Validation of sleep nasendoscopy for assessment of snoring with bispectral index monitoring.

Bispectral index (BIS) monitor is a neurophysiological monitoring device which continually analyses a patient's electroencephalogram during sedation and general anaesthesia to assess the level of consciousness and depth of anaesthesia. BIS monitoring, whilst performing sleep nasendoscopy (using midazolam and propofol), has helped validate depth of sedation and allowed comparison with levels of sedation of control patients during natural sleep. A prospective study of 30 patients with snoring undergoing sleep nasendoscopy with BIS monitoring was conducted. BIS monitoring was recorded throughout the procedure and assessment of snoring was made at the appropriate level of sedation and snoring. BIS values were compared with control patients. The 30 patients undergoing sleep nasendoscopy had average BIS values ranging from 50.72 to 61.2. Similar results were seen with BIS and oxygen saturation in the control group. BIS monitoring provides an adjunct to the assessment of sleep nasendoscopy in determining the level of sedation required for snoring assessment. Comparable BIS values and oxygen saturation levels were obtained between controls and patients during sedation-induced sleep, thus validating the role of sleep nasendoscopy.

The nose, snoring and obstructive sleep apnoea.

Snoring and obstructive sleep apnoea are both due to multilevel anatomical obstruction, and the nose and nasal pathology both contribute in many cases. This paper addresses some of the issues surrounding the problem and briefly discusses the role of medication and nasal dilators and in more detail the implication of nasal surgery in various aspects of sleep related breathing disorders (SRBD). Nasal obstruction leads to mouth breathing, which destabilises the upper airway and aggravates SRBD.

Obstructive Sleep Apnea in Obese Patients: a UK Population Analysis.

BACKGROUND: Obstructive sleep apnea (OSA) is an increasingly common disorder associated with increased cardiovascular disease, mortality, reduced productivity, and an increased risk of road traffic accidents. A significant proportion of patients with OSA in the UK are undiagnosed. This study aims to identify risk factors for OSA in an obese cohort. METHOD: A population-based study was conducted of obese patients (BMI ≥ 30 kg/m2) from the Clinical Practice Research Datalink (CPRD). A logistic regression model was used to calculate odds ratios (ORs) for developing OSA according to other clinicopathological characteristics. Multivariate analysis was conducted of individual factors that affect the propensity to develop OSA. Statistical significance was defined as p < 0.050. RESULTS: From 276,600 obese patients identified during a data extraction of the CPRD in July 2017, the prevalence of OSA was 5.4%. The following risk factors were found to be independently associated with increased likelihood of OSA: male sex (OR = 3.273; p < 0.001), BMI class II (OR = 1.640; p < 0.001), BMI class III (OR = 3.768; p < 0.001), smoking (OR = 1.179; p < 0.001), COPD (OR = 1.722; p < 0.001), GERD (OR = 1.557; p < 0.001), hypothyroidism (OR = 1.311; p < 0.001), acromegaly (OR = 3.543; p < 0.001), and benzodiazepine use (OR = 1.492; p < 0.001). Bariatric surgery was associated with reduced risk of OSA amongst this obese population (OR = 0.260; p < 0.001). CONCLUSIONS: In obese patients, there are numerous comorbidities that are associated with increased likelihood of OSA. These factors can help prompt clinicians to identify undiagnosed OSA. Bariatric surgery appears to be protective against developing OSA.

Rhinological interventions for obstructive sleep apnoea - a systematic review and descriptive meta-analysis.

OBJECTIVES: Obstructive sleep apnoea is a common chronic sleep disorder characterised by collapse of the upper airway during sleep. The nasal airway forms a significant part of the upper airway and any obstruction is thought to have an impact on obstructive sleep apnoea. A systematic review was performed to determine the role of rhinological surgical interventions in the management of obstructive sleep apnoea. METHODS: A systematic review of current literature was undertaken; studies were included if they involved comparison of a non-surgical and/or non-rhinological surgical intervention with a rhinological surgical intervention for treatment of obstructive sleep apnoea. RESULTS: Sixteen studies met the selection criteria. The pooled data suggest that there are reductions in the apnoea/hypopnea index and respiratory disturbance index following nasal surgery. However, the current body of studies is too heterogeneous for statistically significant meta-analysis to be conducted. CONCLUSION: Nasal surgery may have limited benefit for a subset of patients based on current evidence.

Influence of ethnicity on the frequency of nasal surgery.

