El paciente roncador: evaluación y alternativas terapéuticas / The snoring patient: evaluation and therapeutic alternatives

El ronquido es un problema altamente prevalente, que afecta a millones de personas a nivel mundial. Impacta negativamente en la calidad de vida al afectar la relación de pareja y la calidad de sueño, además de constituir un factor de riesgo cardiovascular. El objetivo de esta revisión es analizar y discutir los aspectos más relevantes de esta condición, desde su etiopatogenia hasta las diferentes alternativas terapéuticas disponibles. En la evaluación del paciente roncador se debe realizar un minucioso examen de nariz, boca, faringe, cuello y esqueleto facial, además de estimar el riesgo de que exista una apnea obstructiva del sueño asociada. Son de utilidad una serie de cuestionarios que permiten asignar puntaje a la sintomatología del paciente y evaluar su impacto en la vida diaria. En general, el estudio deberá incluir exámenes radiológicos, endoscopías de la vía aérea superior (con el paciente despierto y bajo sueño inducido por medicamentos) y estudios del sueño, que se pueden realizar tanto en forma ambulatoria como hospitalizado. Existe una amplia gama de tratamientos disponibles para el ronquido, los que han demostrado una alta efectividad en diferentes subgrupos de pacientes: bajar de peso, dejar de fumar, medicamentos antialérgicos, terapia postural, ejercicios faríngeos, dispositivos de avance mandibular y procedimientos quirúrgicos que van desde intervenciones mínimamente invasivas hasta procedimientos avanzados como cirugía robótica, avances máxilo-mandibulares y la estimulación del nervio hipogloso. Es clave para manejar exitosamente el ronquido el realizar una evaluación detallada del paciente y establecer un plan terapéutico personalizado.

Snoring is a highly prevalent problem, affecting millions of people worldwide. It negatively impacts quality of life by affecting couple relationships and sleep quality, as well as being a cardiovascular risk factor. The aim of this review article is to analyze and discuss the most relevant aspects of this condition, ranging from its etiology and pathogenesis to the different available therapeutic options. When evaluating a snoring patient, a thorough examination of the nose, mouth, pharynx, neck and facial skeleton should be performed, and the risk of having an associated obstructive sleep apnea must be estimated. A series of questionnaires are useful to assign scores to the patient's symptoms and assess their impact on daily life. In general terms, patient evaluation should include radiological examinations, upper airway endoscopies (awake and under drug-induced sleep) and sleep studies, which can be performed both on an outpatient or inpatient basis. There is a wide range of treatments available for snoring, which have shown high effectiveness in different patient subgroups: weight loss, quitting smoking, anti-allergic medications, postural therapy, pharyngeal exercises, mandibular-advancement devices and surgical procedures ranging from minimally invasive interventions to advanced procedures such as robotic surgery, maxillomandibular advancement and hypoglossal nerve stimulation. The cornerstone for a successful snoring management is to perform a detailed patient evaluation and to establish a personalized therapeutic plan.

Differences in patients derived from otolaryngology and other specialties with sleep apnea.

BACKGROUND: Snoring is a main concern in patients who consult an otolaryngologist (ENT physicians) and patients who have cardiovascular comorbidities or excessive daytime sleepiness who usually consult with other specialists. The aim of this study was to describe the clinical differences in patients with obstructive sleep apnea (OSA) referred from ENT or other specialists. METHODS: A prospective study was carried out between June 2015 and July 2018 in a tertiary center. We included patients with suspected OSA referred by the Home Sleep Apnea Test (HSAT) from different specialties such as ENT or other specialties. The main outcome measures of our study were demographic characteristics, clinical characteristics, sleep questionnaire results and HSAT results between OSA patients referred from ENT or other specialists. We used a t-test and chi-squared test for analysis. The diagnostic accuracy of the sleep questionnaires was achieved using receiver operating characteristic (ROC) curve and the area under the curve (AUC). RESULTS: A total of 481 patients were included. OSA was occurred in 82.4% of the subjects (90 in ENT and 306 in other specialties). Patients with OSA referred from other specialists were older than ENT patients (55 ± 13 vs 44 ± 12; p < 0.001), there was more obesity (IMC 31 ± 5.0 vs 28.7 ± 3.8; p < 0,001), a larger neck circumference (42.2 cm ± 3.7 vs 40.6 cm ± 3.0; p < 0.001) and more reported comorbidities (p < 0.001). ENT patients reported mild OSA (46% vs 31%, p = 0.015) and more positional apnea (62% vs 39%, p = 0.002). In this group, the STOP-BANG questionnaire showed an AUC 0.695 vs AUC 0.804, and for sensitivity, the best cutoff was 4 points. Patients referred from otorhinolaryngology are different from those referred from other specialties. Clinical evaluation and screening of OSA should be patient-centered according to these clinical findings.

