTS: The external validation results for the unified diagnosis of sinus fungal ball, chronic rhinosinusitis, and normal cases show that the proposed method improves the micro-, macro-average area under the curve, and accuracy by 7.4, 5.6, and 9.6% (from 86.2, 87.0, and 73.4 to 93.6, 92.6, and 83.0%), respectively, compared with a baseline while improving human diagnosis accuracy by 11% (from 71.7 to 83.0%), demonstrating technical differentiation and clinical effectiveness. In addition, the physician's ability to evaluate the AI-derived diagnosis results may be enhanced compared with existing solutions. CONCLUSION: This pioneering study on AI-based diagnosis using CBCT indicates that denoising can improve diagnostic performance and reader interpretability in images from the sinonasal area, thereby providing a new approach and direction to radiographic image reconstruction regarding the development of AI-based diagnostic solutions. Furthermore, we believe that the performance enhancement will expedite the adoption of automated diagnostic solutions using CBCT, especially in locations with a shortage of skilled clinicians and limited access to high-dose scanning.

One-Unit Osteotomy to Correct Deviated Bony Dorsum.

OBJECTIVES: A crooked nose is frequently caused by nasal bony vault deviation, and proper management of the bony vault is an integral part of rhinoplasty. Conventional osteotomy to correct a deviated nose favors simultaneous medial and lateral osteotomies, which allows the free independent movement of each nasal bone. However, patient satisfaction with deviated nose surgery is sometimes low. In the present study, we introduce a one-unit osteotomy procedure that combines bilateral and root osteotomies with unilateral triangular bony wedge resection to allow symmetry of both nasal bones. METHODS: Twenty consecutive patients who presented with bony vault deviation and underwent one-unit osteotomy were enrolled in this retrospective single-center study. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire was used to evaluate each patient's functional outcome. The angle of bony vault deviation before and after one-unit osteotomy was measured using a protractor and compared with the. RESULTS: of 14 patients who had undergone conventional osteotomy. The improvement in dorsal deviation was evaluated using facial photography preoperatively and 3 months postoperatively. RESULTS: NOSE values improved from 8.4±6.4 to 4.1±4.2 (P =0.021). The angle of bony vault deviation improved from 6.9°±2.2° to 2.1°±1.2° (P <0.001) in one-unit osteotomy and from 7.3°±4.0° to 2.7°±1.2° (P =0.001) in conventional osteotomy. The preoperative deviation angle improved by 70.3% in one-unit osteotomy compared with 56.6% in conventional osteotomy, which was a significant difference (P =0.033). The mean grade of the postoperative esthetic outcomes for the remaining deviation was 1.6±0.5, which was similar to that in the conventional osteotomy group. CONCLUSION: One-unit osteotomy is a relatively simple procedure that balances the width of both lateral walls by removing excessive bony fragments from the wider bony wall and providing better structural integrity. This technique improves functional outcomes and has equivalent esthetic. RESULTS: to those of the traditional procedure.

Predictors for short-term and long-term automatic PAP compliance.

STUDY OBJECTIVES: Positive airway pressure (PAP) is considered a standard treatment for obstructive sleep apnea (OSA), but there are compliance issues. As compliance to PAP tends to decrease with time, it is necessary to consider reasons affecting compliance at each period. Therefore, this study aimed to define factors affecting short-term and long-term compliance to PAP therapy. METHODS: One hundred eighty-seven patients with OSA who started PAP treatment between July 2018 to March 2020 were included. Acceptance and compliance rates were monitored. Demographics, polysomnography (PSG) profiles, cephalometric data, and physical examination results were analyzed to identify factors predictive of PAP compliance at short-term (3 months) and long-term (12 months) periods. RESULTS: The acceptance rate of PAP was 92.5%. Compliance at 3 months and 12 months was 79.1% and 51.3%, respectively. Higher apnea-hypopnea index (odds ratio [OR] 1.018, P = .049) and older age (OR 1.032, P = .039) were predictive factors of good automatic PAP (APAP) compliance at 3 months. However, long-term compliance was affected by the percentage of duration with O2 desaturation of < 90% (CT90; OR 1.032, P = .011) and baseline self-reported symptom scores such as nasal obstruction (OR 0.819, P = .038) and awakening (OR 0.796, P = .045). CONCLUSIONS: In PAP use, indicators of OSA severity such as apnea-hypopnea index affect short-term compliance. On the other hand, the mandibular plane to hyoid distance and self-reported symptoms such as nasal obstruction and awakening can affect long-term compliance. CITATION: Park SI, Kim BK, Lee KE, Hong SD, Jung YG, Kim HY. Predictors for short-term and long-term automatic PAP compliance. J Clin Sleep Med. 2023;19(1):17-26.

