Cancer Risk Associated with Continuous Positive Airway Pressure: A National Study.

OBJECTIVE: In 2021 the U.S. FDA issued a Class 1 safety recall notice for specific devices due to a risk of carcinogen exposure. The objective of this study was to evaluate reports of cancer linked to CPAP devices to understand implications for the field of sleep medicine. METHODS: Cases of cancer involving CPAP devices were retrieved from the MAUDE database from 2014 to 2021 and analyzed with descriptive statistics. RESULTS: A total of 2571 patient injuries were associated with CPAP. Reports of cancer (n = 209; 4.62%) were the second most commonly documented patient problem associated with CPAP, although 1950 (43.13%) patients had a device problem without an associated injury. Of the 209 cancer cases associated with CPAP, 200 (95.7%) of the adverse event reports were received by the FDA in 2021. There were 174 (9.15%) descriptions of the CPAP polyurethane sound abatement foam degrading in association with a cancer diagnosis, but degradation was more commonly not associated with malignancy (n = 1728; 90.85%). Other frequently documented CPAP device problems included broken devices (n = 279; 6.92%), fire (n = 182; 4.51%), and patient-device incompatibility (n = 144; 3.57%). CONCLUSION: Malignancy associated with CPAP devices has been reported; however, future studies are required to establish causation. Given 95.7% of those documented cases were reported in 2021, otolaryngologists should be prepared to discuss the risks of carcinogenesis associated with CPAP. The otolaryngology community should also be aware of the potential bandwagon effect and the implications for CPAP compliance. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2270-2274, 2022.

Association of Hypoglossal Nerve Stimulation With Improvements in Long-term, Patient-Reported Outcomes and Comparison With Positive Airway Pressure for Patients With Obstructive Sleep Apnea.

Importance: Hypoglossal nerve stimulation (HNS) and positive airway pressure (PAP) have been shown to improve patient-reported outcomes (PROs) in obstructive sleep apnea (OSA). However, to our knowledge, there are no data that compare change in PROs between HNS and PAP or that indicate whether HNS improves comorbid insomnia or depression in the long term. Objectives: To determine whether HNS is associated with improvements in patient-reported sleepiness, insomnia, and depression in the long term and to compare the respective associations of HNS and PAP with improved PROs. Design, Setting, and Participants: This retrospective cohort study used data from patients treated at the Cleveland Clinic for OSA. Participants received either HNS (referred sample) from November 1, 2015, to September 31, 2018, or PAP (previous cohort) from January 1, 2010, to December 31, 2014, for OSA. Patients were matched 3:1 for PAP:HNS based on age, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), sex, and apnea hypopnea index (AHI). Data were collected at baseline and at prespecified follow-up points. Data were analyzed from March 26, 2020, to September 9, 2021. Exposures: Treatment with HNS vs PAP. Main Outcomes and Measures: Data collected included AHI and Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Insomnia Severity Index (ISI), and Patient Health Questionnaire-9 (PHQ-9; depression) scores. Results: Among 85 patients receiving HNS (mean [SD] age, 62.8 [9.5] years; 59 men [69.4%]; 77 White patients [90.6%]; mean [SD] BMI, 28.8 [3.1]), compared with 217 matched patients receiving PAP (mean [SD] age, 62.1 [9.9] years; 157 men [72.4%]; 173 White patients [81.2%]; mean [SD] BMI, 29.5 [3.1]) included in the analysis, significant improvements were seen in PHQ-9 scores for HNS vs PAP (least square means, -4.06 [95% CI, -5.34 to -2.79] vs -2.58 [95% CI, -3.35 to -1.82]; mean difference, -1.48 [95% CI, -2.78 to -0.19]) with comparable improvements in ESS, FOSQ, and ISI scores. Clinically meaningful differences were observed in 42 of 65 HNS group patients (64.6%) vs 118 PAP group patients (54.5%) for ESS scores, 29 of 49 HNS group patients (59.2%) vs 67 of 217 PAP group patients (30.9%) for FOSQ scores, 14 of 48 HNS group patients (29.2%) vs 53 of 217 PAP group patients (24.4%) for PHQ-9 scores, and 23 of 49 HNS group patients (46.9%) vs 79 of 217 PAP group patients (36.4%) for ISI scores. At the 1-year post-HNS assessment, meaningful improvements were seen in 17 of 28 patients (60.7%) for ESS scores, 11 of 20 patients (55.0%) for FOSQ scores, 7 of 23 patients (30.4%) for PHQ-9 scores, and 11 of 25 patients (44.0%) for ISI scores. Conclusions and Relevance: In this cohort study of patients with OSA, sustained improvements in PROs were observed 1 year after HNS and were comparable to those for PAP at 3 months. These findings suggest that HNS is a viable treatment for improving insomnia and depression in patients with OSA.

Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions, and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum.

Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea. Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction or STAR trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, obstructive sleep apnea phenotypes, individual health status, psychological conditions, and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This article presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel. CITATION: Suurna MV, Jacobowitz O, Chang J, et al. Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum. J Clin Sleep Med. 2021;17(12):2477-2487.

Comparison of Traditional Upper Airway Surgery and Upper Airway Stimulation for Obstructive Sleep Apnea.

OBJECTIVE: To compare patients with moderate-severe obstructive sleep apnea (OSA) undergoing traditional single and multilevel sleep surgery to those undergoing upper airway stimulation (UAS). STUDY DESIGN: Case control study comparing retrospective cohort of patients undergoing traditional sleep surgery to patients undergoing UAS enrolled in the ADHERE registry. SETTING: 8 multinational academic medical centers. SUBJECTS AND METHODS: 233 patients undergoing prior single or multilevel traditional sleep surgery and meeting study inclusion criteria were compared to 465 patients from the ADHERE registry who underwent UAS. We compared preoperative and postoperative demographic, quality of life, and polysomnographic data. We also evaluated treatment response rates. RESULTS: The pre and postoperative apnea hypopnea index (AHI) was 33.5 and 15 in the traditional sleep surgery group and 32 and 10 in the UAS group. The postoperative AHI in the UAS group was significantly lower. The pre and postoperative Epworth sleepiness scores (ESS) were 12 and 6 in both the traditional sleep surgery and UAS groups. Subgroup analysis evaluated those patients undergoing single level palate and multilevel palate and tongue base traditional sleep surgeries. The UAS group had a significantly lower postoperive AHI than both traditional sleep surgery subgroups. The UAS group had a higher percentage of patients reaching surgical success, defined as a postoperative AHI <20 with a 50% reduction from preoperative severity. CONCLUSION: UAS offers significantly better control of AHI severity than traditional sleep surgery. Quality life improvements were similar between groups.

Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation.

OBJECTIVE: An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS. METHODS: International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach. RESULTS: Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups (P = .808). Operative time exhibited a significant downward trend (P < .001), with the median operative time dropping from 150 minutes for the first 10 implants to 134 minutes for the subsequent 10 implants. The decrease in AHI from baseline to 12-month follow-up was equivalent between the first and second ten (22.8 vs 21.2 events/hour, respectively, P < .001). Similarly, the first and second ten groups had equivalent ESS decreases at 6 months (2.0 vs 2.0, respectively, P < .001). ESS outcomes remained equivalent for those with data through 12-months. CONCLUSIONS: Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.

A Multimodal Multi-institutional Solution to Remote Medical Student Education for Otolaryngology During COVID-19.

During the coronavirus 2019 pandemic, there has been a surge in production of remote learning materials for continued otolaryngology resident education. Medical students traditionally rely on elective and away subinternship experiences for exposure to the specialty. Delays and cancellation of clinical rotations have forced medical students to pursue opportunities outside of the traditional learning paradigm. In this commentary, we discuss the multi-institutional development of a robust syllabus for medical students using a multimodal collection of resources. Medical students collaborated with faculty and residents from 2 major academic centers to identify essential otolaryngology topics. High-quality, publicly available, and open-access content from multiple sources were incorporated into a curriculum that appeals to a variety of learners. Multimodal remote education strategies can be used as a foundation for further innovation aimed at developing tomorrow's otolaryngologists.

Reconfiguration of Upper Airway Stimulation Devices Utilizing Awake Endoscopy.