Peritonsillar abscess: treatment with immediate tonsillectomy - 10 years of experience.

CONCLUSION: Immediate tonsillectomy in patients with peritonsillar abscess is a safe and effective treatment that should be considered as an alternative to conventional incision and drainage. OBJECTIVE: To assess the efficacy, safety, and microbiology of immediate tonsillectomy over 10 years, in patients with peritonsillar abscess. METHODS: This was a retrospective study. We reviewed the clinical charts of patients diagnosed with peritonsillar abscess in Clínica Las Condes from September 2000 to August 2010, who were treated with immediate unilateral or bilateral tonsillectomy. The patients' epidemiological information, antibiotic therapy, laterality of the surgery, results of microbiological cultures, complications, and recurrences were recorded. RESULTS: A total of 112 patients were studied, with a mean age of 24 years. There were no events of sepsis, and there were only four cases (3.6%) of postoperative bleeding, two of which resolved spontaneously. Only 29% of the patients required morphine pump-based analgesia in the postoperative period. The mean length of hospital stay was 3.4 days. Among the 28 unilateral tonsillectomies, 4 (14.2%) developed streptococcal tonsillitis and 2 (7.1%) were readmitted with a contralateral peritonsillitis: one cellulitis and one abscess that required drainage and tonsillectomy. The most frequently isolated microorganisms were gram-positive bacteria (Streptococcus pyogenes and other streptococci) and anaerobic bacteria (mainly Bacteroides spp. and Fusobacterium nucleatum).

Otolaryngological complications in patients infected with the influenza A (H1N1) virus.

OBJECTIVE: To describe bacterial upper respiratory infections in patients with influenza A (H1N1) virus during the 2009 pandemic. STUDY DESIGN: Case series with chart review. SETTING: May 17 to July 17, 2009, Clinica Las Condes, Santiago, Chile. SUBJECTS AND METHODS: Patients with clinical and/or laboratory diagnosis of influenza A (H1N1) who presented to the emergency department or other medical specialists with bacterial upper respiratory infection requiring antibiotic treatment within 2 months of influenza diagnosis. RESULTS: A total of 10,048 cases of influenza A (H1N1) were identified by the emergency department. All patients received oseltamivir. Fifty-four patients (0.55%) who presented with bacterial upper respiratory infection within 2 months after the diagnosis of influenza were selected. The median time to presentation with bacterial respiratory infection was 12 days. Median age was 12 years, and 51.8% were male. The most common bacterial upper respiratory infections were acute rhinosinusitis (46.4%; median age, 17 years), acute otitis media (33.9%; median age, 5 years), and pharyngotonsillitis (14.3%; median age, 17 years). Four patients were hospitalized: 3 with streptococcal tonsillitis with prolonged fever and 1 with acute otitis media who later developed pansinusitis and otomastoiditis. There were no deaths in this group of patients. CONCLUSION: There were few bacterial upper respiratory infections associated with influenza A (H1N1) (0.55%). The most common infections were acute otitis media in young children and acute rhinosinusitis and pharyngotonsillitis in young adults. These complications were more often seen during the 2 months following the influenza infection than at the time of diagnosis with influenza. Outcome was favorable for all patients.

Spanish validation of the University of Washington Quality of Life questionnaire for head and neck cancer patients.

OBJECTIVE: The University of Washington Quality of Life (UW-QOL) questionnaire is one of the most widely used instruments to evaluate the quality of life of head and neck cancer patients. The aim of this study was to perform a Spanish translation and validation of the UW-QOL questionnaire. STUDY DESIGN: A cross-sectional study. SETTING: Three tertiary-care hospitals and a laryngectomee rehabilitation center. SUBJECTS AND METHODS: The translation and cultural adaptation of the questionnaire were performed following accepted international guidelines. The psychometric validation was performed on a consecutive series of patients treated for squamous cell carcinoma of the upper aerodigestive tract with no signs of relapse, recruited from May 2007 to December 2008. Eligible subjects were invited to complete the Spanish version of the UW-QOL questionnaire during routine clinical consultation, and complete it again within 15 days. Subjects also completed a validated Spanish version of the Goldberg Mental Health Survey and were evaluated by the use of the Karnofsky Index. RESULTS: A Spanish version of the questionnaire was developed in iterative fashion. In the psychometric validation process, a total of 76 patients were analyzed. Reliability was excellent, including both internal consistency (Cronbach's alpha of 0.84) and test-retest reliability (intraclass correlation coefficient between 0.91 and 0.97 with a confidence interval of 95%). Construct validity was supported by statistically significant relationships between the Karnofsky Index, the Goldberg Mental Health Survey, and the translated UW-QOL questionnaire. CONCLUSION: The Spanish version of the UW-QOL questionnaire appears to be culturally appropriate and psychometrically valid.