Clinical Practice Guideline: Clinical Efficacy of Nasal Surgery in the Treatment of Obstructive Sleep Apnea.

Obstructive sleep apnea (OSA) is a common disorder characterized by upper airway obstruction during sleep. To reduce the morbidity of OSA, sleep specialists have explored various methods of managing the condition, including manifold positive airway pressure (PAP) techniques and surgical procedures. Nasal obstruction can cause significant discomfort during sleep, and it is likely that improving nasal obstruction would enhance the quality of life and PAP compliance of OSA patients. Many reliable studies have offered evidence to support this assumption. However, few comprehensive guidelines for managing OSA through nasal surgery encompass all this evidence. In order to address this gap, the Korean Society of Otorhinolaryngology-Head and Neck Surgery (KORL-HNS) and the Korean Society of Sleep and Breathing designated a guideline development group (GDG) to develop recommendations for nasal surgery in OSA patients. Several databases, including OVID Medline, Embase, the Cochrane Library, and KoreaMed, were searched to identify all relevant papers using a predefined search strategy. The types of nasal surgery included septoplasty, turbinate surgery, nasal valve surgery, septorhinoplasty, and endoscopic sinus surgery. When insufficient evidence was found, the GDG sought expert opinions and attempted to fill the evidence gap. Evidence-based recommendations for practice were ranked according to the American College of Physicians' grading system. The GDG developed 10 key action statements with supporting text to support them. Three statements are ranked as strong recommendations, three are only recommendations, and four can be considered options. The GDG hopes that this clinical practice guideline will help physicians make optimal decisions when caring for OSA patients. Conversely, the statements in this guideline are not intended to limit or restrict physicians' care based on their experience and assessment of individual patients.

Obstructive Sleep Apnea and Its Influence on Intracranial Aneurysm.

Obstructive sleep apnea syndrome (OSAS) is associated with cerebrovascular disease, which can lead to life-threatening outcomes. The purpose of the study was to investigate the relationship between OSAS and comorbid intracranial aneurysms. We retrospectively reviewed 564 patients who underwent a polysomnography and brain magnetic resonance angiography as part of their health checkup. We calculated the prevalence of an intracranial aneurysm and OSAS in patients and measured the size of the intracranial aneurysm if present. The mean patient age was 55.6 ± 8.5 years, and 82.3% of them were men. The prevalence of an intracranial aneurysm in patients with OSAS was 12.1%, which is significantly higher than patients with non-OSAS (5.9%, p = 0.031). Patients with OSAS had a much higher prevalence of intracranial aneurysms, after adjusting all possible confounding factors such as age, sex, smoking status, alcohol drinking, and body mass index (odds ratio: 2.32; 95% confidence interval: 1.07-5.04). Additionally, the OSAS group had noticeably larger aneurysms compared with those of the non-OSAS group (3.2 ± 2.0 mm vs. 2.0 ± 0.4 mm, p = 0.013). We found a significant association between OSAS and intracranial aneurysms. OSAS could be another risk factor for the development of intracranial aneurysms.

Improvements in airflow characteristics and effect on the NOSE score after septoturbinoplasty: A computational fluid dynamics analysis.

Septoturbinoplasty is a surgical procedure that can improve nasal congestion symptoms in patients with nasal septal deviation and inferior turbinate hypertrophy. However, it is unclear which physical domains of nasal airflow after septoturbinoplasty are related to symptomatic improvement. This work employs computational fluid dynamics modeling to identify the physical variables and domains associated with symptomatic improvement. Sixteen numerical models were generated using eight patients' pre- and postoperative computed tomography scans. Changes in unilateral nasal resistance, surface heat flux, relative humidity, and air temperature and their correlations with improvement in the Nasal Obstruction Symptom Evaluation (NOSE) score were analyzed. The NOSE score significantly improved after septoturbinoplasty, from 14.4 ± 3.6 to 4.0 ± 4.2 (p < 0.001). The surgery not only increased the airflow partition on the more obstructed side (MOS) from 31.6 ± 9.6 to 41.9 ± 4.7% (p = 0.043), but also reduced the unilateral nasal resistance in the MOS from 0.200 ± 0.095 to 0.066 ± 0.055 Pa/(mL·s) (p = 0.004). Improvement in the NOSE score correlated significantly with the reduction in unilateral nasal resistance in the preoperative MOS (r = 0.81). Also, improvement in the NOSE score correlated better with the increase in surface heat flux in the preoperative MOS region from the nasal valve to the choanae (r = 0.87) than in the vestibule area (r = 0.63). Therefore, unilateral nasal resistance and mucous cooling in the preoperative MOS can explain the perceived improvement in symptoms after septoturbinoplasty. Moreover, the physical domain between the nasal valve and the choanae might be more relevant to patient-reported patency than the vestibule area.

