Transoral robotic-assisted tongue base resection in pediatric obstructive sleep apnea syndrome: case presentation, clinical and technical consideration.

Pediatric obstructive sleep apnea syndrome (OSAS) is primarily caused by adenotonsillar hypertrophy. However, tongue base hypertrophy is increasingly being recognized as a cause, even after adenotonsillectomy. We report three cases of pediatric OSAS successfully treated by transoral robotic reduction of the tongue base. In all children, we were able to achieve improved retrolingual patency while avoiding significant procedure-related morbidity. In conclusion, tongue base reduction by transoral robotic surgery appears to be a feasible solution for the base of tongue obstruction due to lingual tonsil hypertrophy in pediatric patients.

Addressing the Retrolingual Space in Obstructive Sleep Apnea: Outcomes Stratified by Friedman Stage in Patients Undergoing Transoral Robotic Surgery.

BACKGROUND/AIMS: To stratify outcomes in patients with moderate to severe obstructive sleep apnea-hypopnea syndrome (OSAHS) undergoing transoral robotic surgery (TORS) ± multilevel procedures according to Friedman stage. METHODS: A total of 118 patients with moderate to severe OSAHS between 2010 and 2013 were stratified preoperatively by Friedman stage. All patients had TORS-assisted lingual tonsillectomy, either stand-alone or in combination with palatal surgery. Apnea-hypopnea index (AHI) was measured preoperatively and 3 months postoperatively. Success was defined as a decrease in AHI by 50% and AHI <20. RESULTS: The average pre- and postoperative AHI was 43.0 and 22.6, respectively, and the overall success rate was 63%. When stratifying by Friedman stage, success was seen in 75% of stage I, 70% of stage II, 66% of stage III, and 10% of stage IV patients. When stratifying by preoperative BMI, success was seen in 75% of stage II and 72% of stage III patients with BMI <30, compared to 58% of stage II and 56% of stage III patients with BMI >30. CONCLUSIONS: TORS-assisted lingual tonsillectomy ± multilevel procedures can be successful in treating patients with moderate to severe OSAHS with Friedman stage I-III anatomy. Success rates are even greater if patients are stratified according to preoperative BMI, as those with BMI <30 are more likely to achieve success even with Friedman stage II-III anatomy.

Body mass index predicts success in patients undergoing transoral robotic surgery for obstructive sleep apnea.

OBJECTIVE: To determine the predictors of success in patients undergoing transoral robotic surgery (TORS) and multilevel procedures for the management of moderate-to-severe obstructive sleep apnea hypopnea syndrome (OSAHS). METHODS: A total of 121 patients (83 male, 38 female) underwent TORS between 2010 and 2013. All patients had robotic assisted lingual tonsillectomy, either as stand-alone surgery or in combination with palatal Z-plasty, lateral pharyngoplasty or uvulopalatopharyngoplasty. The apnea-hypopnea index (AHI) and body mass index (BMI) were measured preoperatively and 3 months postoperatively. Success was defined as AHI <20 and a decrease in AHI by 50%. RESULTS: There was a significant difference in the preoperative and postoperative AHI in the entire cohort (42.7 vs. 22.2; p < 0.001). Overall, 84.3% of patients had an improvement in their AHI, 51.2% of patients met the criteria for success, and 14% met the criteria for cure defined as AHI <5. When stratifying by BMI, there was a significant difference in success when comparing patients with a BMI <30 versus those with a BMI >30 (69.4 vs. 41.7%; p = 0.004). The cure rate was 15.3% in patients with a BMI <30 and 11.1% in those with a BMI >30 (p = 0.54). CONCLUSIONS: TORS lingual tonsillectomy and multilevel procedures were successful in treating moderate-to-severe OSAHS in selected patients. Preoperative BMI helps the clinician to predict success in these patients, with two thirds of patients having a clinically useful benefit.

Clinical outcomes and complications associated with TORS for OSAHS: a benchmark for evaluating an emerging surgical technology in a targeted application for benign disease.

