Value of Surgical and Nonsurgical Treatment for Sleep Apnea: A Closer Look at Health Care Utilization.

OBJECTIVE: To determine how surgery, continuous positive airway pressure (CPAP), and no treatment impact health care utilization in patients who have obstructive sleep apnea (OSA). STUDY DESIGN: This is a retrospective cohort study of patients between the ages of 18 and 65 that were diagnosed with OSA (9th International Classification of Diseases) from January 2007 to December 2015. Data were collected over 2 years, and prediction models were generated to evaluate trends over time. SETTING: A population-based study using real-world data and insurance databases. METHODS: A total of 4,978,649 participants were identified, all with at least 25 months of continuous enrollment. Patients with previous soft tissue procedures not approved for OSA (nasal surgery), or without continuous insurance coverage were excluded. A total of 18,050 patients underwent surgery, 1,054,578 were untreated, and 799,370 received CPAP. IBM Marketscan Research database was utilized to describe patient-specific clinical utilization, and expenditures, across outpatient, and inpatient services, and medication prescriptions. RESULTS: When the cost of the intervention was eliminated in the 2-year follow-up, the monthly payments of group 1 (surgery) were significantly less than group 3 (CPAP) in overall, inpatient, outpatient, and pharmaceutical payments (p < .001). The surgery group was associated with less cumulative payments compared to the other 2 groups when the cost of the intervention (CPAP or surgery) was eliminated in all comorbidities and age groups. CONCLUSION: Treating OSA with surgery can lessen overall health care utilization compared to no treatment and CPAP.

Automatic scoring of drug-induced sleep endoscopy for obstructive sleep apnea using deep learning.

BACKGROUND: Treatment of obstructive sleep apnea is crucial for long term health and reduced economic burden. For those considered for surgery, drug-induced sleep endoscopy (DISE) is a method to characterize location and pattern of sleep-related upper airway collapse. According to the VOTE classification system, four upper airway sites of collapse are characterized: velum (V), oropharynx (O), tongue (T), and epiglottis (E). The degree of obstruction per site is classified as 0 (no obstruction), 1 (partial obstruction), or 2 (complete obstruction). Here we propose a deep learning approach for automatic scoring of VOTE obstruction degrees from DISE videos. METHODS: We included 281 DISE videos with varying durations (6 s-16 min) from two sleep clinics: Copenhagen University Hospital and Stanford University Hospital. Examinations were split into 5-s clips, each receiving annotations of 0, 1, 2, or X (site not visible) for each site (V, O, T, and E), which was used to train a deep learning model. Predicted VOTE obstruction degrees per examination was obtained by taking the highest predicted degree per site across 5-s clips, which was evaluated against VOTE degrees annotated by surgeons. RESULTS: Mean F1 score of 70% was obtained across all DISE examinations (V: 85%, O: 72%, T: 57%, E: 65%). For each site, sensitivity was highest for degree 2 and lowest for degree 0. No bias in performance was observed between videos from different clinicians/hospitals. CONCLUSIONS: This study demonstrates that automating scoring of DISE examinations show high validity and feasibility in degree of upper airway collapse.

International Consensus Statement on Obstructive Sleep Apnea.

BACKGROUND: Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS: Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS: The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION: This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Safety of tongue base procedures for sleep apnoea in adults: A systematic review and metanalysis from the YO-IFOS study group.

OBJECTIVE: Tongue base and hypopharynx are the major sites of obstruction in OSA patients with failed palatal surgery. In recent years, several minimally invasive procedures have been developed to address tongue base obstruction. However, the research focus has consistently been on the effectiveness of surgery in reducing obstructive sleep apnoea rather than on postoperative complications. In this systematic review and metanalysis we aim to review the complication rate of minimally invasive base of tongue procedures for OSAS in adults. DATA SOURCES: PubMed (Medline), the Cochrane Library, EMBASE, Scopus, SciELO and Trip Database. REVIEW METHODS: Data sources were checked by three authors of the YO-IFOS sleep apnoea study group. Three authors extracted the data. Main outcome was expressed as the complication rate and 95% confidence interval for each surgical technique. RESULTS: 20 studies (542 patients) met the inclusion criteria. The mean complication rate is 12.79%; 4.65% for minor complications, 6.42% if they are moderate, and 1.77% if severe. The most reported complication overall is infection, in 1.95% of cases, followed by transient swallowing disorder, occurring in 1.30% of the total sample. CONCLUSION: The heterogeneity amongst the included studies prevents us from obtaining solid conclusions. The available evidence suggests that minimally invasive base of tongue procedures may present a wide spectrum of complication rates, ranging from 4.4% in tongue base radiofrequency to up to 42.42% in tongue base ablation.