OBJECTIVES: Determine the rates of, reasons for, and effectiveness of device reprogramming utilizing in-office awake endoscopy (AE) in subjects who underwent upper airway stimulation (UAS) surgery. STUDY DESIGN: Retrospective chart review. METHODS: Retrospective chart review at a tertiary care center on patients implanted with UAS devices from November 2015 to July 2018. RESULTS: Sixty patients were implanted with UAS devices. Average pre- and postsurgical total apnea-hypopnea index (AHI) was 40.6 and 4.2 with a 36.4 total AHI reduction. Treatment success based on Sher criteria was observed in 88% of patients. Postoperative titration polysomnography revealed an average functional threshold (FT) and minimum therapeutic amplitude (MTA) of 1.6 and 2.1 V, respectively. A total of 24 AEs were performed in 19 (32%) patients. The most common complaints and reasons for AE were perceived stimulus discomfort (42%), frequent awakenings (32%), and persistent fatigue or non-normalized AHI (21%). After first AE, there was a 0.87 (53%) and 0.93 (45%) V reduction in FT and MTA, respectively. CONCLUSION: Patients with obstructive sleep apnea continue to succeed with UAS. Fewer than one-third of patients had postsurgical complaints requiring device reconfiguration utilizing AE to assess the pharyngeal airway and optimize device settings. Reduction in the FT and MTA after AE may improve compliance by reducing discomfort and frequent awakenings. Periodic monitoring of patients with implanted UAS devices is necessary to optimize efficacy and maintain patient compliance. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2494-2498, 2020.

Preoperative Predictors of Response to Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea.

OBJECTIVE: Hypoglossal nerve stimulation (HGNS) is an effective treatment for patients with obstructive sleep apnea (OSA) who fail continuous positive airway pressure (CPAP). We assessed the relationship between patient characteristics and response to HGNS. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary care institution. SUBJECTS AND METHODS: This study included CPAP-intolerant patients with moderate to severe OSA after HGNS system implantation from November 2015 to December 2017. Patient measures, drug-induced sleep endoscopy (DISE) findings, and apnea-hypopnea indices (AHIs) were recorded. RESULTS: Forty-eight patients underwent implantation with the following median measures: age, 66 years; body mass index, 28.6; and neck circumference, 41.0 cm. Patients were classified by Friedman tongue position (II, 27%; III, 56%; IV, 17%) and Mallampati grade (I, 25%; II, 50%; III, 23%; IV, 2%). By DISE, 71% had anterior-posterior palatal collapse. Additionally, 38% had lateral oropharynx collapse; 50%, tongue base collapse; and 27%, epiglottis collapse. Following implantation, median AHI improved from 38.5 to 2.7 (P < .001), and 92% of patients had no worse than mild OSA (8% moderate). Patients with Friedman tongue position grade II/III experienced greater change in AHI as compared with grade IV (94.2% vs 73.8%, P < .001). Patients with Mallampati score I/II experienced greater improvement versus score III/IV (94.7% vs 66.5%, P < .001). No DISE findings, including any obstruction or collapse, were associated with change in AHI. CONCLUSION: This study further confirms HGNS as an effective treatment of CPAP-intolerant OSA. Office measures such as Friedman tongue position IV and Mallampati III/IV were associated with mildly decreased response. DISE findings were not associated with patient response.

Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy.

OBJECTIVE/HYPOTHESIS: The ADHERE Registry is a multicenter prospective observational study following outcomes of upper airway stimulation (UAS) therapy in patients who have failed continuous positive airway pressure therapy for obstructive sleep apnea (OSA). The aim of this registry and purpose of this article were to examine the outcomes of patients receiving UAS for treatment of OSA. STUDY DESIGN: Cohort Study. METHODS: Demographic and sleep study data collection occurred at baseline, implantation visit, post-titration (6 months), and final visit (12 months). Patient and physician reported outcomes were also collected. Post hoc univariate and multivariate analysis was used to identify predictors of therapy response, defined as ≥50% decrease in Apnea-Hypopnea Index (AHI) and AHI ≤20 at the 12-month visit. RESULTS: The registry has enrolled 1,017 patients from October 2016 through February 2019. Thus far, 640 patients have completed their 6-month follow-up and 382 have completed the 12-month follow-up. After 12 months, median AHI was reduced from 32.8 (interquartile range [IQR], 23.6-45.0) to 9.5 (IQR, 4.0-18.5); mean, 35.8 ± 15.4 to 14.2 ± 15.0, P < .0001. Epworth Sleepiness Scale was similarly improved from 11.0 (IQR, 7-16) to 7.0 (IQR, 4-11); mean, 11.4 ± 5.6 to 7.2 ± 4.8, P < .0001. Therapy usage was 5.6 ± 2.1 hours per night after 12 months. In a multivariate model, only female sex and lower baseline body mass index remained as significant predictors of therapy response. CONCLUSIONS: Across a multi-institutional study, UAS therapy continues to show significant improvement in subjective and objective OSA outcomes. This analysis shows that the therapy effect is durable and adherence is high. LEVEL OF EVIDENCE: 2 Laryngoscope, 130:1333-1338, 2020.

