Reduction of postural nasal resistance following oropharyngeal surgery in patients with moderate-severe obstructive sleep apnea.

BACKGROUND: Patients with obstructive sleep apnea (OSA) have elevated nasopharyngeal resistances due to increased turbulent airflow. The study aims to investigate the effect of oropharyngeal surgery on nasal resistance in patients with various severity levels of OSA. METHODOLOGY: Patients with greater or equal to 5 events hourly on the apnea-hypopnea index (AHI) were enrolled. Patients with retropalatal obstruction underwent uvulopalatopharyngoplasty, while patients with concurrent retrolingual obstruction under- went uvulopalatopharyngoplasty (UPPP) plus tongue base suspension. Before surgery and after surgery, subjective outcomes were assessed using a visual analog scale (VAS), and objective outcomes were assessed using overnight polysomnography and rhinomanometry. The limitation of the study was that UPPP instead of expansion sphincter pharyngoplasty was performed in this study. RESULTS: Sixty-two patients were enrolled, while 30 patients were diagnosed as mild OSA (group Mild) and 32 patients were mo- derate-severe OSA (group MS). The preoperative VAS of nasal obstruction in recumbency during sleep was significantly reduced after surgery in group MS. However, no significant differences between preoperative and postoperative VAS were found in group Mild. The postoperative anterior and posterior total nasal resistances (TNR) in sitting and supine positions were not significantly different from those before surgery in group. In contrast, the postoperative posterior TNR in supine position was 0.292±0.301(Pa/ cm3/s), compared with 0.425±0.343(Pa/cm3/s) preoperatively. CONCLUSIONS: Oropharyngeal surgery improves nasal obstruction during sleep and lowers the supine TNR measured in poste- rior rhinomanometry in patients with moderate-severe OSA. Oropharyngeal surgery is a possible treatment for postural nasal obstruction in patients with moderate-severe OSA.

Prognostic impact of pre-treatment neutrophil-to-lymphocyte ratio (NLR) in nasopharyngeal carcinoma: A retrospective study of 180 Taiwanese patients.

OBJECTIVES: Nasopharyngeal cancer (NPC) is an endemic disease in Taiwan. Prognostic factors the anatomical TNM stage are important for its prognostic stratification. An elevated neutrophil-to-lymphocyte ratio (NLR) has been reported to be associated with poor prognosis in various solid tumours. In this study, we analysed the prognostic impact of the NLR in NPC in Taiwan. DESIGN: Single-institution retrospective study. SETTING: Medical centre. PARTICIPANTS: One hundred and eighty patients with NPC treated at the Far Eastern Memorial Hospital, Taiwan, from January 2007 to December 2013. MAIN OUTCOME MEASURES: The association between the clinical or haematological presentations and the prognosis. RESULTS: The majority of the 180 patients included in this study were men (80%) and were <65 years old (91.7%). A neck mass (55.6%) was the most common clinical presentation, followed by nasal (39.4%) and aural (30.6%) symptoms. In addition, the majority (75.4%) of patients had advanced stage (III and IV) disease. Patients with a high NLR (≧3.6) had significantly lower progression-free survival, overall survival and disease-specific survival rates. The association between high NLR and poor prognosis was more pronounced in patients with advanced disease than in those with early-stage NPC. The results of a multivariate analysis revealed that advanced age, clinical symptoms including headache, diplopia and facial numbness, advanced disease stage, and high NLR were independent prognostic factors. CONCLUSION: A high NLR is an independent poor prognostic factor of NPC in Taiwan.

A real-time prediction model for post-irradiation malignant cervical lymph nodes.

