Role of DISE in the surgical outcome for patients with obstructive sleep apnea.

PURPOSE: To investigate and compare the surgical outcomes of DISE and non-DISE-guided surgery in cases with obstructive sleep apnea. METHODS: Sixty-three patients with severe OSA and BMI ≤35 kg/m2 were included in the study. Patients were randomly divided into group A where surgical intervention was performed without DISE, and group B where surgery was planned according to the findings of DISE. RESULTS: In group A, the mean AHI, LO2, and Snoring index showed a highly significant improvement (P < 0.0001). Group B had highly significant improvements as regards PSG data (P < 0.0001). High significant differences exist when comparing the operative time of both groups (P < 0.0001). On comparing the success rates in both groups, no statistically significant differences were reported (p = 0.6885). CONCLUSION: Preoperative topo-diagnosis with DISE does not significantly affect the surgical outcomes in OSA. Primary OSA cases could benefit from a no-DISE cost-effective surgical protocol that entails multilevel surgical interventions in a reasonable time.

Anterolateral advancement palatoplasty with tonsillectomy for retropalatal obstruction in selected cases of obstructive sleep apnea.

PURPOSE: This study tried to assess the surgical outcome of anterolateral advancement palatoplasty (ALP) with simultaneous tonsillectomy for the treatment of retropalatal obstruction in selected cases of obstructive sleep apnea (OSA). METHODS: In this clinical trial, 22 adult OSA patients having predominant retropalatal collapse were managed by ALP and tonsillectomy.Thirteen patients had positional OSA (PP) and 9 patients had non-positional (NPP). ALP entailed the stripping of a horizontal trapezoid area of mucosa/submucosa of the soft palate and suturing with one central simple suture and two paramedian sutures made as an anterolateral parallelogram. Uvula was not jeopardized and no lateral mucosal cuts were made. RESULTS: Postoperative data of the study group showed high significant improvement (p < 0.001) as regards apnea-hypopnea index (AHI), mean lowest oxygen saturation level (LO2), Epworth sleepiness scale (ESS) and snoring visual analog scale (VAS-s). The overall percentage of improvement as regards the AHI was 60%.On comparison of postoperative data of PP and NPP, significant difference was reported as regards AHI (p = 0.009), while non-significant differences were reported (p > 0.05) as regards LO2, ESS and VAS-s. Postoperative means of AHI in supine position showed a significant difference (p = 0.03). Upon comparison of means of ODI and T90% of PP and NPP, a highly significant difference was reported in both pre- and postoperative comparison (< 0.001). CONCLUSION: Anterolateral advancement palatoplasty seems to be an easy, effective and low-cost procedure. More favorable outcomes were reported among positional-dependent subjects. The procedure could be employed in multilevel, single-stage surgery for patients with OSA.

Trans-hyoid hyoidthyroidpexy: A modified technique for selected cases of obstructive sleep apnea.

OBJECTIVE: Hypopharyngeal collapse (HC) considered a challenge in surgery of obstructive sleep apnea (OSA). Several procedures were presented to deal with HC indirectly via providing support to the lateral walls of the hypopharynx preventing transverse collapse but hyoidthryoidpexy had gained more popularity. The procedure aimed to fix the mobile hyoid bone to a rigid mid-line neck structure, thus preventing the bone and its attached muscles from collapsing during sleep with the negative intrathoracic pressure on inspiration. STUDY DESIGN: A prospective case series study. METHODS: From April 2018 to January 2020, A Modified Technique of Trans hyoid hyoidthyroidpexy was applied for all included patients (24) patients with symptoms of OSA showing predominant lateral wall collapse of the hypopharynx (with retro-palatal collapse) with other OSA surgery. RESULTS: 6-8 months postoperatively, the Apnea Hypopnea index dropped from 43.75 ± 8.44 to 16.28 ± 7.35 (P < 0.0001; t = 10.6988). 14 patients (58.33%) were reported as successful while 7 patients (29.17%) were considered responders and three patients (12.5%) were considered non responders. The mean lowest oxygen desaturation elevated from 77.56 ± 5.64 to 92.38 ± 6.25 (p < 0.0001). Epworth Sleepiness Scale improved (P < 0.0001) from 16.85 ± 4.23 to 5.17 ± 3.89. CONCLUSION: Trans-hyoid hyoidthyroidpwxy is a modified technique of hyoidthyroidpexy. The procedure reported good outcomes in treating OSA. It is a simple, cost-effective and less traumatic technique. It could be combined with other multilevel surgical procedures.