Volume of parapharyngeal fat pad in obstructive sleep apnea syndrome: prognostic role for multilevel sleep surgery.

STUDY OBJECTIVES: To evaluate the prognostic role of volume of parapharyngeal fat pad (VPPFP) after multilevel sleep surgery in patients with obstructive sleep apnea syndrome. METHODS: This retrospective cohort study was conducted in 50 patients with moderate to severe obstructive sleep apnea syndrome who underwent polysomnography (preoperative and postoperative 6 months) and preoperative facial computed tomography with multilevel sleep surgery between May 2010 and February 2019. All patients had failed or refused positive airway pressure treatment. RESULTS: Of the 50 patients with moderate to severe obstructive sleep apnea syndrome who underwent multilevel sleep surgery, 46 were male (92.0%) with mean ± standard deviation age of 41.2 ± 12.5 years. On the preoperative polysomnography, mean ± standard deviation of apnea-hypopnea index and CT90 (cumulative percentage of time spent at oxygen saturation less than 90%) were 43.4 ± 19.3 events/h and 5.6 ± 9.6%, respectively. The average VPPFP measured by facial computed tomography scan was 4.9 ± 1.9 cm3. Multiple linear regression analysis showed that VPPFP was significantly correlated (R2 = 0.38) with age (ß = 0.05; 95% confidence interval [CI], 0.01-0.09) and body mass index (ß = 0.31; 95% CI, 0.16-0.45). Surgical success rate was 38%, and VPPFP higher than 5.1 cm3 was significantly associated with surgical failure after covariate adjustment (P = .01; odds ratio = 0.09; 95% CI, 0.02-0.48). Postoperative apnea-hypopnea index was positively correlated (R2 = 0.40) with CT90 (ß = 1.33; 95% CI, 0.74-1.92) and VPPFP (ß = 3.52; 95% CI, 0.30-6.74). CONCLUSIONS: VPPFP correlated with age and body mass index, and high VPPFP and CT90 were associated with high postoperative apnea-hypopnea index. VPPFP larger than 5.1 cm3 was a possible risk factor for surgical failure, which may inform a decision on multilevel sleep surgery as salvage therapy for positive airway pressure treatment. CITATION: Kim BK, Park SI, Hong SD, Jung YG, Kim HY. Volume of parapharyngeal fat pad in obstructive sleep apnea syndrome: prognostic role for multilevel sleep surgery. J Clin Sleep Med. 2022;18(12):2819-2828.

Internal Nasal Valve Modification via Correction of High Dorsal Deviation Using a Modified Mattress Suture Technique.

High dorsal deviation of the septum can cause nasal obstruction due to internal nasal valve (INV) stenosis. We have developed a new technique using a modified mattress suture on the bony-cartilaginous junction to correct high dorsal septal deviation. This study focused on the effect of this suturing technique on the modification of the INV. We enrolled 40 patients who underwent septoplasty using a modified mattress suture technique. We retrospectively analyzed the data of the preoperative and postoperative INV angles and cross-sectional areas (CSAs), which were measured using computed tomography. In addition, we compared the patients' subjective nasal symptoms, which were measured with the preoperative and postoperative Nasal Obstruction Symptom Evaluation (NOSE) instrument. Postoperative increases in the narrow side INV angle and CSA were achieved. Additionally, the wide side INV angle and CSA were significantly decreased postoperatively. The INV and CSA ratio (wide/narrow) were also decreased postoperatively and were brought closer to 1. The subjective nasal symptoms also exhibited significantly reduced NOSE values. In this study, we confirmed the effects of septoplasty using a modified mattress suture technique for INV modification through the comparison of the preoperative and postoperative INV angles and CSAs.

Influence of Lingual Tonsillar Volume in Patients with Obstructive Sleep Apnea.