Incidence and risk factors of chronic opioid use after sleep apnea surgery.

STUDY OBJECTIVES: To assess the incidence and risk factors of chronic opioid use after obstructive sleep apnea surgery. METHODS: Using IBM MarketScan research database, adults (>18 years) who underwent a variety of sleep surgery procedures between 2007 and 2015 were identified. Individuals with 1 year of insurance coverage before and after the surgical procedure were included. Additional anesthesia event(s) in the year following the procedure of interest and those who filled an opioid prescription within the year prior to surgery (not naive) were excluded. Outcomes included rates of persistent opioid use (additional opioid prescriptions filled 90-180 days postoperatively), prolonged use (additional opioid prescriptions filled 181-365 days postoperatively), and inappropriate use (> 100 morphine milligram equivalents). Evaluated variables include demographics, surgical procedures, and comorbidities. RESULTS: A total of 10,766 surgical procedures met the inclusion criteria. There was a trend of increased rates of perioperative opioid prescription. After multivariable logistic regression analysis, perioperative opioid prescription and smoking were independent risk factors for inappropriate opioid use (odds ratio [OR] = 31.51, P < .001; OR = 1.41, P = .016, respectively). Opioid prescription and hypertension were independent risk factors for persistent opioid use (OR = 37.8, P < .001, OR = 1.38, P = .008). Perioperative opioid prescription, previous opioid dependence diagnosis, smoking, and male sex were associated with continuous prolonged opioid use (OR = 73.1, 8.13, 1.95, and 1.55, respectively; P < .001, P = .020, P = .024, and P = .032, respectively). CONCLUSIONS: While efforts by different societies are being implemented to control the opioid crisis, we found that perioperative opioid prescription for airway surgery targeting obstructive sleep apnea is an independent risk factor for persistent, prolonged, and inappropriate opioid use. CITATION: Abdelwahab M, Marques S, Howard J, et al. Incidence and risk factors of chronic opioid use after sleep apnea surgery. J Clin Sleep Med. 2022;18(7):1805-1813.

Racial Disparities in Surgical Treatment of Obstructive Sleep Apnea.

Objective: Determine risk factors for failure to receive surgical treatment among patients with obstructive sleep apnea. Study Design: Population-based observational longitudinal cohort study. Setting: Population-based database. Methods: Multivariate analysis of 500,792 individuals with obstructive sleep apnea from Optum's deidentified Clinformatics Data Mart database (2004-2018). Results: Black race, increased age, diabetes, atrial fibrillation, obesity, and congestive heart failure were independently associated with a decreased rate of surgery for obstructive sleep apnea. Asian race, hypertension, arrhythmias other than atrial fibrillation, pulmonary disease, and liver disease were independently associated with an increased rate of surgery for obstructive sleep apnea. Conclusion: Racial disparities in health outcomes related to health care access and in economic resources have an enormous impact on public health and social equity. We found differences in rates of surgery for obstructive sleep apnea based on race. These data are consistent with others demonstrating disparities in medical treatment of sleep apnea with positive pressure and underline a need for a change in awareness and treatment in these populations.

A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla.