OBJECTIVE: To determine whether surgery for nasal obstruction differs in frequency between ethnic groups. METHOD: Ethnicity data was collected from all patients attending otolaryngology clinic appointments and compared to census data. Odds ratios with confidence intervals were calculated for attendance at otolaryngology clinics, rhinology clinics, undergoing septoplasty, septorhinoplasty and/ or turbinate surgery for each ethnic group over a 3-year period. RESULTS: The ethnic groups of the 39493 outpatient attendees closely mirrored demographic data from the 2001 Census. Non-Chinese Asian ethnic groups were more likely to undergo septal surgery than the general (mainly white) population (odds ratio 1.44, 95% CI 1.25 to 1.66, p < 0.00001), whereas Black groups (odds ratio 0.31 [0.23 - 0.41], p < 0.00001) and Chinese (odds ratio 0.28 [0.11 - 0.70], p = 0.00311) were much less likely. Similar results were found for rhinoplasty and turbinate surgery. CONCLUSIONS: There is strong statistical evidence for large differences in the frequency of surgery for nasal obstruction between ethnic groups. Asian groups were more likely to undergo surgery, whereas Chinese and Blacks were less likely than the general population, which was predominantly white in this study. This may be due to anatomical variations, differences cultural views towards surgery, or inequalities in clinician's attitudes.

Latest trends in the assessment and management of paediatric snoring and sleep apnoea.

OBJECTIVE: To investigate the assessment and management of paediatric snoring and obstructive sleep apnoea in UK otolaryngology departments. METHOD: A telephone questionnaire survey of UK otolaryngology departments was conducted over a 16-week period. RESULTS: The response rate was 61 per cent (85 out of 139 trusts). Use of pre-operative pulse oximetry was reported by 84 per cent of respondents, mainly to diagnose obstructive sleep apnoea (73 per cent) or stratify post-operative risk (46 per cent). Thirty-one per cent of respondents reported using post-operative pulse oximetry. Twenty-five per cent of respondents have a dedicated management protocol for paediatric obstructive sleep apnoea and snoring. Thirty-four per cent require prior clinical commissioning group approval before performing surgery. Fifty-eight per cent of respondents reported following up their obstructive sleep apnoea patients after surgery. The mean follow-up period (±standard deviation) was 6.8 ± 1.2 weeks. CONCLUSION: There is variation in the assessment and management of paediatric snoring and obstructive sleep apnoea across the UK, particularly in the use of pre- and post-operative pulse oximetry monitoring, and further guidelines regarding this are necessary.

Sleep nasendoscopy as a predictor of treatment success in snorers using mandibular advancement splints.

This study assessed the effect on the upper airway during sleep nasendoscopy of mimicking the action of a mandibular advancement splint. Twenty-seven subjects with a diagnosis of sleep-disordered breathing were referred for mandibular advancement splint therapy following sleep nasendoscopy. Sleep nasendoscopy was repeated for all subjects with, and without, the appliance in situ. Follow-up sleep studies with a mandibular advancement splint in situ were undertaken for 19 individuals with significant obstructive sleep apnoea. With the mandibular advancement splint, subjective snoring levels and airway patency improved as predicted in all but one individual. Residual palatal flutter was predicted for five subjects and occurred in eight individuals. Follow-up sleep studies showed highly statistically significant reductions in median apnoea-hypopnoea index (from 28.1 to 6.1, p < 0.001). Mimicking the action of a mandibular advancement splint during sleep nasendoscopy helps considerably in the patient selection process for this form of treatment.

Radiofrequency thermotherapy in the treatment of tongue base lymphoid hyperplasia: case report.

OBJECTIVE: This paper describes a case where a patient diagnosed with tongue base lymphoid hyperplasia was successfully treated with radiofrequency excision and interstitial radiofrequency-induced thermotherapy. CASE REPORT: A 53-year-old female presented with globus sensation, mild dysphagia, nocturnal breathing problems and 'hot potato voice' dysphonia. On flexible nasendoscopy, a visible tongue mass was seen to obstruct the posterior oropharynx. On magnetic resonance imaging scans, this mass looked suspicious of lymphoma, but on histology was confirmed to be benign reactive lymphoid hyperplasia. Sleep study findings indicated moderate obstructive sleep apnoea, with an apnoea-hypopnoea index of 18.1 events per hour. She was treated with radiofrequency-induced thermotherapy on three separate occasions. RESULTS: A post-operative sleep study showed a dramatic improvement in the patient's apnoea-hypopnoea index (3.8 events per hour). This correlated well with the improvement in her sleep quality and reduction of snoring. Over the follow-up period, there has been sustained resolution of dyspnoea, with almost total restoration of voice quality.

Pulse oximetry in paediatric obstructive sleep apnoea: is it used appropriately?