OBJECTIVE: To establish a real-time predictive scoring model based on sonographic characteristics for identifying malignant cervical lymph nodes (LNs) in cancer patients after neck irradiation. METHODS: One-hundred forty-four irradiation-treated patients underwent ultrasonography and ultrasound-guided fine-needle aspirations (USgFNAs), and the resultant data were used to construct a real-time and computerised predictive scoring model. This scoring system was further compared with our previously proposed prediction model. RESULTS: A predictive scoring model, 1.35 × (L axis) + 2.03 × (S axis) + 2.27 × (margin) + 1.48 × (echogenic hilum) + 3.7, was generated by stepwise multivariate logistic regression analysis. Neck LNs were considered to be malignant when the score was ≥ 7, corresponding to a sensitivity of 85.5%, specificity of 79.4%, positive predictive value (PPV) of 82.3%, negative predictive value (NPV) of 83.1%, and overall accuracy of 82.6%. When this new model and the original model were compared, the areas under the receiver operating characteristic curve (c-statistic) were 0.89 and 0.81, respectively (P < .05). CONCLUSIONS: A real-time sonographic predictive scoring model was constructed to provide prompt and reliable guidance for USgFNA biopsies to manage cervical LNs after neck irradiation.

Effects of comorbidity and medication use on the haemodynamic status during office-based laryngeal procedures: A prospective cohort study.

OBJECTIVE: Office-based laryngeal procedures (OBLPs) are emerging as effective alternative modalities for vocal disorders. This study systematically investigates the haemodynamic status of patients, specifically focusing on the potential effects of underlying comorbidity and medication use. DESIGN: Prospective cohort study. SETTING: Tertiary referral centre. PARTICIPANTS: We prospectively recruited 214 consecutive patients who received OBLPs during January-December 2015. All procedures were performed under local anaesthesia without sedation, in an upright (sitting) position. MAIN OUTCOME MEASURES: We measured heart rate (HR), systolic and diastolic blood pressure, and oxygen saturations at baseline (before procedure), immediately after local anaesthesia to the pharynx and larynx, immediately after completing of procedure, and 20 minutes after the procedure. RESULTS: Systolic, diastolic blood pressures and HR all significantly increased after local anaesthesia, and gradually decreased after the procedure (P<.01). Oxygen concentration remained unchanged. Patients with comorbidity and those receiving vasoactive medications showed significantly higher perioperative blood pressures than the other patients (P<.05), but the trend remained similar. Prominent hypertension (systolic ≥160 mm Hg or diastolic ≥100 mm Hg) was noted in 17 patients, more commonly in patients with older age, higher baseline blood pressures and receiving vasoactive medications. Only 2% of patients with normal baseline measurements developed prominent hypertension perioperatively. Tachycardia (HR≥100 bpm) developed in 22 patients, more frequently in patients with higher baseline HRs, and perceiving greater discomforts. CONCLUSION: This study revealed that routine haemodynamic monitoring may not be necessary for all the OBLPs, but should be considered for older patients, those with higher baseline blood pressure or HR, sensitive patients who might be more susceptible to perioperative discomfort, and those receiving vasoactive medications.

Involvement of two distinct signalling pathways in IGF-1-mediated central control of hypotensive effects in normotensive and hypertensive rats.

AIMS: Insulin-like growth factor-1 (IGF-1) is abundantly expressed in the nucleus tractus solitarii (NTS). In a previous study, we revealed that the induction of nitric oxide (NO) production in the NTS reduces blood pressure (BP). It is well known that both acute administration and chronic administration of IGF-I reduce BP. The aim of this study was to evaluate the short-term hypotensive effect of IGF-1 in the NTS and to delineate the underlying molecular mechanisms of IGF-1 in the NTS of normotensive WKY rats and spontaneously hypertensive rats (SHRs). METHOD: Microinjections of the phosphatidylinositol 3-kinase (PI3K) inhibitor LY294002 and the MAP kinase-ERK kinase (MEK) inhibitor PD98059 into the NTS in WKY rats and SHRs were used to study the involvement of IGF-1-induced depressor effects. RESULT: An IGF-1 (7.7 pmol) injection into the NTS resulted in a significant decrease in BP and HR in WKY rats and SHRs. Immunoblotting and immunohistochemical analysis showed that the microinjection of LY294002 (0.6 pmol) or PD98059 (3.0 pmol) into the NTS attenuated the IGF-1-induced depressor effects and Akt or ERK phosphorylation in WKY rats. An attenuation effect of LY294002, but not PD98059, was found in the SHRs. However, the mRNA and protein expression levels of the IGF-1R showed no significant differences in the NTS of the WKY rats and the SHRs. CONCLUSION: These results suggest that distinct Akt and ERK signalling pathways mediated the IGF-1 control of the central depressor effects in WKY rats and SHRs. ERK signalling defects may be associated with the development of hypertension.