BACKGROUND: The aim of this study was to create benchmarks for evaluating clinical outcomes and complications of transoral robotic surgeries (TORS) in a multicenter setting. METHODS: 243 TORS for obstructive sleep apnea/hypopnea syndrome (OSAHS) operations, carried out between 2008 and 2012, were analyzed at 7 different centers. The average hospitalization was 3.5 days. The mean patient age was 50 ± 12 years, the average BMI at the time of the procedure was 28.53 ± 3.87 and the majority of the patients were men (81%). RESULTS: The mean preoperative and postoperative apnea/hypopnea index was 43.0 ± 22.6 and 17.9 ± 18.4, respectively (p < 0.001). The mean preoperative and postoperative Epworth Sleepiness Scale score was 12.34 ± 5.19 and 5.7 ± 3.49, respectively (p < 0.001). The mean pre- and postoperative lowest O2 saturation was 79.5 ± 8.77 and 83.9 ± 6.38%, respectively (p < 0.001). CONCLUSIONS: Patients undergoing TORS as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation of success with minimal long-term morbidity.

Hypoglossal Nerve Stimulator Explantation: A Case Series.

Hypoglossal nerve stimulation (HGNS) has emerged as a successful surgical treatment strategy for moderate to severe obstructive sleep apnea in patients failing first-line positive airway pressure therapy. HGNS explantation due to adverse events such as pain and infection is rare and has yet to be well described. Here, our correspondence describes the first case series of patients who have undergone explantation of the Inspire HGNS system. Five patients were identified who underwent HGNS explantation. Three patients underwent explantation due to magnetic resonance imaging (MRI) incompatibility. One patient underwent explantation due to poor cosmesis. One patient underwent explantation due to surgical site infection. Average operative explant time was 163 minutes. MRI incompatibility, poor cosmesis, and device-related infection are reasons for HGNS explantation. Future need for MRI or chest wall surgery should be considered in patients being evaluated for HGNS implants.

Evaluation of In-Office Volitional Snore as a Screening Tool for Candidacy for Hypoglossal Nerve Stimulation.

Candidacy evaluation for hypoglossal nerve stimulation (HGNS) is resource intensive. This proof-of-concept study investigates use of in-office volitional snore during flexible laryngoscopy as an efficient, cost-effective screening tool for HGNS evaluation. Adults with moderate to severe obstructive sleep apnea that failed continuous positive airway pressure treatment (n = 41) underwent evaluation for HGNS from 2018 to 2019. Volitional snore and drug-induced sleep endoscopy (DISE) data were collected and scored by VOTE classification (velum/palate, oropharynx, tongue base, epiglottis). A chi-square test of independence was performed that demonstrated a significant relationship between volitional snore and DISE (χ2 = 4.39, P = .036) for velum collapse pattern. Sensitivity and specificity of volitional snore for detecting velum collapse pattern were 93.6% (95% CI, 75.6%-99.2%) and 40% (95% CI, 12.2%-73.8%), respectively, illustrating its utility in screening for HGNS. Patients who demonstrate anterior-posterior velum collapse on volitional snore may be excellent candidates for confirmatory DISE at the time of HGNS implantation.

The Rise of Upper Airway Stimulation in the Era of Transoral Robotic Surgery for Obstructive Sleep Apnea.

Introduced in 2010, transoral robotic surgery (TORS) is recognized as an effective treatment of moderate to severe obstructive sleep apnea (OSA) in the setting of lymphoid and muscular tongue base hypertrophy. Upper airway stimulation (UAS) or hypoglossal nerve stimulation has emerged as a promising treatment of patients with moderate to severe OSA who have failed continuous positive airway pressure. UAS has shown favorable success rates and low morbidity compared with traditional soft tissue and skeletal framework surgery. UAS is in its infancy as a surgical procedure and concerns exist regarding narrow candidacy criteria, postimplant device titration, and durability of treatment response.