OBJECTIVES: This study assessed the use of pulse oximetry testing in children with suspected obstructive sleep apnoea in a hospital setting. METHODS: A retrospective review of patients who underwent pulse oximetry testing between April 2013 and October 2013 was performed. Primary outcome measures included positive pulse oximetry results, defined as a McGill oximetry score of 2-4. RESULTS: Thirty-seven test results were usable for analysis: from 21 pre- and 16 post-operative tests. Only four patients had positive test results. There was a significant difference between pre- and post-operative quality of life outcome scores in the surgical group (p < 0.0001). CONCLUSION: Pre-operative pulse oximetry should be used as a guide to help triage patients who require specialist paediatric services, such as a paediatric intensive care unit. The use of pulse oximetry, particularly in the post-operative setting, is unlikely to change patient management and can incur unnecessary financial costs to UK National Health Service Hospital Trusts.

Ototoxicity in vitro: effects of neomycin, gentamicin, dihydrostreptomycin, amikacin, spectinomycin, neamine, spermine and poly-L-lysine.

The effects that the aminoglycoside-aminocyclitol antibiotics amikacin, dihydrostreptomycin, gentamicin, neomycin, and spectinomycin, the neomycin fragment neamine, and the polybasic compounds spermine and poly-L-lysine, have on outer hair cells in cochlear cultures prepared from the early post-natal mouse have been assessed using both scanning and transmission electron microscopy (SEM and TEM). The antibiotics were used at concentrations ranging from 0.25-1.0 mM, spermine from 10 microM to 3.0 mM, and poly-L-lysine from 0.05-2 microM. Qualitative assessment of apical surface damage allows the antibiotics to be ranked in the following order: neomycin > gentamicin > dihydrostreptomycin > amikacin > neamine > spectinomycin. At a concentration of 1 mM spectinomycin is essentially non-toxic and the effects of neamine are marginal. Poly-L-lysine and spermine also cause surface damage, with poly-L-lysine being substantially more toxic than any of the antibiotics, and spermine ranking, on the basis of SEM observations, between dihydrostreptomycin and amikacin. TEM indicates that although all toxic compounds cause damage to the apical surface of the hair cell, only neomycin, poly-L-lysine and spermine induce the formation of whorls of tightly packed membrane resembling myelin within the apical surface lesions to any great extent. Apical-surface changes induced by dihydrostreptomycin and amikacin are simply large distensions of the cell filled with cytoplasmic organelles of normal appearance. Although the effects of the aminoglycoside antibiotics are largely limited to the apical surface of the cell, poly-L-lysine induces complete necrosis of the cell, and spermine causes a dramatic increase in cytoplasmic electron density and condensation of the nuclear chromatin.

The effect of laser assisted uvulopalatoplasty on the sense of smell and taste.

AIM: To assess the effect, if any, of Laser Assisted Uvulo Palatoplasty (LAUP) on the sense of smell and taste. MATERIALS AND METHODS: A prospective study examined 33 patients undergoing LAUP for snoring. Significant sinonasal pathology was excluded in all patients by a complete examination including rigid nasal endoscopy. None of the cases had any systemic illness or drug history that was likely to affect the sense of smell or taste. Twenty-eight patients were male and five female. The mean age was 44 years (range, 25-67). Twelve patients (36%) were regular smokers, and eight patients (24%) were ex-smokers all of whom reported a change in smell and taste after stopping. Preoperative assessment utilised a visual analogue score of smell and taste perception, the University of Pennsylvania Smell Identification Test (UPSIT) for the assessment of olfaction (maximum score of 40), and whole mouth testing for solutions of NaCl, sucrose, quinine, citric acid and acetic acid. LAUP technique was standardised for each case and reassessment was performed 3 months postoperatively. RESULTS: Three patients failed to complete the study and were excluded. The mean values for visual analogue score pre and post surgery were 9.1 and 8.9 respectively, which was not significant using Wilcoxon Rank test (P = 0.257). The mean value of the UPSIT scores before surgery were 32.3 (+4.0), range, 24-39, and after surgery 31.2 (+4.3), range 20-37. There was no significant difference in pre and post UPSIT scores (p = 0.068). Whole mouth taste testing had a preoperative mean value of 4.1 and a postoperative value of 4.2. The difference was not statistically significant, Wilcoxon Rank test (p = 0.317). CONCLUSION: In this study there was no significant change in the patients' perception of smell and taste or in their objective measurement following a standardised Laser Assisted Uvulopalatoplasty.

Management of epistaxis: a national survey.

A survey to assess variations in management and outcome of patients admitted with epistaxis was conducted. A questionnaire was sent to all consultant otolaryngologists working at NHS hospitals in England and Wales requesting information about management of patients admitted with epistaxis over a 3 month period. Data analysis of information provided by 102 consultants for a total of 933 patients was performed. The average number of patients admitted with epistaxis over a period of 3 months per consultant was 10.2. More than 70% of the patients were aged 60 years or over. Approximately 75% of the patients required nasal packing; the most common pack used was BIPP (Bismuth Iodine Paraffin Paste). Of the patients, 5.6% required general anaesthesia, with less than 1% requiring formal arterial ligation. The mean duration of stay in hospital was 2.9 days. Few complications were reported. Patients admitted with epistaxis were generally managed conservatively, with very few requiring surgical intervention. There was remarkable consensus in various aspects of management of patients admitted with epistaxis.

