Clinical Characteristics of Patients with Dental Malocclusion: An Otolaryngologic Perspective.

Purpose: Allergic rhinitis (AR), which is a major cause of upper airway obstruction, may affect the development of the dental malocclusion. This retrospective study was aimed to investigate association between AR and dental malocclusion in otolaryngologic perspectives. Methods: Patients (n = 217) referred to the otolaryngology department before initiating orthodontic treatment were recruited. The frequency and severity of AR symptoms, sinonasal outcome test (SNOT-22) scores, physical examination findings, acoustic rhinometry results, and treatment modalities were retrospectively assessed. Patients with positive skin prick test findings (SPT) (n = 173; orthodontic group) were compared with age- and sex-matched patients being treated for AR (AR group). Results: We found that 76.5% of the enrolled patients had subjective nasal symptoms, and 93.1% patients showed abnormal physical examination findings such as inferior turbinate hypertrophy (82.0%), adenotonsillar hypertrophy (31.8%), or deviated nasal septum (7.4%). The 173 (79.7%) patients with positive SPT results exhibited a significantly higher incidence of rhinorrhoea, sneezing, and inferior turbinate hypertrophy compared to those with negative SPT results. The proportion of patients who underwent pharmacological or surgical treatments was significantly higher among patients with nasal obstruction (92.0%) than among patients without nasal obstruction (36.9%). The frequency and mean visual analogue symptom scores for nasal obstruction, rhinorrhoea, and sneezing, as well as all SNOT-22 domain scores, were significantly higher in the AR group than in the orthodontic group. The minimal cross-sectional area measured with acoustic rhinometry showed no significant difference between groups. Conclusion: Patients with dental malocclusion had a high SPT (+) rate and a high prevalence of structural abnormalities of the upper airway. The early detection and treatment of subclinical AR, other rhinological problems, and structural abnormalities of the upper airway in patients with malocclusion may help us manage malocclusion from an otolaryngologic perspective.

Role of Transient Receptor Potential Vanilloid 1 in Sonic Hedgehog-Dependent Taste Bud Differentiation.

Taste bud cell differentiation is extremely important for taste sensation. Immature taste bud cells cannot function during taste perception transmission to the nerve. In this study, we investigated whether hedgehog signaling affected taste bud cell differentiation and whether transient receptor potential vanilloid 1 (TRPV1) played a key role in dry mouth. The induction of dry mouth due to salivary gland resection (SGR) was confirmed on the basis of reduced salivation and disrupted fungiform papillae. The expression of keratin 8 (K8) of taste bud cells, neurofilament (NF), sonic hedgehog (Shh), and glioma-associated oncogene homolog 1 (Gli1) around taste bud cells was downregulated; however, the expression of TRPV1, P2X purinoceptor 3 (P2X3), and hematopoietic stem cell factor (c-Kit) was upregulated at the NF ends in the dry mouth group. To investigate the effect of TRPV1 defect on dry mouth, we induced dry mouth in the TRPV-/- group. The K8, NF, and P2X3 expression patterns were the same in the TRPV1 wild-type and TRPV1-/- dry mouth groups. However, Shh and c-Kit expression decreased regardless of dry mouth in the case of TRPV1 deficiency. These results indicated that TRPV1 positively regulated proliferation during taste bud cell injury by blocking the Shh/Gli1 pathway. In addition, not only cell proliferation but also differentiation of taste bud cells could not be regulated under TRPV1-deficiency conditions. Thus, TRPV1 positively regulates taste bud cell innervation and differentiation; this finding could be valuable in the clinical treatment of dry mouth-related taste dysfunction.

Long-term outcome of concurrent coblator turbinoplasty with adenotonsillectomy in children with allergic rhinitis.

BACKGROUND: Allergic rhinitis (AR) is one of the most prevalent chronic diseases in children. Patients with AR tend to have more persistent symptoms after adenotonsillectomy (T&A). OBJECTIVES: This study was aimed to evaluate the outcome of additional concurrent coblation-assisted turbinoplasty with adenotonsillectomy (T&A + T) in patients with AR. MATERIAL AND METHODS: This study included 104 children who underwent T&A, and 67 who underwent T&A + T. All patients were diagnosed as AR and were aged < 12 years at the time of surgery. Symptoms (snoring, mouth breathing, nasal obstruction, rhinorrhea, itching, and sneezing) were evaluated preoperatively and postoperatively via a questionnaire and a telephone survey. RESULTS: None of the six symptoms investigated differed significantly between the two groups preoperatively, and all evaluated symptoms exhibited dramatic improvements after the surgery in both groups. The T&A + T group showed significantly greater difference of improvement in mouth breathing and nasal obstruction than T&A group. There were no significant difference of improvements in snoring, rhinorrhea, itching and sneezing postoperatively between two groups. In multiple regression analysis, postoperative obstructive symptoms including mouth breathing and nasal obstruction were significantly associated with concurrent turbinoplasty. CONCLUSION: Concurrent turbinoplasty should be considered especially in patients who have AR and adenotonsillar hypertrophy to improve obstructive symptoms.