Background: Patients with narrow high-arch palate present with limited response to standard septal, turbinate, and valve procedures for nasal obstruction. Objective: To measure the effectiveness of minimally invasive nasal endoscopic (MINE) Lefort I osteotomy among subjects with narrow high-arched palate in managing nasal obstruction. Methods: Prospective cohort study was performed where subjects with narrow high-arched palate underwent MINE distraction osteogenesis maxillary expansion (DOME) from August 2019 to January 2021. Nasal obstruction symptom evaluation (NOSE) score, mean time to opioid cessation, and mean duration of cranial nerve V2 hypoesthesia were evaluated. Results: Among 12 subjects, the. mean NOSE score decreased from 58.89 to 15.83 (p = 0.004). There were no complaints of lip mobility or deformity. Conclusion: MINE-DOME can reduce nasal obstruction in a certain phenotype of patients and further improve patient-centric outcomes by limiting the approach to the Lefort I osteotomy to an endoscopic nasal approach.

Surgical procedure and treatment results of pharyngoplasty CWICKs for obstructive sleep apnea.

OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) is performed as a surgical treatment at the oropharyngeal level for obstructive sleep apnea, but there are problems with variations in treatment effects and postoperative complications. Therefore, to improve those, we have devised and put into practice the so-called CWICKs, which is a modified version of barbed reposition pharyngoplasty as a surgical method. We outline the procedure of CWICKs and report the treatment results in comparison with the conventional UPPP. METHODS: CWICKs are surgeries that use resorbable wound closure devices to pull the posterior palatal arch outward and elevate it anteriorly and superiorly to maintain an open upper airway during sleep at the soft palate level. We compared the therapeutic effects of 46 patients evaluated by polysomnography before and after surgery among CWICKs performed in our department between January 2015 and December 2019 and 91 patients who underwent UPPP in our department between January 2000 and December 2008. RESULTS: In 46 patients who underwent CWICKs, significant improvement was observed before and after surgery using the apnea hypopnea index (AHI), obstructive apnea index (OAI), ration of each sleep stage, and SpO2 level > 90%. The improvement rate of AHI was 68.4%, and the surgical success rate was 58.7%. Postoperative patient satisfaction was also good, and significant improvement in subjective sleepiness (Epworth Sleepiness Scale) and subjective sleep quality (Pittsburgh Sleep Quality Index) was observed before and after surgery. No postoperative complications such as dysphagia or scar stenosis were observed in any of the patients in the CWICKs group. Compared with the 91 cases of UPPP, which is the conventional method, there was no significant difference in the improvement rate of AHI (p = 0.199), but the improvement rate of OAI had significantly improved (p = 0.013). Regarding the postoperative sleep stage, In the CWICKs group, a significant decrease in stage 1 and a significant increase in stage 2, stage 3, and stage rapid eye movement were observed, whereas in the UPPP group, no significant improvement in stage 3 was observed. Multivariate analysis of surgical success did not show an association with surgical methods (CWICKs or UPPP). On the other hand, an association was shown with age (<45), palatine tonsil size (≥3 / 5), high MPH (≥14 mm), and OAI rate (> 1/3). CONCLUSION: The treatment outcome of CWICKs was equal to or better than that of the conventional UPPP. Future follow-up is required for long-term prognosis, but no serious postoperative complications, such as dysphagia or scar stenosis, have been observed. CWICKs are considered to be minimally invasive, simple, and effective surgical procedures with few complications.

Perioperative Antibiotic Use in Sleep Surgery: Clinical Relevance.

OBJECTIVE: Upper airway surgery is a common therapeutic approach recommended for patients with obstructive sleep apnea (OSA) to decrease disease burden. We aimed to evaluate the effect of perioperative antibiotic prescription on complication rates. STUDY DESIGN: Retrospective cohort (national database). SETTING: Tertiary referral center. METHODS: This is a retrospective study of a large national health care insurance database (Truven MarketScan) from 2007 to 2015. Subjects diagnosed with OSA who had uvulopalatopharyngoplasty (UPPP) were included and stratified in single versus multilevel surgery. Other variables included smoking, age, sex, antibiotic prescription, and comorbidities based on the Elixhauser index. Evaluated outcomes were postoperative bleeding, intubation, pneumonia, superficial surgical site infection, tracheostomy, and hospital readmission. A multivariate regression model was created to assess each complication. RESULTS: A total of 5,798,528 subjects received a diagnosis of OSA, of which 39,916 were >18 years old and underwent UPPP, either alone or with additional procedures. The mean age was 43 years, and 73.4% were male. Antibiotic prescription was associated with less bleeding in UPPP alone, UPPP with nasal surgery, and UPPP with nasal and tongue surgery (P < .001, P < .001, and P = .006, respectively). It was also associated with a lower prevalence of surgical site infection, pneumonia, tracheostomy, intubation, and hospital readmission (P < .001). On a multivariate model, antibiotic prescription was significantly associated with a decreased rate of complications. CONCLUSIONS: Although former studies recommended against the use of antibiotics after tonsillectomy, our results suggest that antibiotic prescription after UPPP for OSA was associated with less bleeding, surgical site infection, pneumonia, intubation, tracheostomy, and hospital readmission 30 days postoperatively.