Anterior Ethmoidal Artery: A Computed Tomography Analysis and New Classifications.

Objective to determine the anterior ethmoidal artery (AEA) anatomy and variations by computed tomography (CT) in adult and their relations to and presents new AEA classifications. Methods One hundred and fifty paranasal CT scans (300 sides) were included. Axial images were acquired with multiplanar reformates to obtain delicate details in coronal and sagittal planes. Results One hundred and forty-four AEAs canal (48%), 293 AEAs foramen (97.7%), and 229 AEAs sulcus could be detected (76.3%). The mean AEA intranasal length was 6.7 ± 1.27 mm (range: 4.24-10.6 mm). The mean angle between AEA and lamina papyracea was 105.49 ± 9.28 degrees (range: 76.41-129.76 degrees). Of them, 95.8% AEAs had an angle with lamina >90 degrees, while 4.2% had angle <90 degrees. The mean angle between AEA and lateral lamella of cribriform plate was 103.95 ± 13.08 degrees (range: 65.57-141.36 degrees). Of them, 87.5% AEAs had an angle >90 degrees and 12.5% had an angle <90 degrees. The mean distance between AEA and skull base was 1.37 ± 1.98 mm (range: 0-8.35 mm). The AEA types in relation to skull base was type 1 (0-2 mm from skull base; 64.6%), type 2 (2-4 mm; 22.2%), type 3 (4-6 mm; 11.1%), and type 4 (>6 mm; 2.1%). The mean distance between the AEA and frontal sinus ostium was 9.17 ± 4.72 mm (range: 0-25.36 mm). AEA classification according to distance from AEA to frontal sinus ostium was 17.4% type 1 (<5 mm), 41.7% type 2 (5-10 mm), 31.9% type 3 (10-15 mm), and 9% type 4 (>15 mm). Conclusion Provided AEA details improve surgeons' awareness of AEA variations in the endoscopic field and can help residents in training.

Changes in Serum Leptin Level After Multilevel Surgery in Patients with Obstructive Sleep Apnea.

OBJECTIVE: Leptin hormone plays an important role in metabolic control and is elevated in obstructive sleep apnea (OSA). The aim of this study was to assess the hypothesis that surgical treatment will reduce leptin levels in OSA patients. STUDY DESIGN: Prospective study. SUBJECTS AND METHODS: Twenty-three patients with multilevel OSA underwent modified genioglossus muscle advancement with anterolateral advancement pharyngoplasty between April 2018 and September 2019. Serum leptin level was measured preoperatively and 3 months postoperatively for all patients and 18 control subjects. All patients were evaluated before and 3 months after surgery by history taking, clinical examination, polysomnography, cephalometry, and Epworth Sleepiness Scale. RESULTS: Preoperatively, patients with OSA had a higher Leptin level (18.46 ± 4.73 ng/mL) than did control subjects (7.07 ± 1.26 ng/mL) (P < .001). Surgery resulted in a significant reduction in the level of leptin from 18.46 ± 4.73 ng/mL to 8.03 ± 2.22 ng/mL (P < .001). Reductions in leptin level was correlated with changes in apnea hypopnea index (AHI) (r = 0.61, P = .002) and minimum oxygen saturation (SaO2) (r = -0.54, P = .008). CONCLUSION: Effective multilevel surgery in the form of modified genioglossus muscle advancement with anterolateral advancement pharyngoplasty could significantly reduce leptin level in OSA patients and this reduction is correlated with the degree of OSA improvement in term of AHI and SaO2. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E665-E670, 2021.

Eustachian Tube: Computed Tomography Analysis.