Previous Surgery and Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea.

OBJECTIVE: To examine whether previous palate or hypopharyngeal surgery was associated with efficacy of treatment of obstructive sleep apnea with hypoglossal nerve stimulation. STUDY DESIGN: Cohort (retrospective and prospective). SETTING: Eleven academic medical centers. SUBJECTS AND METHODS: Adults treated with hypoglossal nerve stimulation were enrolled in the ADHERE Registry. Outcomes were defined by the apnea-hypopnea index (AHI), in 3 ways: change in the AHI and 2 definitions of therapy response requiring ≥50% reduction in the AHI to a level <20 events/h (Response20) or 15 events/h (Response15). Previous palate and hypopharyngeal (tongue, epiglottis, or maxillofacial) procedures were documented. Linear and logistic regression examined the association between previous palate or hypopharyngeal surgery and outcomes, with adjustment for age, sex, and body mass index. RESULTS: The majority (73%, 217 of 299) had no previous palate or hypopharyngeal surgery, while 25% and 9% had previous palate or hypopharyngeal surgery, respectively, including 6% with previous palate and hypopharyngeal surgery. Baseline AHI (36.0 ± 15.6 events/h) decreased to 12.0 ± 13.3 at therapy titration (P < .001) and 11.4 ± 12.6 at final follow-up (P < .001). Any previous surgery, previous palate surgery, and previous hypopharyngeal surgery were not clearly associated with treatment response; for example, any previous surgery was associated with a 0.69 (95% CI: 0.37, 1.27) odds of response (Response20 measure) at therapy titration and a 0.55 (95% CI: 0.22, 1.34) odds of response (Response20 measure) at final follow-up. CONCLUSION: Previous upper airway surgery was not clearly associated with efficacy of hypoglossal nerve stimulation.

Uvulopalatopharyngoplasty vs CN XII stimulation for treatment of obstructive sleep apnea: A single institution experience.

OBJECTIVES: Hypoglossal nerve stimulation (HNS) therapy is an emerging surgical treatment for select patients with obstructive sleep apnea (OSA). This study aims to compare outcomes in patients with moderate to severe OSA who underwent HNS surgery (Inspire Medical Systems) and those who underwent traditional airway reconstructive surgery, specifically uvulopalatopharyngoplasty (UPPP). METHODS: Patients who underwent HNS implantation (n = 20), all with moderate to severe OSA, inability to adhere to positive pressure therapy, and compliant with previously published inclusion criteria, were compared to a historical cohort that were intolerant of CPAP with similar inclusion criteria who all underwent UPPP (n = 20) with some also undergoing additional procedures such as septoplasty/turbinate reduction. Data including body mass index (BMI), pre- and post-implant apnea-hypopnea index (AHI) were assessed. RESULTS: For patients who underwent HNS, mean preoperative BMI was 28.0. Mean AHI decreased significantly from 38.9 ±â€¯12.5 to 4.5 ±â€¯4.8. All patients achieved an AHI < 20 post implant with 65% (13/20) with an AHI ≤ 5. For patients who underwent traditional airway surgery, mean preoperative BMI was 27.5; mean AHI decreased from 40.3 ±â€¯12.4 to 28.8 ±â€¯25.4. CONCLUSION: While both traditional surgery and HNS are effective treatments for patients with moderate to severe OSA with CPAP intolerance, our study demonstrates that HNS is "curative" in normalizing the AHI to <5 in the majority of patients. For select patients, HNS therapy provides excellent objective improvement in outcome measures.

Healthcare usage after uvulopalatopharyngoplasty - Impact of analgesic regimen.