A Comprehensive Strategy for Improving Nasal Outcomes After Large Maxillomandibular Advancement for Obstructive Sleep Apnea.

Background: Rate of corrective nasal surgery after maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) has been reported to be 18.7% for functional and aesthetic indications. Objective: Describe a comprehensive strategy to optimize nasal outcomes with MMA for OSA. Methods: A retrospective review of patients undergoing MMA for OSA in a tertiary referral center was performed, with a comprehensive perioperative intervention to optimize nasal outcomes from January 2014 to February 2018. Outcomes included the Apnea-Hypopnea Index (AHI), oxygen saturation (SpO2) nadir, corrective nasal surgery needed after MMA, and Nasal Obstruction Symptom Evaluation (NOSE) scores. Results: AHI after MMA showed significant reduction (-34.65, p < 0.001), SpO2 nadir increased (+6.08, p < 0.001), and NOSE scores decreased (-5.96, p < 0.001). Corrective nasal surgery needed after MMA was reported in 6.5% (8 of 122) subjects at a mean of 8.5 months, ranging from 1 to 24.7 months. Six subjects underwent either septoplasty and/or valve stenosis repair, and two subjects underwent functional and aesthetic rhinoplasty. Conclusion: A perioperative strategy was applied since 2014 that showed effectiveness in reducing post-MMA corrective nasal surgery to 6.5%.

The Impact of Maxillary Expansion on Adults' Nasal Breathing: A Systematic Review and Meta-Analysis.

OBJECTIVE: Nasal surgery fails to restore nasal breathing in some cases. Maxillary constriction is suggested as a major cause of failure. It is thought that maxillary constriction leads to the closure of the internal and external nasal valves. Moreover, it is well established in the literature that maxillary expansion, both in adults and children, increases upper airway volume. However, it is yet unclear whether maxillary expansion may improve nasal function.Review Methods: Pubmed (Medline), the Cochrane Library, EMBASE and Trip Database were checked by two authors from the Rhinology Study Group of the Young Otolaryngologists section of the International Federation of Otorhinolaryngological Societies. Two authors extracted the data. The main outcome was expressed as the value (in variable units) prior to treatment (T0), after expansion procedures (T1), after the retention period (T2), and after a follow-up period (T3). RESULTS: A total of 10 studies (257 patients) met the inclusion criteria. The data pooled in the meta-analysis reveals a statistically significant reduction of 0.27 Pa/cm3/s (CI 95% 0.15, 0.39) in nasal resistance after palatal expansion As far as subjective changes are concerned, the pooled data for the change in the NOSE score shows a statistically significant mean reduction after maxillary expansion of 40.08 points (CI 95% 36.28, 43.89). CONCLUSION: The initial available evidence is too limited to suggest maxillary expansion as a primary treatment option to target nasal breathing. However the data is encouraging with regards to the effect of maxillary expansion on nasal function. Further higher quality studies are needed in order to define clearer patient selection criteria, distinguish optimal techniques, and demonstrate long-term efficacy in long term follow up studies.

Association of Systemic Diseases With Surgical Treatment for Obstructive Sleep Apnea Compared With Continuous Positive Airway Pressure.