BACKGROUND: Eustachian tube has a major role in ventilation, drainage, and protection of the middle ear. High resolution computed tomography magnifies the role of preoperative imaging for detailed inner and middle ear anatomical information. The aim of this study was to find an applicable way by computed tomography imaging for assessment of Eustachian tube. The goal was to provide improved understanding of the Eustachian tube measurements and the relationship with middle ear in Egyptian population. Computed tomography measurements for Eustachian tube were done including; length of the bony and cartilaginous portions, Total length of Eustachian tube, as well as the width and height of the tympanic orifice of the Eustachian tube. Also, tubotympanic and Reid plane- Eustachian tube angles were measured. RESULTS: Within 200 studied ears in 100 subjects, the mean total Eustachian tube length was 40.19 ±â€Š3.05 mm, mean length of the bony Eustachian tube was 11.69 ±â€Š1.8 mm with significant longer Eustachian tube on left side, The mean length of the cartilaginous Eustachian tube was 28.5 ±â€Š2.95 mm with significantly longer cartilaginous and total length in male (P < 0.0001). The mean width and height of the tympanic orifice of the Eustachian tube was 5.4 ±â€Š0.79 and 4.85 ±â€Š0.75 mm, respectively. The mean tubotympanic angle of the Eustachian tube was 148.11 ±â€Š2.82°. The mean Reid plane- Eustachian tube angle was 27.69 ±â€Š2.08° with significantly wider angle in males (P < 0.022). CONCLUSION: The Eustachian tube measurements can easily be obtained on computed tomography images, and are representative for the Eustachian tube anatomy. There is importance of extending computed tomography examinations beyond the middle ear cavity and the mastoids to the Eustachian tube in order to have more data on its condition and relations with different pathological conditions. Computed tomography provides improved understanding of the Eustachian tube measurements and relationship with middle ear structures.

Sphenopalatine Foramen Computed Tomography Landmarks.

OBJECTIVE: The aim of the study was to assess different radiologic bony landmarks for endoscopic localization of the sphenopalatine foramen (SPF). METHODS: Paranasal computed tomography (CT) scans of adults without sinonasal pathology were included. On axial cuts, the anteroposterior distances from the SPF to maxillary line, anterior head of the middle turbinate, basal lamella of the middle turbinate, choanal arch, and posterior fontanel of the maxillary sinus ostium were measured. While on coronal cuts, the vertical distances from the SPF to the nasal floor was measured. The registered measurements were then studied and statistically analyzed. RESULTS: In 70 patients (140 sides, 840 measurements), the mean distances from the SPF to nasal floor, choanal arch, maxillary line, anterior head of the middle turbinate, basal lamella, and posterior fontanel were 25.6 ±â€Š2.4, 8.5 ±â€Š1.38, 36.4 ±â€Š2.6, 34.6 ±â€Š4.26, 8.1 ±â€Š1.27, and 13.7 ±â€Š1.7 mm, respectively, without significant differences between right and left sides. Females showed significantly shorter mean distances between SPF and the nasal floor (P = 0.0011), choanal arch (P = 0.0459), and posterior fontanel (P < 0.0001) than males. While no significant differences were detected between both sexes as regard distances from SPF to maxillary line (P = 0.5579), anterior head of middle turbinate (P = 0.8581), and basal lamella (P = 0.0638). CONCLUSION: Preoperative CT can provide multiple easily detected, reliable, and simple bony landmarks that can help SPF endoscopic localization. Thus the authors recommend adding these measurements to the preoperative CT checklist for patients scheduled for sphenopalatine artery ligation and/or excision of vascular lesions.

Lamina papyracea position in patients with nasal polypi: A computed tomography analysis.

OBJECTIVE: This study aimed to describe the positions of the lamina papyracea (LP) in patients who had nasal polypi, by computed tomography (CT) analysis. METHODS: Paranasal CT scans of patients diagnosed to have nasal polypi were included in the study. CT images were acquired with multiplanar reformates to obtain delicate details in coronal planes for all subjects. Positions of the LP were registered then analyzed in relation to nasal polypi grading. RESULTS: Forty seven subjects (94 nasal sides) were included in the current study. Grade I lamina detected in 50% or more of all cases. Patients who had larger polypi (polyp grade 3, 4) were associated with significantly more medial LP (grade II) than smaller polypi (polyp grade 0, 1, 2) (P=0.00386). CONCLUSION: The current study improves surgeons' awareness of LP position in different grades of nasal polypi and highlights that larger polypi are significantly associated with more medial LP than smaller polypi. This may be one of the causes of the higher incidence of complication in larger polypi and can help for safer surgery.