OUTCOME OBJECTIVES: 1) Analyze differences in healthcare usage between subjects receiving different perioperative analgesic medications after uvulopalatopharyngoplasty (UPPP) surgery. 2) Comment on the impact of perioperative analgesic medication on length of hospital stay and complications after UPPP. METHODS: A retrospective cohort study of 120 UPPPs conducted by a single surgeon in the past 5years was conducted. Subjects were grouped based on perioperative pain medication regimen into three groups; narcotics alone (n=83), narcotics with gabapentin (n=27), or narcotics with ketorolac tromethamine (n=10). The primary outcome variable was total number of clinic/emergency room and/or telephone encounters related to post-UPPP pain. Secondary outcomes included length of post-operative hospital stay, number of telephone and/or clinical encounters in which the patient complained specifically of pain or requested a refill for analgesics, and post-operative complications. RESULTS: No significant difference was found between the three analgesic regimens in post-operative hospital stay length (p=0.28, median stay 23.5h), number of clinic or telephone encounters related to pain (p=0.26, mean value 0.71 encounters), or post-operative complication rate (p=0.82, 5.9% complication rate). CONCLUSION: This study shows no significant difference in post-operative healthcare usage between patients with peri-operative analgesic regimens including narcotics alone, gabapentin with narcotics, or ketorolac with narcotics. Post-operative complication rate and length of stay did not differ between groups. These data suggest that these three medication regimens have similar impact on post-operative course for UPPP patients. Therefore, the most affordable or simplest options have equivalent effects on post-operative healthcare usage.

Otolaryngology sleep medicine curriculum objectives as determined by sleep experts.

PURPOSE: (1) Ascertain the most important concepts and topics for otolaryngology resident education in sleep medicine and surgery, as determined by faculty who teach sleep medicine to otolaryngology residents. (2) Create learning objectives within the area of otolaryngologic sleep medicine in order to design a sleep medicine curriculum for otolaryngology residents. MATERIALS AND METHODS: Two web-based surveys were sent to 163 academic otolaryngologists who teach sleep medicine. The first survey determined the topics, and their relative importance, considered most vital to learn during otolaryngology training. Using the Delphi method, the second clarified questions regarding topics determined by the first survey. Sleep medicine learning objectives for residents were ascertained from responses. RESULTS: The response rate of first and second surveys were 24.5% and 19%, respectively. Topics ranked most important for resident education included upper airway anatomy, polysomnogram interpretation, and understanding the range of medical and surgical therapies used to treat sleep disorders. Respondents listed surgical therapy as the most critical topic that most residents do not understand well. The second survey clarified the specific anatomic features, surgical techniques, and polysomnography data points deemed most critical for resident learning. CONCLUSIONS: Academic otolaryngology sleep experts hold opinions regarding relative value of different topics for teaching sleep medicine, which is useful in creating a curriculum for otolaryngology residents. Otolaryngology learning objectives related to sleep medicine identified during this study are being used to create an online curriculum to supplement resident education.

Variability of Ratings in the Otolaryngology Standardized Letter of Recommendation.

OBJECTIVE: To determine the variability of ratings given to students on the otolaryngology standardized letter of recommendation (SLOR). STUDY DESIGN: Retrospective review. SETTING: Academic otolaryngology training program. SUBJECTS AND METHODS: 496 SLORs to the Cleveland Clinic Otolaryngology Training Program were reviewed. The SLORs were extracted from the applications and analyzed. The distributions of ratings across the 10 categories were statistically analyzed including distribution and standard deviation. Rankings were grouped into deciles for this analysis. RESULTS: Ratings across the 10 domains revealed clustering of results across the top 2 deciles. The distribution of the bell-shaped curve was shifted significantly to the left, representing the upper deciles. No evidence of gender or geographic bias was found. Longer length of time of association between the applicant and the letter writer correlated to a higher ranking. CONCLUSION: The explosion of applications being sent out by candidates for otolaryngology residency programs has prompted the implementation of the SLOR. The lack of variation in the ratings across the 10 domains does not allow for differentiation among student applicants. Reliance on the narrative letter of recommendation attached to the SLOR still remains the most significant way to differentiate among applicants. Refinements will need to be made in either the structure or use of the SLOR for it to be a more useful tool.

Referral Patterns and Positive Airway Pressure Adherence upon Diagnosis of Obstructive Sleep Apnea.