Importance: The efficacy of surgical treatments for obstructive sleep apnea (OSA) is variable when considering only the Apnea Hypopnea Index as the treatment end point. However, only a few studies have shown an association between these procedures and improved clinically relevant outcomes, such as cardiovascular, endocrine, and neurological sequelae of OSA. Objective: To evaluate the association of surgery for OSA with clinically relevant outcomes. Design, Setting, and Participants: This retrospective cohort study used the Truven MarketScan Database from January 1, 2007, to December 31, 2015, to identify all patients diagnosed with OSA who received a prescription of continuous positive airway pressure (CPAP), were 40 to 89 years of age, and had at least 3 years of data on file. Data were analyzed September 19, 2019. Interventions: Soft tissue and skeletal surgical procedures for the treatment of OSA. Main Outcomes and Measures: The occurrence of cardiovascular, neurological, and endocrine complications was compared in patients who received CPAP alone and those who received surgery. High-dimensionality propensity score matching was used to adjust the models for confounders. Kaplan-Meier survival analysis with a log-rank test was used to compare differences in survival curves. Findings: A total of 54 224 patients were identified (33 405 men [61.6%]; mean [SD] age, 55.1 [9.2] years), including a cohort of 49 823 patients who received CPAP prescription alone (mean [SD] age, 55.5 [9.4] years) and 4269 patients who underwent soft tissue surgery (mean [SD] age, 50.3 [7.0] years). The median follow-up time was 4.47 (interquartile range, 3-8) years after the index CPAP prescription. In the unadjusted model, soft tissue surgery was associated with decreased cardiovascular (hazard ratio [HR], 0.92; 95% CI, 0.86-0.98), neurological (HR, 0.49; 95% CI, 0.39-0.61), and endocrine (HR, 0.80; 95% CI, 0.74-0.86) events. This finding was maintained in the adjusted model (HR for cardiovascular events, 0.91 [95% CI, 0.83-1.00]; HR for neurological events, 0.67 [95% CI, 0.51-0.89]; HR for endocrine events, 0.82 [95% CI, 0.74-0.91]). Skeletal surgery (n = 114) and concomitant skeletal and soft tissue surgery (n = 18) did not demonstrate significant differences in rates of development of systemic complications. Conclusions and Relevance: In this cohort study, soft tissue surgery for OSA was associated with lower rates of development of cardiovascular, neurological, and endocrine systemic complications compared with CPAP prescription in a large convenience sample of the working insured US adult population. These findings suggest that surgery should be part of the early treatment algorithm in patients at high risk of CPAP failure or nonadherence.

Insights into Friedman stage II and III OSA patients through drug-induced sleep endoscopy.

BACKGROUND: The Friedman staging is a classic system to predict outcomes of obstructive sleep apnea (OSA) surgery. Increasing stage indicates more severe upper airway (UA) obstruction and worse surgical successful rate. In previous studies, the UA obstruction between stages were usually assessed based on awake examination. Drug-induced sleep endoscopy (DISE) is a new method that can evaluate airway collapse characteristics during sleep. Therefore, we planned to compare Friedman staging and DISE findings and fulfill the knowledge gap on the correlation between awake and sedated UA examination. METHODS: Retrospective case series study that assessed patients with OSA who underwent DISE. Subjects were classified to stage II and stage III groups based on Friedman staging system. UA collapse characteristics based on velum, oropharynx, tongue base, epiglottis (VOTE) classification, including single/multiple obstruction sites, single/combined upper and lower obstruction levels, collapse degree and patterns in different sites, and surgical results among the groups were analyzed. RESULTS: A total of 175 cases were analyzed. No significant differences were found in baseline measurements between groups. Stage III patients (n=102) had a higher proportion (74.5%) with 3 or 4 obstruction sites than stage II (57.5%, n=73). Velum (V) + oropharynx (O) + tongue base (T) was the most common multi-sites combined obstruction pattern with 33% in stage II and 37% in stage III, isolated lower level obstruction was the least with 6% and 4%, respectively. No significant differences were found in obstruction sites and levels. 106 patients underwent surgeries and 33 had post-surgical sleep study, 73.7% and 63.6% response rate were found in stage II and III with no significant difference. CONCLUSIONS: Upper and lower combined obstruction was the main pattern of collapse in both, Friedman stage II and III patients. Patients with OSA and Friedman stage III had more than 2 sites of obstruction than stage II patients.