Tracheostomy in the Intensive Care Unit: a University Hospital in a Developing Country Study

Abstract Introduction Tracheostomy is the commonest surgical procedure in intensive care units (ICUs). It not only provides stable airway and facilitates pulmonary toilet and ventilator weaning, but also decreases the direct laryngeal injury of endotracheal intubation, and improves patient comfort and daily living activity. Objective The objective of this study is to assess the incidence, indications, timing, complications (early and late), and the outcome of tracheostomy on patients in the intensive care units (ICU) at a university hospital in a developing country. Methods This study is an observational prospective study. It was performed at the otolaryngology department and ICU new surgery hospital on 124 ICU admitted patients. We collected patients' demographic records, cause of admission, indications of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered patientś tracheostomy records including the incidence, timing, technique, type, early and late complications, and outcome. All tracheostomized patients received follow-up for 12 months. Results The indication for tracheostomy in ICU patients was mostly prolonged intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done within 17 to 26 days after intubation with a mean of 19.4 ± 2.07 days. Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic stenosis. Conclusion Prolonged endotracheal intubation is theman indication of tracheostomy, performed after two weeks of intubation. Although there were no major early complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy that needs to be investigated to be prevented.

Tracheostomy in the Intensive Care Unit: a University Hospital in a Developing Country Study.

Introduction Tracheostomy is the commonest surgical procedure in intensive care units (ICUs). It not only provides stable airway and facilitates pulmonary toilet and ventilator weaning, but also decreases the direct laryngeal injury of endotracheal intubation, and improves patient comfort and daily living activity. Objective The objective of this study is to assess the incidence, indications, timing, complications (early and late), and the outcome of tracheostomy on patients in the intensive care units (ICU) at a university hospital in a developing country. Methods This study is an observational prospective study. It was performed at the otolaryngology department and ICU new surgery hospital on 124 ICU admitted patients. We collected patients' demographic records, cause of admission, indications of tracheostomy, mechanical ventilation, and duration of ICU stay. We also gathered patients tracheostomy records including the incidence, timing, technique, type, early and late complications, and outcome. All tracheostomized patients received follow-up for 12 months. Results The indication for tracheostomy in ICU patients was mostly prolonged intubation (80.5%), followed by diaphragmatic paralysis (19.5%). All tracheostomies were done by the open approach technique. Tracheostomy for prolonged intubation was done within 17 to 26 days after intubation with a mean of 19.4 ± 2.07 days. Complications after tracheostomy were 13.9% tracheal stenosis and 25% subglottic stenosis. Conclusion Prolonged endotracheal intubation is the man indication of tracheostomy, performed after two weeks of intubation. Although there were no major early complications, laryngotracheal stenosis is still a challenging sequel for tracheostomy that needs to be investigated to be prevented.

The Efficacy of Nasal Steroids in Treatment of Otitis Media with Effusion: A Comparative Study

Introduction Otitis media with effusion (OME) continues to be an important pediatric clinical problem, and more studies are needed to decide the proper treatment for it. Objective To assess the efficacy of nasal steroids in the management of OME by comparing its results with that of oral steroid and that of nasal saline spray as placebo. Methods This study was carried on 60 patients with OME who were divided into three groups: in group 1, 20 patients received mometasone furoate spray, one puff in each nostril daily, for 3 months; in group 2, 20 patients received oral prednisolone, 5 mg three times per day for the first 3 weeks; in group 3, 20 patients received nasal saline spray, one puff in each nostril daily for 3 months. Results A highly significant difference between systemic or topical (nasal spray) steroid therapy and saline nasal spray was detected (p < 0.001), and the difference between systemic and topical steroid was nonsignificant (p > 0.05). Conclusion Nasal steroid spray can be used as an effective treatment for OME, giving a significant result similar to systemic steroid. Further studies are needed to investigate its use for longer duration and in recurrent cases.(AU)

The Efficacy of Nasal Steroids in Treatment of Otitis Media with Effusion: A Comparative Study.