OBJECTIVE: Obstructive sleep apnea (OSA) is a serious medical condition that adds to patient morbidity and mortality. Treatment with positive airway pressure (PAP) is the standard of care, but many patients refuse or do not tolerate PAP. Little is known about the subsequent management of these patients. We sought to understand what types of treatment, if any, adult patients with OSA receive who either fail or refuse PAP therapy within our institution. STUDY DESIGN: Retrospective chart review. SETTING: Academic hospital. SUBJECTS: All adult patients undergoing polysomnogram during the months of March and April 2010 (n = 1174) who were diagnosed with OSA. METHODS: The electronic medical record was reviewed to determine the subsequent management of patients with a diagnosis of OSA, including tolerance or failure of PAP and referral to specialists upon intolerance. RESULTS: Of 1174 patients, 616 met inclusion criteria. Ultimately, 260 (42%) had documented adherence to PAP. Of 241 untreated patients, 84 patients (35%) were referred for further attempts at management of diagnosed OSA. Nearly half of patients with diagnosed OSA did not have continued treatment or referral. CONCLUSION: To our knowledge, this is the first study to define the subsequent management of patients who have failed or refused PAP. Despite the known sequelae of OSA, clinicians are not treating a significant percentage of patients with diagnosed OSA. Those who fail to tolerate PAP therapy are unlikely to be referred for additional treatment. Therapies other than PAP may be warranted in this population.

Managing snoring: when to consider surgery.

Snoring can range in significance from merely annoying the patient's bed partner to being a symptom of obstructive sleep apnea, a risk factor for heart disease and stroke. If conservative measures do not help, primary care physicians can refer patients for consideration of a variety of surgical procedures to keep the airway open during sleep.

Patient reported outcomes in endoscopic and open transcervical treatment for Zenker's diverticulum.

OBJECTIVES/HYPOTHESIS: To compare long-term symptomatic outcomes between external transcervical (ET) and endoscopic stapling diverticulotomy (ESD) surgeries for Zenker's diverticulum. STUDY DESIGN: Retrospective review. METHODS: Patients undergoing surgery for Zenker's diverticulum surgery between 1998 and 2010 with at least 1 year follow-up were telephoned and questioned for dysphagia, choking, regurgitation, and halitosis based on a validated Gastrointestinal Quality-of-Life Index. Symptom degree preoperatively and at phone call was assessed. Patients rated their overall postoperative symptoms as worsened, unchanged, improved, or completely resolved. RESULTS: A total of 96 patients were eligible for inclusion and 55 were successfully contacted. Of these, 24 underwent ESD and 31 had ET operations. Average follow-up time was significantly longer for the ET group than the ESD group (5.7 vs. 3.1 years respectively, P < 0.01). Gender, age at operation, diverticulum size, and preoperative symptom scores were not statistically different between the two groups. For both techniques, symptom scores showed significant improvement postoperatively (P < 0.01). A greater proportion of patients undergoing ET procedures reported their symptoms to be completely resolved or improved compared with the ESD group (93% vs. 67%, P = 0.015). Patients undergoing ET demonstrated a greater change or improvement in survey score compared to ESD patients (7.23 vs. 3.42, P = 0.014). CONCLUSION: Both the ET and ESD surgeries significantly benefit patients, regardless of diverticulum size. Long-term symptomatic outcomes between the two populations indicate that patients with ET procedures attain a greater degree of resolution of preoperative symptoms.

Safety of outpatient surgery for obstructive sleep apnea.

OBJECTIVE: Determine the safety experience of adult obstructive sleep apnea patients undergoing airway surgery. STUDY DESIGN: A retrospective cohort study. SETTING: The experience of members of a large Medicaid managed care organization between January 10, 2009, and June 30, 2011. SUBJECTS AND METHODS: Four hundred fifty-two adult Medicaid obstructive sleep apnea (OSA) patients (404 ambulatory, 48 inpatient) receiving head and neck airway surgery form the basis of this report. Four safety indicators were reported from administrative data for 30 days: emergency room visit, inpatient admission, observation day, and 3 or more primary care physician visits. The occurrence of myocardial infarction, deep venous thrombosis, stroke, pulmonary embolism, tracheostomy, or transfusion was noted. RESULTS: Ninety-four percent of the nasal, 86% of the palatal, and 79% of the nasal/palatal surgeries (89% overall) were ambulatory. The observed catastrophic complication rate among ambulatory patients was zero (95% confidence interval, 0.0%-1.1%). Emergency room visits for pain-related diagnoses were the most common adverse outcome (51%). Administrative data sets can be used to provide insight into practice safety questions. CONCLUSION: Contrary to guidelines, most OSA patients underwent ambulatory head and neck airway surgery. The observed catastrophic complication rate was zero. Administrative data sets can be used to provide insight into practice safety questions. Further study is warranted of ambulatory surgery management of adult sleep apnea patients.