New Medical Device and Therapeutic Approvals in Otolaryngology: State of the Art Review of 2019.

OBJECTIVE: To review new devices and drugs relevant to otolaryngology-head and neck surgery that were approved by the US Food and Drug Administration (FDA) in 2019. DATA SOURCES: Approval notifications for 2019 were extracted from the ENT (ear, nose, and throat) and general and plastic surgery sections of the FDA's medical devices and therapeutics listings. REVIEW METHODS: New therapeutics and medical devices identified from the query were analyzed by members of the American Academy of Otolaryngology-Head and Neck Surgery's Medical Devices and Drugs Committee. Technologies were assessed by 2 independent reviewers to ascertain relevance to otolaryngology, prioritized, and classified to subspecialty field with critical review based on extant scientific literature. CONCLUSIONS: Query of the FDA drug and device database returned 105 ENT devices (50 cleared, 55 with premarket approval, and 0 de novo), 543 general and plastic surgery devices (372 cleared, 170 with premarket approval, and 1 de novo), and 46 new otolaryngology-relevant drug approvals that occurred in 2019. Advances spanned all subspecialty areas with otology predominating, primarily due to hearing-related technologies. While scientific evidence was available for all new devices, there was significant heterogeneity in rigor of supporting scientific data. IMPLICATIONS FOR PRACTICE: Technological and pharmaceutical innovation is an important catalyst for advances in the surgical specialties. Familiarity with new devices and therapeutics in otolaryngology-head and neck surgery ensures that clinicians keep abreast of developments with potential to improve prevailing standards of care.

Safeness, subjective and objective changes after turbinate surgery in pediatric patients: A systematic review.

OBJECTIVE: Inferior turbinates are the main structure related to impaired nasal breathing. When medical treatment fails, surgery is the next step, according to clinical guidelines. However, despite the widespread acceptance of this procedure, there is some controversy about performing it in children. DATA SOURCES: Pubmed (Medline), the Cochrane Library, EMBASE, Scopus, Science direct, SciELO and Trip Database. REVIEW METHODS: We looked for articles in which the individual outcome of turbinate surgery in pediatric patients was investigated independently of whether it was the main objective of the study or not. RESULTS: 13 papers (1111 patients) met the inclusion criteria. 6 authors performed diverse objective assessment and 11 authors used subjective scales. All of them found improvement after surgery. Due to the heterogeneity of the methods used, they could not be included in a metanalysis. Eleven out of the 13 authors reported 3.12% complication rates, being minor bleeding the most common (1.30%), followed by crust (0.49%) and pain (0.47%). CONCLUSIONS: There is a lack of high quality studies in children. Turbinate surgery in children is a safe technique with low complication rates. The available evidence suggests improvement in subjective outcomes after turbinate surgery in children. We cannot make a formal recommendation of a surgical technique in children given the lack of high quality studies, and since comparison between available papers is not possible. Although the evidence at our disposal is weak, it suggests that the safest techniques are MAIT, radiofrequency, coblation and laser.

Ethyl alcohol threshold test: a fast, reliable and affordable olfactory Assessment tool for COVID-19 patients.

OBJECTIVE: COVID-19 patients may present mild symptoms. The identification of paucisymptomatic patients is paramount in order to interrupt the transmission chain of the virus. Olfactory loss could be one of those early symptoms which might help in the diagnosis of COVID-19 patients. In this study, we aim to develop and validate a fast, inexpensive, reliable and easy-to-perform olfactory test for the screening of suspected COVID-19 patients. STUDY DESIGN: Phase I was a case-control study and Phase II a transversal descriptive study. SUBJECTS AND METHODS: Olfaction was assessed with the ethyl alcohol threshold test and symptoms with visual analogue scales. The study was designed in two phases: In Phase I, we compared confirmed COVID-19 patients and healthy controls. In Phase II, patients with suspected COVID-19 infection referred for testing were studied. RESULTS: 275 participants were included in Phase I, 135 in Phase II. The ROC curve showed an AUC of 0.749 in Phase I, 0.737 in Phase II. The cutoff value which offered the highest amount of correctly classified patients was ≥ 2 (10% alcohol) for all age intervals. The odds ratio was 8.19 in Phase I, 6.56 in Phase II with a 75% sensitivity. When cases report normal sense of smell (VAS < 4), it misdiagnoses 57.89% of patients detected by the alcohol threshold test. CONCLUSION: The olfactory loss assessed with the alcohol threshold test has shown high sensitivity and odds ratio in both patients with confirmed COVID-19 illness and participants with suspected SARS-CoV-2 infection.