The implication of sleep position in the evaluation of surgical outcomes in obstructive sleep apnea.

OBJECTIVE: To investigate the effect of sleep position on surgical outcomes in obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective review of 69 consecutive patients. SUBJECTS AND METHODS: Preoperative and postoperative polysomnographic data and Epworth sleepiness scale were obtained. Patients were categorized into success, response, no response, and failure groups according to apnea-hypopnea index (AHI) after uvulopalatopharyngoplasty. Proportions of supine or lateral position and AHI of each position were evaluated. Position-corrected AHI was developed in order to eliminate the effect of sleep position. RESULTS: Preoperative proportion of supine position in the failure group (n = 26) was 41.3 percent, which was the lowest among four groups (P = 0.010), and increased to 60.8 percent postoperatively (P = 0.028). Twenty-two (84.6%) among the failure group had supine position dependency. Regrouped by position-corrected AHI, 15 patients moved into different groups. Postoperative AHI showed positive correlation with increased supine position when BMI was controlled (r = 0.515, P = 0.006). CONCLUSION: Without appropriate correction based on the change of sleep position, the fluctuation of sleep position in each polysomnography might confound surgical outcomes in OSA patients. Thus, it is a substantial issue how to control or reflect the positional effect on AHI when treatment results are evaluated.

The Impact of Allergic Rhinitis on Symptom Improvement in Pediatric Patients After Adenotonsillectomy.

OBJECTIVES: It is well known that allergic rhinitis (AR) has positive association with adenotonsillectomy. However, the impact of AR on symptom improvement after adenotonsillectomy is not well documented. Hence, we aimed to evaluate the effect of AR on the symptom improvement after adenotonsillectomy between AR and nonallergic patients. METHODS: A retrospective analysis was performed on 250 pediatric patients younger than 10 years old who received adenotonsillectomy from June 2009 to June 2014 in a tertiary referral hospital. All patients underwent skin prick test or multiple allergen simultaneous test (MAST) before surgery and classified into AR group and control group. Obstructive and rhinitis symptoms including snoring, mouth breathing, nasal obstruction, rhinorrhea, itching, and sneezing were evaluated before and 1 year after surgery using questionnaire and telephone survey. RESULTS: AR group was 131 and control group was 119, showing higher prevalence (52.4%) of AR among adenotonsillectomized patients. Both groups showed dramatic improvement of symptoms such as snoring and mouth breathing after surgery (all P<0.05). However, AR group showed significantly less improvement than control group in snoring, mouth breathing, nasal obstruction, and rhinorrhea (all P<0.05). Multivariate analysis showed that preoperative mouth breathing and snoring were dependent on tonsil grade and postoperative symptoms were mainly dependent on presence of AR. Nasal obstruction was dependent on tonsil grade and presence of AR preoperatively and presence of AR postoperatively. These suggest the importance of AR as a risk factor for mouth breathing, snoring, and nasal obstruction. CONCLUSION: AR has positive association with adenotonsillectomy and not only allergic symptoms but also obstructive symptoms such as snoring and mouth breathing improved less in AR group than control group. Hence, patients with AR should be monitored for long-term basis and more carefully after adenotonsillectomy.

Mouth opening during sleep may be a critical predictor of surgical outcome after uvulopalatopharyngoplasty for obstructive sleep apnea.

STUDY OBJECTIVES: To evaluate the value of mouth opening during sleep for predicting surgical outcomes after uvulopalatopharyngoplasty (UPPP). METHODS: Retrospectively, 69 out of 120 consecutive patients with obstructive sleep apnea who underwent uvulopalatopharyngoplasty at an academic tertiary referral center were included in this study. Sixty-nine subjects underwent cephalometry, nocturnal polysomnography and sleep videofluoroscopy before and after UPPP. Multiple parameters from the above studies were evaluated as potential predictors of UPPP outcomes. RESULTS: Multivariate analysis showed that an increased angle of mouth opening during sleep was the only significant predictor for surgical failure (p < 0.001). The angle of mouth opening could predict surgical outcome with predictive values of 72.4% and 82.5% for success and failure, respectively. CONCLUSIONS: Sleep videofluoroscopy during sleep revealed that the simple measurement of mouth-opening angle could outstandingly predict surgical outcome.

Determinants of treatment outcome after use of the mandibular advancement device in patients with obstructive sleep apnea.