Machine Learning Diagnosis of Peritonsillar Abscess.

Peritonsillar abscess (PTA) is a difficult diagnosis to make clinically, with clinical examination of even otolaryngologists showing poor sensitivity and specificity. Machine learning is a form of artificial intelligence that "learns" from data to make predictions. We developed a machine learning classifier to predict the diagnosis of PTA based on patient symptoms. We retrospectively collected clinical data and symptomatology from 916 patients who underwent attempted needle aspiration for PTA. Machine learning classifiers were trained on a subset of the data to predict the presence or absence of purulence on attempted aspiration. The performance of the model was evaluated on a holdout set. The accuracy of the top-performing algorithm, the artificial neural network, was 72.3%. Artificial neural networks can use patient symptoms to exceed human ability to predict PTA in patients with clinical suspicion for PTA. Similar models can assist medical decision making for clinicians who have suspicion of PTA.

Implication of Fusobacterium necrophorum in recurrence of peritonsillar abscess.

OBJECTIVE: Peritonsillar abscess (PTA) is a common infectious complication of pharyngeal infection managed by otolaryngologists and emergency room physicians. Streptococcus and Fusobacterium (e.g., Fusobacterium necrophorum, FN) species are commonly isolated pathogens. The aim of this study was to determine the implication of culture results on abscess recurrence following drainage. METHODS: Single-institution retrospective review of patients treated at the University of Michigan between 2000 and 2017. Demographic and clinical outcome data were analyzed, including treatment details, culture data, and recurrence. RESULTS: One hundred fifty-six of the 990 patients in our study developed recurrence of their abscess (16%). The age ranges most susceptible to recurrence included adolescent (22.9%) and young adult groups (17.1%). Recurrent patients were more likely to have experienced acute progression of symptoms (79% vs. 71%, P = 0.03), trismus (67% vs. 55%, P = 0.006), voice changes (65% vs. 57%, P = 0.04), and dysphagia (72% vs. 61%, P = 0.01) compared to nonrecurrent patients. They were also more likely to have clinical lymphadenopathy noted on initial examination (67% vs. 56%, P = 0.009). Culture data was sent for 852 patients (86%). The presence of FN was significantly more prevalent in the recurrent group (P < 0.0001). CONCLUSION: There is a high observed prevalence of FN species within PTA aspirates in the recurrent PTA population. PTA aspirate should be sent for anaerobic growth to screen for Fusobacterium species. In addition, follow-up and lower threshold for subsequent tonsillectomy should be considered in this at-risk group. LEVEL OF EVIDENCE: 3 Laryngoscope, 129:1567-1571, 2019.

Predictors of intratonsillar versus peritonsillar abscess: A case-control series.

OBJECTIVES/HYPOTHESIS: An uncommon phenomenon in relation to the peritonsillar abscess (PTA) is the intratonsillar abscess (ITA) or formation of an abscess within tonsillar parenchyma. This study sought to characterize our experience with diagnosis and management of ITAs in the context of the PTA patient population. STUDY DESIGN: Case-control series. METHODS: This is a single-institution retrospective review of patients treated at the University of Michigan between 2000 and 2017. RESULTS: Six hundred fifty-five adult patients were identified. The incidence of ITA within the PTA population was 7% (n = 43). Patients with ITA had lower mean white blood cell count (P = .03), lower proportion of trismus (P < .0001), otalgia (P = .007), vocal changes (P < .0001), and fewer incidences of acute progression of symptoms (P = .0007). On multivariable analysis, ITA patients were noted to be older, present with a longer duration of symptoms, and have greater incidence of neck pain and lymphadenopathy. Drainage was attempted in fewer ITA patients and was rarely successful (15%) in comparison to successful drainage for PTA patients (69%) (P < .0001). CONCLUSIONS: Symptomatology differs for ITA, as fewer present with the classic PTA symptoms of otalgia, trismus, and voice alterations. The lack of classic symptoms likely leads to delayed presentation. A greater number of ITA patients presented with neck pain and lymphadenopathy. In the ITA population, aspiration attempts were more infrequent and less successful in yielding purulence. Given infrequent yield of pus and low overall recurrence rate, the diagnosing clinician should consider medical management in this distinct patient population. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:1354-1359, 2019.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study.

OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort. METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression. RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m2 . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely). CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. LEVEL OF EVIDENCE: 2B Laryngoscope, 129:761-770, 2019.

Predictors of intratonsillar abscess versus peritonsillar abscess in the pediatric patient.

OBJECTIVE: To determine the incidence of intratonsillar abscess (ITA) patients within the population of patients diagnosed with peritonsillar abscess (PTA) and to further characterize the differences in symptomatology and successful treatment strategies between the two groups. METHODS: This study is a retrospective chart review of patients diagnosed with PTA or ITA at our institution from 2000 to 2017. Descriptive and inferential statistics are reported, including univariate and multivariate analyses. RESULTS: A total of 335 pediatric (<18 years) patients presenting with a PTA or ITA were identified, 31 (9%) of whom were diagnosed with ITA. Patients with ITAs had significantly lower proportions of trismus, otalgia, and dysphagia and were less likely to experience acute progression from their initial symptoms. The ITA group had fewer attempted aspiration and drainage attempts, with those attempts significantly less successful than for the PTA group. Recurrence was uncommon in ITA patients in comparison to PTA patients. CONCLUSIONS: Intratonsillar abscess should be considered in the differential diagnosis for patients presenting with sore throat and concern for a pharyngeal infection or abscess. These patients have a significantly lower proportion of otalgia, trismus, vocal changes, and dysphagia. Given the low success rate of drainage attempts and lower recurrence rate, diagnosing physicians should consider medical management rather than procedural drainage in this patient population.

Dosing of proton pump inhibitors is suboptimal among otolaryngologists treating reflux-induced upper-respiratory disease.

OBJECTIVE: To evaluate the practice of otolaryngologists treating reflux-induced upper-respiratory disease in a nationwide survey. STUDY DESIGN: Survey study using an anonymous questionnaire containing clinical vignettes. SUBJECTS AND METHODS: The survey was mailed to all 6,899 board-certified fellow members in practice in the American Academy of Otolaryngology-Head and Neck Surgery residing in the United States. RESULTS: One thousand seven hundred twenty questionnaires were returned. Respondents empirically treated reflux-induced upper-respiratory disease with proton pump inhibitors once daily and twice daily 63% and 31%, respectively. Fifteen percent did not instruct their patients on how to take the proton pump inhibitors. Of those who instructed their patients, 22% advised dosing before breakfast, 32% before breakfast and again before dinner, and 46% recommended other timings. When prescribing twice-per-day dosing, 64% responded to give before breakfast and dinner and 28% responded before breakfast and at bedtime. CONCLUSION: Suboptimal dosing of proton pump inhibitors is prevalent among otolaryngologists treating reflux-induced upper-respiratory disease.

Does drug-induced sleep endoscopy predict surgical success in transoral robotic multilevel surgery in obstructive sleep apnea?