Introduction Otitis media with effusion (OME) continues to be an important pediatric clinical problem, and more studies are needed to decide the proper treatment for it. Objective To assess the efficacy of nasal steroids in the management of OME by comparing its results with that of oral steroid and that of nasal saline spray as placebo. Methods This study was carried on 60 patients with OME who were divided into three groups: in group 1, 20 patients received mometasone furoate spray, one puff in each nostril daily, for 3 months; in group 2, 20 patients received oral prednisolone, 5 mg three times per day for the first 3 weeks; in group 3, 20 patients received nasal saline spray, one puff in each nostril daily for 3 months. Results A highly significant difference between systemic or topical (nasal spray) steroid therapy and saline nasal spray was detected (p < 0.001), and the difference between systemic and topical steroid was nonsignificant (p > 0.05). Conclusion Nasal steroid spray can be used as an effective treatment for OME, giving a significant result similar to systemic steroid. Further studies are needed to investigate its use for longer duration and in recurrent cases.

Hypopharyngeal reconstruction: a comparison of three alternatives.

This study aimed to evaluate the operative outcomes of using gastric pull-up (GPU), pectoralis major myocutaneous flap (PMMF), and jejunal free flap (JFF) to reconstruct the hypopharynx after resection of hypopharyngeal and cervical esophageal carcinoma. Retrospective clinical study. Otolaryngology Department, Zagazig University Hospital, Egypt and Surgical Department, National Cancer Institute, Cairo, Egypt. Records of 104 patients who underwent resection of carcinoma of the hypopharynx and cervical esophagus were reviewed to determine the indications for radical resection, location, and stage of the primary tumor, gross and pathological surgical resection margins, operative complications, morbidity, and mortality. Reconstruction was performed using the GPU for group (1) (n = 33), PMMF for group (2) (n = 34), and JFF for group (3) (n = 37). The hypopharynx was the most common primary tumor site for group (2) and group (3) whereas group (1) had lesions more frequently in the cervical esophagus. The overall postoperative morbidity rate was 20.2% with a perioperative mortality rate of 6.7% and there was no significant difference between the three groups. There was no graft necrosis in group (1) compared to 5.9% in group (2) and 5.4% in group (3). Pulmonary complications occurred commonly (30.3%) in group (1) compared to 11.8% in group (2) and 10.8% in group (3) The overall 3 years survival rate was 67.3% and there was no significant difference between the three groups. The outcomes of the three techniques are equally successful when used appropriately. The nature of the defect indicates the method of reconstruction. For short reconstruction above the thoracic inlet, PMMF or JFF are equally effective and in tumors requiring total esophagectomy, GPA is indicated.

Effect of central inset pharyngeal flap for velopharyngeal insufficiency on eustachian tube function.

OBJECTIVES/HYPOTHESIS: The aim of this study was to assess the effect of the central inset pharyngeal flap, used for correcting persistent velopharyngeal incompetence after cleft palate repair, on Eustachian tube (ET) function. METHODS: This study included 28 patients who were diagnosed with persistent velopharyngeal insufficiency following primary cleft palate repair, together with otitis media with effusion (OME) and/or ET dysfunction that failed to improve after the primary palatoplasty and extensive medical treatment. Diagnosis of velopharyngeal insufficiency (VPI) in these cases was performed by video nasoendoscopy and speech assessment. Prior to and after surgery, patients were assessed through otoscopic, tympanometric, and audiometric evaluation. RESULTS: All postoperative otoscopic findings were significantly better than preoperative (P < 0.05) finding, except for tympanic membrane (TM) calcification (P > 0.05). Postoperative tympanometry revealed type A curve (normal) in 30 ears (53.6%), with significant improvement in ET function after this type of flap (P < 0.001). CONCLUSION: ET can be improved after performing the superiorly based flap with new central inset in patients with persistent VPI following palatoplasty. Thus, there is no need for surgical interference to manage OME in these cases, except after trying this technique.