Neck Swelling With Valsalva.

We present a rare case of bilateral pharyngocoeles in a patient with symptomatic neck swelling prominently seen with the Valsalva manoeuvre. Pharyngocoeles have only been reported a handful of times in the literature. Due to their rarity, they can easily be misdiagnosed as a laryngocoele, Zenker's diverticulum, or jugular venous phlebectasia. The diagnosis in this case was confirmed on computed tomography imaging of the neck with Valsalva performed. Our patient underwent surgical excision of the symptomatic pharyngocoele on the right side while conservative management was opted for the asymptomatic left pharyngocoele. His risk factors for developing bilateral pharyngocoeles are most likely due to the use of continuous positive airway pressure (CPAP) machine at high pressures coupled with pharyngeal wall weakness. To our knowledge, this is the first case of pharyngocoeles associated with CPAP machine use. It is important to perform a thorough assessment to appropriately diagnose and treat patients with this anatomical anomaly.

Long-term control of laryngeal plasma cell mucositis with systemic immunosuppression.

Plasma cell mucositis (PCM) is a rare non-neoplastic plasma cell proliferative disorder of the mucous membranes, which typically presents as soft tissue lesions involving oral, upper airway or genital mucosa. Laryngeal involvement resulting in stridor has been reported in four other cases previously, with three requiring tracheostomy. We present a case of supraglottic stenosis in a 53-year-old woman presenting with dysphonia and stridor, requiring surgical resection on three occasions accompanied by tracheostomy on two occasions; biopsy was consistent with PCM. Due to relapsing disease activity, high-dose prednisolone and mycophenolate mofetil were commenced with prednisolone eventually being ceased. After 2 years of mycophenolate mofetil therapy, the patient's disease has been controlled without need for further surgical intervention. This is the first reported case of prolonged symptomatic improvement with the use of systemic immunosuppressive therapy with mycophenolate mofetil in PCM.

Treating obstructive sleep apnea with hypoglossal nerve stimulation.

BACKGROUND: Reduced upper airway muscle activity during sleep is fundamental to obstructive sleep apnea (OSA) pathogenesis. Hypoglossal nerve stimulation (HGNS) counteracts this problem, with potential to reduce OSA severity. STUDY OBJECTIVES: To examine safety and efficacy of a novel HGNS system (HGNS, Apnex Medical, Inc.) in treating OSA. PARTICIPANTS: Twenty-one patients, 67% male, age (mean ± SD) 53.6 ± 9.2 years, with moderate to severe OSA and unable to tolerate continuous positive airway pressure (CPAP). DESIGN: Each participant underwent surgical implantation of the HGNS system in a prospective single-arm interventional trial. OSA severity was defined by apnea-hypopnea index (AHI) during in-laboratory polysomnography (PSG) at baseline and 3 and 6 months post-implant. Therapy compliance was assessed by nightly hours of use. Symptoms were assessed using the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Calgary Sleep Apnea Quality of Life Index (SAQLI), and the Beck Depression Inventory (BDI). RESULTS: HGNS was used on 89% ± 15% of nights (n = 21). On these nights, it was used for 5.8 ± 1.6 h per night. Nineteen of 21 participants had baseline and 6-month PSGs. There was a significant improvement (all P < 0.05) from baseline to 6 months in: AHI (43.1 ± 17.5 to 19.5 ± 16.7), ESS (12.1 ± 4.7 to 8.1 ± 4.4), FOSQ (14.4 ± 2.0 to 16.7 ± 2.2), SAQLI (3.2 ± 1.0 to 4.9 ± 1.3), and BDI (15.8 ± 9.0 to 9.7 ± 7.6). Two serious device-related adverse events occurred: an infection requiring device removal and a stimulation lead cuff dislodgement requiring replacement. CONCLUSIONS: HGNS demonstrated favorable safety, efficacy, and compliance. Participants experienced a significant decrease in OSA severity and OSA-associated symptoms. CLINICAL TRIAL INFORMATION: NAME: Australian Clinical Study of the Apnex Medical HGNS System to Treat Obstructive Sleep Apnea. REGISTRATION NUMBER: NCT01186926. URL: http://clinicaltrials.gov/ct2/show/NCT01186926.

Antibiotic prophylaxis in septorhinoplasty? A prospective, randomized study.

BACKGROUND: The routine use of antibiotics in septorhinoplasty is widespread and recommended in many textbooks despite the lack of scientific evidence for their use. This practice has led to extensive discussions in the face of the emerging threat of antibiotic resistance and rising health care costs. The aim of our study was to investigate the role of antibiotic prophylaxis in septorhinoplasty. METHODS: The authors conducted a prospective, randomized, single-blind study at a tertiary referral center in a private practice setting, including 200 patients undergoing septorhinoplasty over a 4-year period. One hundred patients received preoperative single-shot antibiotics, and the other 100 received a combined regimen with preoperative single-shot antibiotics plus a postoperative 7-day course of oral antibiotics. RESULTS: Three patients (3 percent) developed postoperative local wound infections in the group with combined treatment; no infections occurred in the group treated with the preoperative single intravenous dose at induction alone, and the difference was not statistically significant. The rate of common antibiotic-induced side effects (e.g., nausea, diarrhea, skin rashes, pruritus) was significantly higher in the combined treatment group (29 percent versus 2 percent, p = 0.03). The cost for antibiotics and medication to treat the side effects per patient was significantly higher in the combined treatment group (93.45 AUD versus 14.50 AUD, p= 0.04). CONCLUSION: The authors' results would suggest that a single dose of antibiotics administered preoperatively in endonasal septorhinoplasty with autologous cartilage grafting is sufficient for prophylaxis of postoperative infections, thus eliminating the costs for postoperative antibiotics and the management of their side effects.