OBJECTIVES/HYPOTHESIS: The aim of this study was to determine if drug-induced sleep endoscopy (DISE) was predictive of success for patients undergoing transoral robotic surgery (TORS) and multilevel procedures for sleep apnea. STUDY DESIGN: Retrospective case series of patients who underwent TORS surgery for sleep apnea METHODS: Before and after polysomnograms were analyzed to assess improvement, success, and cure. Improvement was defined as any decrease in apnea-hypopnea index (AHI), success as an AHI <20 with a decrease >50%, and cure as an AHI <5. DISE videos were scored using the NOHL (nose, oropharynx, hypopharynx, larynx) and VOTE (velum, oropharynx, tongue, epiglottis) classification systems. RESULTS: One hundred one patients were available for analysis. Eighty-seven percent of patients had an improvement in their AHI. Fifty-one percent met criteria for success, whereas 17% were cured. The degree of collapse at individual NOHL and VOTE subsites as well as total additive scores did not predict improvement, success, or cure. Patients with no oropharyngeal lateral collapse in the VOTE classification system were more likely to improve following surgery (P = .001); however, this effect did not hold for success or cure. Multivariate analysis of DISE variables was not predictive of success. CONCLUSIONS: In obstructive sleep apnea patients, there is a 51% success rate and a 17% cure rate. DISE, as scored by the NOHL and VOTE system, did not readily identify patients who would benefit most from surgery. Patients with lateral oropharyngeal collapse may be poorer candidates. Prospective, larger studies are required to further evaluate the use of DISE in predicting success following TORS. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:971-976, 2017.

Transoral robotic surgery in benign diseases including obstructive sleep apnea: Safety and feasibility.

OBJECTIVES/HYPOTHESIS: To evaluate the safety and feasibility of the da Vinci Surgical System in transoral robotic-assisted surgery for benign indications. STUDY DESIGN: A multicenter, single-arm, retrospective case series. METHODS: Perioperative outcomes were recorded for patients presenting with obstructive sleep apnea, airway obstruction, lingual tonsillar/tonsillar/tongue base hypertrophy, or dysphagia who underwent one or more transoral procedures, including lingual tonsillectomy and tongue base resection (partial glossectomy) at one of three US institutions. RESULTS: Between January 2010 and October 2013, 285 patients (age 51.5 years, body mass index 30.5 kg/m(2) ) underwent 293 procedures. No conversions or blood transfusions were needed. The average operative time was 86.7 minutes, and the average volume of tissue resected (lingual tonsil and tongue base) was 8.3 mL. Hospital stays averaged 1.8 days, and the postoperative complication rate was 20.7%. There were no complications specifically related to the use the da Vinci Surgical System, and none of the complications were life threatening. CONCLUSIONS: These results demonstrate that it is safe and feasible to use the da Vinci Surgical System to perform lingual tonsillectomy and base of tongue resection (partial glossectomy) procedures for benign indications. LEVEL OF EVIDENCE: 4

Evaluation of Salivary Transcriptome Markers for the Early Detection of Oral Squamous Cell Cancer in a Prospective Blinded Trial.

BACKGROUND: Oral squamous cell cancer (OSCC) is often diagnosed in late stages. Informative biomarkers could play a key role in early diagnosis. Prior case-control studies identified discriminatory salivary mRNA markers for OSCC. The National Cancer Institute (NCI) recommends prospective-specimencollection, retrospective-blinded-evaluation (PRoBE) design study for rigorous biomarker identification and validation. METHODS: A PRoBE design study enrolled 170 patients with lesions suspicious for OSCC. Saliva was collected before performing oral biopsy. Six pre-specified oral-cancer-associated mRNAs (IL1ß, IL8, OAZ1, SAT, S100P, and DUSP1) and five housekeeping mRNAs (MT-ATP6, RPL30, RPL37A, RPL0, and RPS17) were measured by quantitative polymerase chain reaction (PCR) without knowledge of tissue diagnosis. A pre-specified multi-marker panel from prior NCI - Early Detection Research Network (EDRN) studies was evaluated in this new PRoBE dataset. Individual marker cycle thresholds (Ct) from PCR were also compared in cancer versus control, and new discriminatory models were generated. RESULTS: The EDRN model was validated based on pre-specified statistical analysis plan. Ct values of individual mRNAs reflect an approximately twofold to nearly fourfold increase in concentration in invasive OSCC (P less than 0.01 for all). A new model from this intended-use population with incorporation of housekeeping genes demonstrates a maximal sum of sensitivity and specificity of 150.7% with an area under the receiver operating characteristic (ROC) curve of over 0.85. CONCLUSION: The validation of six pre-specified individual salivary transcriptome markers of OSCC and a pre-specified multi-marker model in a new prospective population supports the robustness of these markers and the multi-marker methodology. New models generated in this intended-use population have the potential to further enhance the decision process for early biopsy. Lesions at very low risk for cancer could be identified noninvasively as could those at significantly increased risk. Further study is necessary to assure effective implementation of this technology into routine clinical practice.

