Retrograde Cricopharyngeus Dysfunction, a New Motility Disorder: Single Center Case Series and Treatment Results.

Background/Aims: Retrograde cricopharyngeus dysfunction (R-CPD) is a new clinical entity characterized by inability to belch and associated symptoms of loud gurgling noises, chest and/or abdominal pressure, abdominal bloating, and excessive flatulence. R-CPD can be treated with botulinum toxin (BT) injection in the upper esophageal sphincter. We hereby report patient demographics, symptomatology, and treatment results of a series of consecutive patients who presented at our center. Methods: Data on 50 consecutive patients presenting with R-CPD were prospectively collected using a standardized questionnaire prior to, 1 month after treatment and at the end of follow-up. All patients were diagnosed using a set of clinical symptoms. Results: Fifty patients (26 females) were included, median age was 27.5 years (range, 17-65). Median body mass index was 22.7 kg/m2 (range, 16.6-37.5). Inability to belch was present in all patients, > 90% of patients experienced gurgling noises and abdominal/chest discomfort as result of their condition. One month after injection of BT, 40.8% of patients experienced complete relief of symptoms, 24.5% good symptom improvement, 24.5% some symptom improvement and 10.2% no improvement. At median follow-up of 29 months (range, 3-50) post-treatment, 51.3% (n = 20/39) of patients reported persistent complete relief of symptoms, 12.8% good improvement of symptoms (n = 5/39), in 15.4% some improvement (6/39) and 20.5% loss of or no response (n = 8/39). Only minor and transient side effects were reported. Conclusions: Our case series of 50 patients with R-CPD shows very good short-term and good long-term improvement of symptoms after injection of BT. These results are in line with previous studies.

Comparative Effectiveness of the Different Treatment Modalities for Snoring.

OBJECTIVE: To evaluate what effects treatments of sleep-disordered breathing have on snoring and sleepiness: snoring surgery including osteotomies, mandibular advancement device (MAD), and continuous positive airway pressure (CPAP). STUDY DESIGN: Single-institution prospective comparative effectiveness trial. SETTING: University-affiliated secondary care teaching hospital. SUBJECTS AND METHODS: We prospectively studied 224 patients presenting with snoring at our department. All patients underwent detailed evaluation, including symptom questionnaires, clinical examination, polysomnography, and drug-induced sleep endoscopy. Based on these results, a treatment was proposed after multidisciplinary consultation. Treatment was evaluated through 4 questionnaires before treatment and 6 weeks and 6 months after. Treatment success was defined as a global snoring visual analog scale score ≤3 at 6 months. RESULTS: A total of 195 patients complied with full workup and were proposed treatment. The mean age was 46 ± 11 years; the mean body mass index, 27 ± 4; and the median apnea-hypopnea index, 10.0 (interquartile range, 4.7-20.1). After discussion, 116 (59.5%) patients agreed to start treatment (46%, surgery; 26% MAD; 28% CPAP). All symptom scores, including Epworth Sleepiness Scale, decreased significantly for all treatments at 6 weeks and 6 months. Treatment was successful in 67% of the surgery patients, 67% of the MAD group, and 76% of the CPAP group. Only 6.7% reported an unchanged snoring score in the surgery group, compared with 13.6% in the MAD group and 9.6 % in the CPAP group. CONCLUSION: Multidisciplinary agreed-on treatment of snoring is effective across the proposed treatments.

Drug-induced sleep endoscopy changes snoring management plan very significantly compared to standard clinical evaluation.