This study aimed to evaluate the influence of lingual tonsil (LT) volume measured using a three-dimensional (3D) reconstruction volume rendering program on clinical parameters and polysomnography (PSG) results. A total of 100 patients who underwent PSG, computed tomography (CT), and allergy test from April 2016 to April 2020 were randomly selected. LT volume was measured using an imaging software program that enables 3D reconstruction of CT images. PSG parameters were analyzed by dividing the subjects into two groups according to LT volume (each 50 people). Based on the medial volume of 0.863 cm3, the upper half LT volume group and the lower half LT volume group were analyzed. Clinical factors such as body weight, neck circumference, body mass index (BMI), and age showed no difference between the two groups. Among PSG parameters, supine arousal index and non-rapid eye movement (NREM) arousal index were significantly higher in the upper half LT volume group (p = 0.012, 0.037). However, there was no significant difference in apnea-hypopnea index (AHI) between the upper and lower half LT volume groups (p = 0.749). Arousal snoring index and REM arousal index also showed no difference between the two groups. The prevalence of allergic rhinitis was not different in the two groups. High LT volume is associated with NREM arousal and arousal in the supine position, but it is not related to AHI.

Endoscopic Debridement of Post-Radiation Nasopharyngeal Necrosis: The Effects of Resurfacing With a Vascularized Flap.

OBJECTIVES: Post-radiation nasopharyngeal necrosis (PRNN) is a serious complication that severely impacts the quality of life and survival of nasopharyngeal carcinoma patients. Endoscopic debridement is considered the first-line treatment for PRNN. This study aimed to analyze clinical outcomes, focusing on the mucosal resurfacing status and the effectiveness of salvage operations. METHODS: Twenty-seven patients who underwent endoscopic debridement were retrospectively analyzed. The patients were divided into two groups according to the initial surgical modality: debridement with a nasoseptal flap (NSF; n=21) and debridement only (no NSF; n=6). Clinical features, postoperative mucosal status, internal carotid artery (ICA) rupture, survival, and final mucosal status were evaluated. The NSF group was categorized according to flap viability to analyze risk factors for flap failure. RESULTS: Regardless of the initial modality, most patients experienced symptom improvement (96.0% for headache and 100% for foul odor); however, complete cranial nerve palsy did not improve in any patients. In the NSF group, complete healing was observed in 66.7%, while all patients in the no-NSF group underwent salvage surgery because none maintained complete healing. In the NSF group, 19.0% of patients required salvage surgery. After the last operation, favorable symptom improvement was noted (100% for headache and 90.0% for foul odor), and 77.8% had completely healed mucosa, whereas only 14.8% and 7.4% had partial healing and persistent necrotic mucosal status. The necrotic or uncovered NSF subgroup showed statistically non-significant tendencies for old age, advanced necrosis stage, advanced T stage, ICA involvement, high frequency and dose of radiation therapy, diabetes mellitus, and underlying comorbidities. Two ICA ruptures and three deaths occurred. CONCLUSION: Resurfacing the nasopharynx with NSF after endoscopic debridement showed better outcomes than debridement only for PRNN treatment. Despite initial NSF failure, additional resurfacing reconstructive surgery offers advantages in symptom mitigation, quality of life, and survival.

Detection of maxillary sinus fungal ball via 3-D CNN-based artificial intelligence: Fully automated system and clinical validation.

BACKGROUND: This study aims to develop artificial intelligence (AI) system to automatically classify patients with maxillary sinus fungal ball (MFB), chronic rhinosinusitis (CRS), and healthy controls (HCs). METHODS: We collected 512 coronal image sets from ostiomeatal unit computed tomography (OMU CT) performed on subjects who visited a single tertiary hospital. These data included 254 MFB, 128 CRS, and 130 HC subjects and were used for training the proposed AI system. The AI system takes these 1024 sets of half CT images as input and classifies these as MFB, CRS, or HC. To optimize the classification performance, we adopted a 3-D convolutional neural network of ResNet 18. We also collected 64 coronal OMU CT image sets for external validation, including 26 MFB, 18 CRS, and 20 HCs from subjects from another referral hospital. Finally, the performance of the developed AI system was compared with that of the otolaryngology resident physicians. RESULTS: Classification performance was evaluated using internal 5-fold cross-validation (818 training and 206 internal validation data) and external validation (128 data). The area under the receiver operating characteristic over the internal 5-fold cross-validation and the external validation was 0.96 ±0.006 and 0.97 ±0.006, respectively. The accuracy of the internal 5-fold cross-validation and the external validation was 87.5 ±2.3% and 88.4 ±3.1%, respectively. As a result of performing a classification test on external validation data from six otolaryngology resident physicians, the accuracy was obtained as 84.6 ±11.3%. CONCLUSIONS: This AI system is the first study to classify MFB, CRS, and HC using deep neural networks to the best of our knowledge. The proposed system is fully automatic but performs similarly to or better than otolaryngology resident physicians. Therefore, we believe that in regions where otolaryngology specialists are scarce, the proposed AI will perform sufficiently effective diagnosis on behalf of doctors.