Selective neck dissection for the treatment of neck metastasis from squamous cell carcinoma of the head and neck.

OBJECTIVE: Our objective was to determine the proportion of patients disease free in the neck, with the primary site controlled, who have been treated with a selective neck dissection (SND) for squamous cell carcinoma (SCCa) of the upper aerodigestive tract, and who had cervical metastasis less than 3 cm. STUDY DESIGN: A cohort of patients who fit the inclusion/exclusion criteria was identified retrospectively. Then all surviving patients were followed for a minimum of 2 years. METHODS: A group of 52 patients who had 58 selective neck dissections for cervical metastases from SCCa of the upper aerodigestive tract were identified. The mean age was 56 years (range, 20-85 y), there were 40 males and 12 females, and mean follow-up was 24.5 months (range, 1-64 mo). Twenty-six patients had clinically negative (cNo) neck examinations and 26 had clinically positive neck examinations. Postoperative radiation was given for extracapsular spread, greater than 2 positive nodes, T3, T4, or recurrent disease if the patient had not received radiation before surgery. These radiation criteria excluded 18 patients from postoperative radiation treatment. RESULTS: Kaplan-Meier survival analysis showed that the regional control rate with the primary site controlled was 0.94. Six patients developed recurrent neck disease. Three of these 6 patientswere surgically salvaged. Four recurrences were in the dissected field and 2 were out of the dissected field (level V). CONCLUSIONS: With similar indications for radiation therapy, the regional control rate in this cohort is comparable to control rates obtained with modified radical neck dissection.

Transoral robotic surgery for obstructive sleep apnea: perioperative management and postoperative complications.

IMPORTANCE: Patients who undergo surgery for obstructive sleep apnea (OSA) have acceptable perioperative morbidity that is similar to that seen in other sleep-related surgical procedures. OBJECTIVE: To perform the first large-scale evaluation of perioperative management and postoperative complications in patients who undergo transoral robotic surgery (TORS) for OSA. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study from 2010 to 2013 of 166 adult patients with moderate to severe OSA (defined as apnea-hypopnea index, >20) who had experienced failure of conventional therapy with positive airway pressure and underwent TORS at an academic practice with follow-up greater than 3 months. INTERVENTIONS: Transoral robotic surgery with or without additional multilevel airway procedures. MAIN OUTCOMES AND MEASURES: Major and minor complication rates. RESULTS: There were 122 men and 44 women with a mean (SD) age of 54.6 (12.3) years. The mean (SD) American Society of Anesthesiologists (ASA) score was 2.3 (0.5). There were 11 major complications, including secondary bleeding requiring intervention (7 patients), pulmonary embolism requiring anticoagulation therapy (2 patients), aspiration requiring prolonged hospitalization (1 patient), and dysphagia resulting in gastrostomy tube dependence (1 patient). There were 32 minor complications, including dehydration and/or uncontrolled pain (16 patients), globus sensation (8 patients), bleeding (5 patients), lip burn (2 patients), and pharyngeal laceration during intubation (1 patient); the majority resolved without sequelae. Preoperative ASA score (P = .003) and number of procedures performed (P = .004) predicted a postoperative complication. Age (P = .29), body mass index (P = .55), apnea-hypopnea index (P = .67), lowest arterial oxygen saturation (P = .63), number of comorbidities (P = .46), and individual comorbidities did not predict a complication. CONCLUSIONS AND RELEVANCE: Transoral robotic surgery can be safely performed in patients with OSA with an acceptable complication rate. Complications are similar to those seen with other surgical treatments of OSA and were only predicted by ASA score and number of procedures performed.