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.

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study.

OBJECTIVES/HYPOTHESIS: To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA). STUDY DESIGN: Cohort study. METHODS: A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour. RESULTS: Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m2 . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042). CONCLUSIONS: The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1676-1682, 2021.

Recreational motor vehicle use and facial trauma.

OBJECTIVES/HYPOTHESIS: The use of recreational motorized vehicles (RMVs), including all-terrain vehicles (ATVs), snowmobiles, and go-carts, has increased in recent decades. Because RMVs are lightly regulated, there are numerous safety concerns. This analysis examines a nationally representative resource to estimate the incidence of craniofacial trauma secondary to RMV accidents, evaluating injury and demographic patterns. METHODS: The Consumer Product Safety Commission's National Electronic Injury Surveillance System was examined for facial trauma resulting in emergency department (ED) visits stemming from the use of ATVs, motorbikes/scooters, snowmobiles, and utility vehicles. Characteristics including demographics, anatomic sites, mechanism, and location of injury were evaluated, as well as details regarding helmet and alcohol use. RESULTS: There were 1,464 entries extrapolating to an estimated 61,312 ED visits over a 5-year period for facial trauma from RMV use. From 2009 to 2013, there was a 28% reduction in ED visits. The majority of patients were male, and the median age was 17 years. Lacerations (45.1%), contusions/abrasions (26.7%), and fractures (24%) were the most frequent injuries. Among fractures, the most common types were nasal (29%), followed by mandible (20%) and orbital (8%) fractures. All-terrain vehicles (62%) were the most common vehicles. Alcohol consumption resulted in a higher rate of facial fractures (48.5% vs. 22.8%). CONCLUSION: As there is a significant potential for injury, familiarity with injury patterns associated with RMVs is useful in the management of facial trauma. Recreational motorized vehicles facial trauma results in tens of thousands of ED visits annually. This data reinforces the importance of pursuing further efforts to raise public awareness and improve safety measures.

Transoral robotic surgery for treatment of obstructive sleep apnea: factors predicting surgical response.

OBJECTIVES/HYPOTHESIS: We reviewed our experience with the use of transoral robotic surgery (TORS) for base of tongue (BOT) reduction either alone or as part of multilevel strategy in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS) in order to identify clinical characteristics that may be associated with surgical response. STUDY DESIGN: Case series. METHODS: Between June 2010 and May 2014, BOT reduction via TORS ± partial epiglottectomy ± uvulopalatopharyngoplasty were performed on 72 patients with OSAHS. Thirty-nine patients (15 females and 24 males) with complete preoperative and postoperative clinical information including polysomnograms were included in this study. RESULTS: Mean apnea-hypopnea index (AHI) was 43.9 ± 32.3 preoperatively and 21.9 ± 23.5 postoperatively and reflected a statistically significant (P < 0.001) AHI reduction of 50.9% ± 38.1%. Statistical significant reduction in daytime somnolence, as measured by Epworth Sleepiness Scale (15.6 ± 5.4 preoperatively vs. 5.7 ± 4.3 postoperatively; P < 0.001), was also achieved. No statistical significant difference was found between preoperative and postoperative body mass index (BMI) (32.9 ± 7.0 vs. 32.4 ± 7.3; P = 0.270). Surgical response, as defined by > 50% reduction in AHI and final AHI < 15 with resolution of daytime somnolence, was achieved in 21 patients (53.8%). Clinical characteristics found to be significantly different between the responders and nonresponders were BMI, AHI, and lateral velopharyngeal collapse. Patients with BMI < 30, AHI < 60, or absence of lateral velopharyngeal collapse have excellent surgical response rate of 88.2%, 67.9%, or 66.7%, respectively. CONCLUSIONS: We identified three clinical characteristics associated with increased surgical response rate. This finding may be useful for patient selection and counseling prior to surgery.

Airway management after maxillectomy: routine tracheostomy is unnecessary.

OBJECTIVES/HYPOTHESIS: There is a paucity of data to guide the optimal management of the airway in patients after maxillectomy. The decision on whether a concomitant tracheostomy is needed is often dictated by the surgeon's training and experience. We reviewed our experience with maxillectomy to assess the need for tracheostomy in postoperative airway management. STUDY DESIGN: Retrospective analysis at a university hospital. METHODS: We identified 121 patients who underwent 130 maxillectomies between October 1990 and September 2001. Twenty-four of these were total (all six walls removed), 45 were subtotal (two or more walls removed), and 61 were limited (only one wall removed). Reconstruction ranged from none to microvascular free flap, with split-thickness skin graft being the most common reconstructive option. RESULTS: Only 10 tracheostomies (7.7%) were performed at the time of maxillectomy. These included four tracheostomies in patients who underwent bulky flap reconstruction, two tracheostomies in patients who underwent both flap reconstruction and mandibulectomy, one tracheostomy in a patient who underwent mandibulectomy, one tracheostomy in a patient with mucormycosis in anticipation of prolonged ventilatory support postoperatively, and two tracheostomies at the surgeons' discretion because of concern for upper airway edema. Among the 111 patients who underwent 120 maxillectomies without concomitant tracheostomy, 1 patient (0.9%), a 74 year-old man with oxygen-dependent chronic obstructive pulmonary disease, required repeat intubation on day 3 and again on day 10 after the surgery, because of respiratory failure; fiberoptic examination confirmed the absence of upper airway compromise. CONCLUSIONS: The routine performance of tracheostomy in patients undergoing maxillectomy is unnecessary. Selective use of tracheostomy may be indicated in situations in which mandibulectomy or bulky flap reconstruction is performed or a concern for postoperative oropharyngeal airway obstruction because of edema or packing exists.

Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES/HYPOTHESIS: To evaluate the efficacy of base of tongue (BOT) resection via transoral robotic surgery (TORS) in the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Case series METHODS: Between June 2010 and May 2012, BOT resection via TORS was performed on 27 patients with OSAHS. Patients were excluded from this analysis if other concomitant upper airway procedures such as uvulopalatopharyngoplasty were performed, or if postoperative polysomnograms were not available. RESULTS: Twelve patients who underwent BOT resection alone were included in this study. The median age for these 12 patients was 48.5 (range, 19-64) and included nine females and three males. The mean apnea-hypopnea index (AHI) was 43.9 ± 41.1 preoperatively and 17.6 ± 16.2 postoperatively. This difference in AHI was statistically significant (P = 0.007) and reflected an average AHI reduction of 56.2 ± 28.3%. Statistical significant reductions in daytime somnolence level, as measured by Epworth Sleepiness Scale (13.7 ± 5.2 preoperatively vs. 6.4 ± 4.5 postoperatively, P <0.001), and snoring intensity, as reported by a bed partner using a Visual Analogue Scale (8.6 ± 1.2 preoperatively vs. 4.2 ± 1.9 postoperatively, P <0.001), were achieved. There was no statistical significant difference between the preoperative and postoperative body mass index (34.5 ± 7.3 vs. 33.5 ± 6.7, P = 0.296) or minimum oxygen saturation (83.3 ± 5.5% vs. 84.0 ± 6.4%, P = 0.680). CONCLUSIONS: This is the first study looking at the use of TORS to address obstruction at the level of BOT only, not confounded by surgical alterations at other levels of upper airway. This preliminary result on the use of BOT resection via TORS for the treatment of patients with OSAHS is encouraging and warrants further investigations.

Site involvement as a predictor of airway intervention in angioedema.

OBJECTIVES/HYPOTHESIS: To look for a relationship between which sites are involved in angioedema and the need for airway intervention (intubation, tracheotomy). STUDY DESIGN: Retrospective chart review. METHODS: Charts of 140 patients who were admitted to two hospitals at an academic medical center between July 1, 2006 and June 30, 2008 with the diagnosis of angioedema were reviewed. Charts were reviewed for pertinent data, including demographics, sites of involvement along the upper airway, medical therapy, and airway intervention. Subsites included lips, anterior tongue, floor of mouth, soft palate, base of tongue (BOT), and larynx. RESULTS: The BOT was involved in 19 patients and the larynx was involved in 29 patients. Airway intervention was required in 21 patients (16%). Patients with laryngeal and/or BOT involvement required intervention in 38% of cases (vs. 7% in patients without involvement). Patients with more than three sites involved had a 39% rate of intervention, compared with only 12% in patients with less than three sites involved. Among those patients with laryngeal/BOT involvement, 56% with more than three sites involved required intervention, as compared to 30% of patients with less than three sites involved. CONCLUSIONS: Site of involvement was found to correlate with airway intervention. Involvement of anterior tongue, BOT, and larynx significantly increased the likelihood of intubation or tracheostomy, as did involvement of multiple sites. Thorough evaluation, including fiberoptic laryngoscopy, can aid in determining which patients require airway intervention.

Factors predictive of severity of osteoradionecrosis of the mandible.

BACKGROUND: An analysis of risk factors predictive of severe mandibular osteoradionecrosis (ORN) is needed to aid prophylaxis and management of this condition. METHODS: We retrospectively analyzed 46 patients diagnosed between June 2002 and March 2009: 93% had mandibular ORN, which was staged 0 to III (Store and Boysen). Patient, tumor, treatment-related, and other variables were analyzed for association with mandibular ORN severity. RESULTS: Oral or oropharyngeal tumors comprised 85% of our primary tumors, 80% were stage IV, and 91% were squamous cell carcinomas. Most patients (87%) received 3-dimensional (3D) conformal radiation therapy (RT), with 60 Gray (Gy) median dose; 28% and 72% received primary and adjuvant RT, respectively; 78% received chemotherapy, mostly concurrent (97%) and platinum-based (96%). Median time to development of ORN was 7.5 months. White ethnicity and secondary infection correlated significantly with stage III mandibular ORN (p = .038, p = .0007, respectively). Advanced age, stage IV, RT dose, post-RT, and lack of pre-RT dental extractions appeared predictive of severe mandibular ORN. CONCLUSIONS: The above-cited factors are predictive of severity and can potentially guide prophylaxis and management.