Skeletal Surgery for Obstructive Sleep Apnea.

This article focuses on the role of skeletal surgery within the modified Stanford protocol with particular attention focused on the evolved role of MMA. First, surgery in patients presenting with congenital dentofacial deformity or characteristic drug-induced sleep endoscopy findings, then the growing role of maxillary expansion in a newly identified patient phenotype, and finally genioglossus advancement, are discussed. Less commonly used and validated techniques, such as isolated mandibular advancement and maxillomandibular expansion are not discussed in this article.

Otolaryngology during COVID-19: Preventive care and precautionary measures.

Since the outbreak of novel coronavirus disease (COVID-19) in December 2019, it has spread to various regions and countries, forming a global pandemic. Reducing nosocomial infection is a new issue and challenge for all healthcare systems. Otolaryngology is a high-risk specialty as it close contact with upper respiratory tract mucous, secretions, droplets and aerosols during procedures and surgery. Therefore, infection prevention and control measures for this specialty are essential. Literatures on the epidemiology, clinical characteristics and infection control measures of COVID-19 were reviewed, practical knowledge from first-line otolaryngologists in China, the United States, and Brazil were reviewed and collated. It was recommended that otolaryngology professionals should improve screening in suspected patients with relevant nasal and pharyngeal symptoms and signs, suspend non-emergency consultations and examinations in clinics, and rearrange the working procedures in operating rooms. The guidelines of personal protective equipment for swab sampling, endoscopy and surgery were listed. Indications for tracheotomy during the pandemic should be carefully considered to avoid unnecessary airway opening and aerosol-generation; precautions during surgery to reduce the risk of exposure and infection were illustrated. This review aimed to provide recommendations for otolaryngologists to enhance personal protection against COVID-19 and reduce the risk of nosocomial infection.

Palatopharyngoplasty Resolves Concentric Collapse in Patients Ineligible for Upper Airway Stimulation.

OBJECTIVE: To determine if a modified tissue-preserving palatopharyngoplasty could convert retropalatal concentric collapse to anteroposterior or lateral patterns of collapse on drug-induced sleep endoscopy (DISE) in patients who are not candidates for upper airway stimulation due to complete circumferential collapse at the velum. METHODS: A prospective, nonconsecutive, single-blinded cohort study was performed by two sleep surgeons at a tertiary care center from 2015 to 2018. Inclusion criteria included adults > 18 years of age with a diagnosis of obstructive sleep apnea with an Apnea-Hypopnea Index (AHI) > 15, a body mass index (BMI) < 32, and < 25% central apneas on polysomnography. Twelve patients with complete circumferential collapse underwent a modified palatopharyngoplasty. Postoperatively, a repeat sleep study was performed. A repeat DISE was recommended for those with incomplete surgical response (clinically and/or AHI). RESULTS: Twelve patients with complete circumferential collapse were eligible for the study. Mean BMI was 30.5. Mean preoperative AHI was 54.0 events per hour. Following a modified palatopharyngoplasty, the mean AHI was reduced to 33.1 events per hour, and 100% (12 of 12) of the patients converted from a pattern of complete circumferential collapse to either no collapse at the level of the velum (3) or an anteroposterior pattern of collapse (9). CONCLUSION: We demonstrate that a modified palatopharyngoplasty can successfully convert collapse patterns in patients with complete circumferential collapse. Further studies are required to determine the outcome of these patients following upper airway stimulation implantation. LEVEL OF EVIDENCE: 1B Laryngoscope, 2020.