OBJECTIVE: To determine the predictors affecting treatment outcome after application of the mandibular advancement device (MAD). DESIGN: Retrospective analysis. SETTING: Tertiary care university hospital. PATIENTS: A total of 76 patients (68 men and 8 women) who were treated with the MAD for obstructive sleep apnea (OSA) were included from September 2005 through August 2008. All the subjects underwent cephalometry, nocturnal polysomnography, and sleep videofluoroscopy (SVF) before and at least 3 months after receipt of a custom-made MAD. Sleep videofluoroscopy was performed before and after sleep induction and was analyzed during 3 states of awakeness, normoxygenation sleep, and desaturation sleep. Subjects were divided into success and nonsuccess groups depending on treatment outcome. MAIN OUTCOME MEASURES: Multiple variables from cephalometry and SVF including the length of the soft palate, retropalatal space, retrolingual space, and mouth opening angle were evaluated during sleep events with or without the MAD between success and nonsuccess group. RESULTS: The soft palate was significantly longer in the nonsuccess group than in the success group. The retropalatal and retrolingual airway spaces and mouth opening angle were not different between 2 groups. Application of the MAD increased the retrolingual space and decreased the length of the soft palate and the mouth opening angle significantly in both success and nonsuccess groups. However, retropalatal space was widened only in the success group, which showed that retropalatal space may be important in determining treatment response of the MAD. CONCLUSION: The length of the soft palate showed a difference between success and nonsuccess groups, and widening of retropalatal space might be an important factor for successful outcome with MAD application.

An investigation of upper airway changes associated with mandibular advancement device using sleep videofluoroscopy in patients with obstructive sleep apnea.

OBJECTIVE: To quantitatively evaluate the effects of the mandibular advancement device (MAD) on changes in the upper respiratory tract during sleep using sleep videofluoroscopy (SVF) in patients with obstructive sleep apnea (OSA). DESIGN: Retrospective analysis. SETTING: Academic tertiary referral center. PATIENTS: Seventy-six patients (68 men and 8 women) who were treated with the MAD for OSA were included from September 1, 2005, through August 31, 2008. INTERVENTION: All patients underwent nocturnal polysomnography and SVF before and at least 3 months after receipt of the custom-made MAD. Sleep videofluoroscopy was performed before and after sleep induction and was analyzed during 3 states of awakeness, normoxygenation sleep, and desaturation sleep. MAIN OUTCOME MEASURES: Changes in the length of the soft palate, retropalatal space, retrolingual space, and angle of mouth opening were evaluated during sleep events with or without the MAD. RESULTS: Without the MAD, the length of the soft palate and the angle of mouth opening increased during sleep events, especially in desaturation sleep, compared with the awake state. The retropalatal space and retrolingual space became much narrower during sleep compared with the awake state. The MAD had marked effects on the length of the soft palate, retropalatal space, retrolingual space, and angle of mouth opening. The retropalatal space and retrolingual space were widened, and the length of the soft palate was decreased. The MAD kept the mouth closed. CONCLUSIONS: Sleep videofluoroscopy showed dynamic upper airway changes in patients with OSA, and the MAD exerted multiple effects on the size and configuration of the airway. Sleep videofluoroscopy demonstrated the mechanism of action of the MAD in patients with OSA. The MAD increased the retropalatal and retrolingual spaces and decreased the length of the soft palate and the angle of mouth opening, resulting in improvement of OSA.

The mandibular advancement device and patient selection in the treatment of obstructive sleep apnea.

OBJECTIVES: To evaluate retrospectively the efficacy of the mandibular advancement device (MAD) in Korean patients with obstructive sleep apnea (OSA) in terms of severity and to evaluate prognostic factors deciding the success of MAD application. DESIGN: Retrospective analysis. SETTING: Academic tertiary referral center. PATIENTS: Of 142 patients who underwent MAD application for OSA management, 50 (46 men and 4 women; mean [SD] age, 50.2 [9.8] years) were included from March 2005 through August 2007. INTERVENTION: Full-overnight polysomnography was performed before and at least 3 months after intraoral MAD application in 50 patients. Questionnaires for sleep quality, Epworth sleepiness scale, and cephalometry were also studied. MAIN OUTCOME MEASURES: Treatment results were evaluated and prognostic factors deciding success of MAD application were assessed. RESULTS: The mean (SD) apnea-hypopnea index (AHI) decreased significantly (P < .001) from 36.6 (18.9) to 12.3 (11.4). The success rate, defined by an AHI of lower than 20 and a 50% decrease in AHI, were 74% (37 of 50 patients). Even patients who were not categorized into the success group had a decreased AHI. The success rates of patients with mild, moderate, and severe OSA were 43% (3 of 7), 82% (22 of 27), and 75% (12 of 16), respectively, and a higher success rate in patients with severe OSA showed that MAD could be applied even in patients with severe OSA. The duration of apnea and hypopnea, percentage of patients with snoring, and the Pittsburgh Sleep Quality Index were improved significantly after treatment. Epworth sleepiness scale scores and lowest oxygen saturation did not change significantly. An analysis of prognostic factors did not reveal any significant difference between the success and nonsuccess groups. CONCLUSIONS: The application of MAD significantly improved nocturnal respiratory function and sleep quality in patients with OSA, even in patients with severe OSA. In patients with OSA, MAD can be used as a good alternative treatment modality regardless of severity because it is noninvasive, easy to manufacture, and has good treatment results.