Drug-induced sleep endoscopy (DISE) is a new tool in the work-up of patients with sleep-disordered breathing (SDB). We assessed the impact of DISE on the treatment plan of snoring patients. This is a single institution prospective longitudinal clinical trial. The setting is a private teaching hospital. A consecutive series of 100 snoring patients prospectively underwent a standardised questionnaire, clinical examination, rhinomanometry, allergy skin prick testing, DISE and polysomnography. Management plan before and after DISE evaluation was compared. In 61 patients (excluding 16 patients sent for continuous positive airway pressure, three patients refused sleep endoscopy and 20 were lost to follow-up), we compared the treatment plans. DISE showed single level airway collapse in 13 and multilevel collapse in 48 patients. The site of flutter did not add additional information as compared to the pattern and the location of the collapse. After DISE, the initial management plan changed in 41% of patients irrespective of the type of initial management plan. The only somewhat accurate initial treatment plan was uvulopalatopharyngoplasty (unchanged in 11/13 patients). Excluding moderate to severe obstructive sleep apnea patients DISE is an indispensable tool in treatment decision in all SDB patients. We suggest to simplify the protocol for DISE reporting.

CO2 laser-assisted stapedotomy combined with àWengen titanium clip stapes prosthesis: superior short-term results.

OBJECTIVE: To report on the short-term results of CO2-laser assisted stapedotomy combined with the àWengen titanium clip stapes prosthesis. A comparison with published series using other prostheses and/or different stapedotomy techniques is made. STUDY DESIGN: Retrospective case series. PATIENTS: Patients with a history and audiologic data matching stapes fixation and computed tomographic imaging excluding other anomalies such as malleus fixation, dehiscent superior semicircular canal, and large vestibular aqueduct that may mimic stapes fixation-like hearing loss. INTERVENTION: All patients underwent CO2 laser-assisted stapedotomy (Lumenis Co. Israel CO2 laser, Acuspot 712, SurgiTouch 870 scanner) and subsequent reconstruction by means of the àWengen titanium clip stapes prosthesis by Heinz Kurz Medizintechnik GmbH (Germany). OUTCOME MEASURES: Comparison and statistical analysis of preoperative and postoperative audiologic data. RESULTS: Sixty-two stapedotomies were performed (61 patients) using the CO2 laser and àWengen titanium clip stapes prosthesis. The mean postoperative air-bone gap 3 months postoperatively was 5.1 +/- 0.5 dB (standard deviation [SD], 4.1 dB; 0.5, 1, 2, 4 kHz). Air-bone gap closure less than or equal to 10 dB was achieved in 54 cases (87%). Air-bone gap closure less than 20 dB was achieved in all cases. The average gain was 27.8 +/- 1.5 dB (SD, 12 dB; 0.5, 1, 2, 4 kHz). The average bone-conduction threshold shift or "overclosure" on 2,000 Hz was 13.6 +/- 1.3 dB (SD, 10 dB). There was no postoperative perceptive hearing loss exceeding 15 dB on any measured frequency. The Amsterdam Hearing Evaluation Plots have also been used to evaluate our data. These data were statistically analyzed and compare favorably to other published series. CONCLUSION: The authors conclude that the combination of CO2 laser-assisted stapedotomy and the àWengen titanium clip stapes prosthesis is a combination likely to yield superior results in experienced hands.

Sensory neuropathic cough: a common and treatable cause of chronic cough.

OBJECTIVE: To describe our experience with chronic sensory neuropathic cough and its response to amitriptyline in a first group of patients. STUDY DESIGN AND SETTING: A prospective cohort of patients is described in detail. Each was referred to an academic laryngological practice after extensive prior negative workup for cough and failure to respond to various treatments. Each of these patients was treated with amitriptyline and asked to report the effect on the cough at fixed intervals by means of telephone interviews. RESULTS: A first cohort of 12 consecutive patients with a chronic, nonproductive cough that lasted between 2 months and 20 years, with no (formerly) discernible cause is described. Purely clinical criteria of inclusion and exclusion are proposed. All patients had at least 40% reduction of self-reported symptoms, with most describing between 75% to 100% short-term relief. CONCLUSION: Sensory neuropathic cough can be diagnosed clinically in patients with chronic idiopathic cough. A trial of amitriptyline 10 mg or of other anti-neuralgia type medications may be helpful. Longer term and controlled trials are warranted to validate this entity and prove efficacy of neurologic medication in chronic sensory neuropathic cough. EBM RATING: C-4.