Three-dimensional analysis of the surface registration accuracy of electromagnetic navigation systems in live endoscopic sinus surgery.

BACKGROUND: Studies on the performance of surface registration with electromagnetic tracking systems are lacking in both live surgery and the laboratory setting. This study presents the efficiency in time of the system preparation as well as the navigational accuracy of surface registration using electromagnetic tracking systems. METHODOLOGY: Forty patients with bilateral chronic paranasal pansinusitis underwent endoscopic sinus surgery after undergoing sinus computed tomography scans. The surgeries were performed under electromagnetic navigation guidance after the surface registration had been carried out on all of the patients. The intraoperative measurements indicate the time taken for equipment set-up, surface registration and surgical procedure, as well as the degree of navigation error along 3 axes. RESULTS: The time taken for equipment set-up, surface registration and the surgical procedure was 179 +- 23 seconds, 39 +- 4.8 seconds and 114 +- 36 minutes, respectively. A comparison of the navigation error along the 3 axes showed that the deviation in the medial-lateral direction was significantly less than that in the anterior-posterior and cranial-caudal directions. CONCLUSION: The procedures of equipment set-up and surface registration in electromagnetic navigation tracking are efficient, convenient and easy to manipulate. The system accuracy is within the acceptable ranges, especially on the medial-lateral axis.

Isolated adult Langerhans' cell histiocytosis in cervical lymph nodes: should it be treated?

OBJECTIVE: We report an extremely rare case of Langerhans' cell histiocytosis involving isolated cervical lymph nodes, and we discuss the diagnosis and treatment of this infrequent disease. METHOD: We present a case report and literature review concerning this disease entity. RESULTS: A 54-year-old man presented with persistent, multiple, left neck masses. Histopathological study of lymph node specimens showed proliferation of Langerhans' cells coupled with eosinophilic and neutrophilic microabscesses. Positive immunohistochemical staining for Cluster of Differentiation 1a (CD1a) in Langerhans' cells confirmed the diagnosis. No other abnormalities were noted on a series of image studies. The patient was managed with 'watchful waiting' without subsequent therapy. The neck lesions regressed gradually over time, and the patient did well over a two-year follow-up period. CONCLUSION: The clinical presentation of Langerhans' cell histiocytosis is highly variable, and the choice of treatment depends on the involved organs. Definitive diagnosis depends on identification of characteristic immunohistochemical or ultrastructural features of the biopsy specimen. Watchful waiting may be an effective management strategy in cases of adult isolated lymph node Langerhans' cell histiocytosis, due to its possible spontaneous regression.

Carotid stenting for irradiation-associated carotid stenosis 3 years after previous carotid endarterectomy.

Extracranial carotid stenosis is a known complication of external irradiation to the head and neck region. We report on a patient with previous carotid endarterectomy for irradiation-associated carotid stenosis. This patient developed symptomatic carotid stenosis over the ipsilateral common carotid artery proximal to the previous endarterectomy site 3 years later, and was successfully treated with carotid angioplasty and stenting. This case illustrates the importance of Duplex scan surveillance after carotid endarterectomy for patients with irradiation-associated carotid stenosis. The complimentary role of carotid endarterectomy and carotid angioplasty for managing such a patient is highlighted.

Acute disseminated encephalomyelitis after para-influenza infection post bone marrow transplantation.

Acute disseminated encephalomyelitis (ADEM) is a parainfectious or postvaccination demyelinating condition, characterized by rapid onset of multifocal neurological deficits, usually occurring in childhood or adolescence. We report case of ADEM in an allogeneic bone marrow transplant recipient, who presented with rapid onset of paraplegia and widespread neurological deficits 6 weeks after parainfluenza pneumonia. Magnetic resonance imaging (MRI) showed typical features of ADEM, involving the subcortical white matter, brain steam and spinal cord. There was a rapid and complete response to pulse high-dose corticosteriod and intravenous immunoglobulin. The importance of recognition and early treatment of this rare condition in transplantation practice is emphasized.