Urinary leukotrienes in patients with nasal polyposis.

OBJECTIVES: To compare urinary leukotriene E4 (ULT) level in patients with nasal polyposis (NP) with and without aspirin intolerance and allergic rhinitis (AR), and correlate it with disease severity. STUDY DESIGN AND SETTING: Prospective study from November 2005 to November 2006. Patients with NP (n = 30) and AR (n = 35) were included. The concentration of ULT was measured in both groups. Oral provocation test with aspirin was performed to patients with NP. ULT level between both groups was compared and correlated with NP disease severity. RESULTS: ULT concentration was elevated on NP and AR. The patients with NP and aspirin intolerance (n = 4) presented higher levels of ULT compared to aspirin-tolerant patients. Leukotriene concentration was not correlated with NP severity. CONCLUSIONS: Patients with NP and aspirin intolerance have increased ULT excretion; thus their measurement can be used as an indicator of arachidonic acid metabolism alteration.

Subtemporal-preauricular approach in the management of infratemporal and nasopharyngeal tumours.

OBJECTIVES: To evaluate the indication, advantages, and results of the subtemporal-preauricular approach in the resection of tumours arising in the infratemporal fossa and related structures of the lateral cranial base. DESIGN: Retrospective analysis of patients treated by the subtemporal-preauricular approach to resect nasopharyngeal and infratemporal tumours. SETTING: Tertiary hospital. METHODS: Forty patients with lateral skull base lesions were managed with the subtemporal-preauricular approach. There were 19 benign lesions and 21 malignant tumours, the most common being nasopharyngeal carcinomas, juvenile angiofibromas, and adenoid-cystic carcinomas. Most of the tumours were at an advanced stage, with skull base involvement in 13 benign tumours and in 14 malignant ones. RESULTS: Major complications occurred in 6 (14%) patients, and there were 2 (5%) postoperative deaths. All 19 patients with benign tumours are alive, although 5 of them (26%) presented with residual or recurrent disease. The 5-year estimated survival rate of the 21 patients with malignant neoplasms was 39%. CONCLUSIONS: The subtemporal-preauricular approach is a safe and versatile approach to the infratemporal fossa and neighbouring areas of the lateral cranial base, offering satisfactory oncologic results in the absence of intracranial involvement.

Amplification of CCND1, EMS1, PIK3CA, and ERBB oncogenes in ethmoid sinus adenocarcinomas.

OBJECTIVE: Assess the amplification of CCND1, EMS1, PIK3CA, ERBB1, and ERBB2 oncogenes in ethmoid sinus adenocarcinomas. STUDY DESIGN AND SETTING: Tissue samples from 13 primary ethmoid adenocarcinomas and 2 recurrences were studied at Hospital Central de Asturias, Oviedo, Spain, between July 1998 and February 2002. A semiquantitative evaluation of CCND1, EMS1, PIK3CA, ERBB1, and ERBB2 amplification was performed by multiplex polymerase chain reaction. RESULTS: Three (23%) cases presented CCND1 amplification, one of them with a concurrent PIK3CA amplification. EMS1 was amplified in the 2 studied recurrences. ERBB1 was amplified in 1 case (8%), whereas none presented ERBB2 amplification. Oncogenic amplifications were only detected in advanced (stage III) tumors; however, no prognostic value could be shown for them. CONCLUSIONS: CCND1, EMS1, PIK3CA, and ERBB1 amplifications are uncommon and appear to be late events in the development of ethmoid sinus adenocarcinoma. SIGNIFICANCE: New information on the carcinogenesis of this infrequent sinonasal tumor is presented.

Prognostic factors of maxillary sinus malignancies.

BACKGROUND: Analysis of a series of tumors of the maxillary sinus show contradictory outcome data. The purpose of this article was to study the prognostic factors that may have implications for patient management. METHODS: We present a retrospective review of 57 patients who underwent a maxillectomy over a 20-year period. RESULTS: At the time of presentation, 86% of patients had advanced local disease (T3-T4). The 5-year disease-specific survival rate of this series was 39%. No significant differences on survival were observed according the histology of the tumor (p = 0.213), extension to the infratemporal fossa (p = 0.314), and postoperative radiotherapy (p = 0.723). Factors that revealed a significant reduction of survival were skull base involvement (p = 0.013), involvement of the orbit (p = 0.043), and recurrent disease (p = 0.048). Multivariate analysis confirmed that the skull base and orbital involvement were significantly associated with disease-specific survival. CONCLUSION: Advanced T stage, base of skull involvement, orbital extension, and local recurrence are highly predictive of poor survival.