Ribavirin treatment for juvenile respiratory papillomatosis.

Juvenile respiratory papillomatosis involving the tracheo-bronchial tree imposes a significant management problem and is sometimes life threatening. The mainstay of treatment is repeated vapourization with a CO2 laser. To date, adjunctive medical treatments have been of limited value. A tracheostomized child with extensive laryngo-tracheo-bronchial papillomatosis who has required bronchoscopic lasering at two-weekly intervals for three years was treated with ribavirin, a broad spectrum anti-viral agent. The drug was administered in nebulized form using a small particle aerosol generator (S.P.A.G.) to the lower respiratory tract (6 gm/150 ml over nine hours) on three consecutive nights every two weeks over seven weeks and also administered orally (15 mg/kg/day). Endoscopic assessments were made every two weeks. At 14 days the papillomata were regressing and far less lasering was required. No further lasering was required up to 56 days. One month after stopping the ribavirin, however, a few sessile papillomata in the tracheo-bronchial tree had recurred and were treated with the laser. No adverse reactions were encountered. During the treatment period there was a significant reduction in the frequency of therapeutic endoscopies. This promising response requires further evaluation to define the role of ribavirin in the treatment of juvenile respiratory papillomatosis.

Celon radiofrequency thermo-ablative palatoplasty for snoring - a pilot study.

A prospective non-randomized study was designed to investigate the effects of Celon radio-frequency thermo-ablation (RFTA) of the soft palate in patients with snoring/mild obstructive sleep apnoea. Ten patients, fulfilling various inclusion/exclusion criteria, underwent single operator sub-mucosal RFTA palatoplasty as an office procedure. Two separate procedures six weeks apart involved each patient receiving six distinct sub-mucosal lesions on each visit. Questionnaires including visual analogue scales (VAS) were used to evaluate post-operative pain and subjective snoring (scored by patient/partner). Polysomnography (PSG) was performed pre-operation and three months following the second procedure. Using non-parametric statistical analysis, a significant reduction in VAS snoring was noted from initial levels to those scored at six and 16 weeks in nine of 10 patients (p = 0.013 and p = 0.007 respectively). (Five of these nine showed a greater than 50 per cent reduction in score). Objectively, six of 10 patients had a reduction in the apnoea-hypopnea Index between the two PSGs, (four of these six showed a greater than 50 per cent reduction) however, this was not statistically significant. Subjective assessment of the PSG snoring signal by the senior author showed eight of 10 patients had either a reduced or much reduced signal at four months. VAS pain confirmed both procedures are well tolerated with minimal analgesia requirements. Minor complaints of transient mild palatal swelling, dry throat, catarrh and referred otalgia were noted and one patient developed mucosal ulceration following both procedures that healed within three weeks. Swallowing and speech were unaffected. These results confirm similar findings using the Somnus Unit, although the Celon device provides additional advantages including inherent safety in a bipolar electrode tip, auto-stop energy application and reduced procedure time.

Septal perforation secondary to Mycobacterium kansasii infection.

We report the first recorded case of a septal perforation caused by Mycobacterium kansasii. This atypical mycobacterium is finding increasing prevalence with the increasing incidence and longevity of human immunodeficiency (HIV) infections. Cases of chest infection, sinusitis, septic arthritis, osteomyelitis, pericarditis, brain abscess, cutaneous and oral lesions have all now been reported. This discovery represents a rare but important differential in the aetiology of septal perforation.

Carcinoid tumour of the larynx: a case report and clinico-pathological review.

Carcinoid tumour of the larynx is a rare condition but one that is being increasingly recognised. We report the case of a 66 year old lady with an advanced malignant laryngeal carcinoid, metastasizing to the regional lymph nodes, thyroid and submandibular glands. Surgery is the treatment of choice in this condition--radiotherapy and chemotherapy being ineffective. Prognosis is poor, and most patients eventually die of distant metastases. The clinical, biochemical and histological findings are reviewed.

Upper airway obstruction secondary to anticoagulant induced haemorrhage necessitating a tracheostomy.

The incidence of major haemorrhagic complications from oral anticoagulants is between 4.4% and 8.2%. Life-threatening haemorrhage is usually either intracranial or gastro-intestinal, but haemorrhage into the upper airways is a distinctly uncommon occurrence. We report the case of an elderly lady who developed an anticoagulant induced haemorrhage into the parapharyngeal area resulting in upper airway obstruction and necessitating an emergency tracheostomy.