Upper airway stimulation therapy and sleep architecture in patients with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To quantify changes in sleep architecture before and after upper airway stimulation (UAS) therapy in patients with obstructive sleep apnea. STUDY DESIGN: Retrospective chart review. METHODS: This study was performed at a single-institution tertiary academic care center. Patients who responded successfully to UAS implantation were selected for this study. Preoperative and postoperative sleep studies were compared to determine sleep architecture changes. Primary outcomes included sleep architecture parameters such as N1, N2, N3, and rapid eye movement (REM) in addition to others. Secondary outcomes included body mass index. RESULTS: Thirty-five patients met inclusion criteria for this study. There was significant improvement across several sleep architecture parameters. N1 sleep percent decreased from 16.7% ± 2.1% preoperatively to 10.1% ± 1.6% postoperatively (P = .023). Time spent in N2 increased from 148.0 ± 12.4 minutes to 185.5 ± 10.4 minutes (P = .030), whereas N3 increased from 21.9 ± 5.0 minutes to 57.0 ± 11.1 minutes (P = .013). No significant changes were observed in REM sleep. Arousal index decreased from 38.8 ± 4.0 to 30.3 ± 4.0 (P = .050). CONCLUSIONS: There was significant improvement across several sleep architecture parameters among patients who responded successfully to UAS implantation. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:1085-1089, 2020.

Novel approach using ultrasonic bone curettage and transoral robotic surgery for en bloc resection of cervical spine chordoma: case report.

Chordomas are rare, locally aggressive neoplasms that develop from remnants of the notochord. The typical approach to chordomas of the clivus and axial cervical spine often limits successful en bloc resection. In this case report, authors describe the first-documented transoral approach using both transoral robotic surgery (TORS) for exposure and the Sonopet bone scalpel under navigational guidance to achieve en bloc resection of a cervical chordoma. This 27-year-old man had no significant past medical history (Charlson Comorbidity Index 0). During a trauma workup following a motor vehicle collision, a CT of the patient's cervical spine demonstrated an incidental 2.2-cm lesion situated along the posterior aspect of the C2 vertebral body. Postoperative imaging showed successful en bloc resection with adequate placement of hardware, and the pathology report demonstrated negative resection margins. The patient tolerated the procedure well, and because of the successful en bloc resection, radiation has been deferred. At 7 months postoperatively, the patient returned to work in New York City. Contrasted MRI at 15 months postoperatively showed the patient to be disease free. This approach offers a promising way forward in the treatment of these complex tumors.

Outcomes of Hypoglossal Nerve Upper Airway Stimulation among Patients with Isolated Retropalatal Collapse.

OBJECTIVE: To examine whether patients with isolated retropalatal collapse perform as well as others following implantation with an upper airway stimulation (UAS) device. STUDY DESIGN: Retrospective review. SETTING: Single-institution tertiary academic care medical center. SUBJECTS AND METHODS: Following drug-induced sleep endoscopy, subjects who met inclusion criteria for implantation with a UAS device received an implant per industry standard. Subjects with isolated retropalatal collapse were compared with those having other patterns of collapse. Outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS). RESULTS: Ninety-one patients were implanted during the duration of the study, and 82 met inclusion criteria for analysis. Twenty-five had isolated retropalatal collapse, while the remaining 57 had other patterns of collapse on drug-induced sleep endoscopy. For all patients, mean preoperative AHI and NOS were 38.7 (95% CI, 35.0-42.4) and 78% (95% CI, 75%-80%), respectively; these improved postoperatively to 4.5 (95% CI, 2.3-6.6) and 91% (95% CI, 91%-92%). There was no significant preoperative difference between groups with regard to demographics, AHI, or NOS. Group comparison showed postoperative AHI to be 5.7 (95% CI, 0.57-10.8) for patients with isolated retropalatal collapse and 3.9 (95% CI, 1.7-6.1) for other patients ( P = .888). Postoperative NOS was 92% (95% CI, 90%-94%) among patients with isolated retropalatal collapse and 91% (95% CI, 90%-92%) for others ( P = .402). CONCLUSIONS: All patients showed significant improvement following implantation with UAS. Patients with isolated retropalatal collapse showed similar improvement to other types of collapse with regard to AHI and NOS.

Novel approach using transoral robotic surgery for resection of cervical spine chordoma.

Chordomas are rare, infiltrative neoplasms of notochordal origin that present along the spinal canal; en bloc surgical resection is paramount to successful treatment. Limited visualization and complex anatomy are major challenges to resection of upper cervical spine chordomas and often require invasive surgery. A 27-year-old male presented with an incidentally discovered chordoma of the midline second cervical vertebra of the spine. To obtain en bloc resection of the lesion while both overcoming limitations due to access and without introducing morbidity from traditional anterior approaches, we elected using transoral robotic surgery for resection. Due to complete resection, the patient remains disease-free and was spared adjuvant radiation. Laryngoscope, 129:1395-1399, 2019.

Management of the Airway for Transoral Robotic Supraglottic Partial Laryngectomy.

Introduction: Over the last several decades, transoral resection techniques for treatment of supraglottic lesions have become increasingly favored to reduce the need for either open transcervical resection or primary chemoradiation. Transoral robotic surgery (TORS) offers advantages in visualization, dissection control, and access to remove bulky tumors en bloc. However, the management of the airway for these cases tends to vary, without clear guidelines as to when a tracheostomy is necessary. Materials and Methods: A retrospective review of all patients who underwent transoral robotic supraglottic partial laryngectomy at a large academic center from May 2005 through December 2016 was performed. Airway management was examined, specifically as it pertains to whether a tracheostomy was performed at the time of surgery or otherwise. Demographic and tumor characteristics were also evaluated. Results: Sixty-three patients were included. Forty (63%) were male, the average age at surgery was 63.6, and the majority (90.5%) underwent resection for squamous cell carcinoma of the supraglottis. Thirty-nine patients (62%) underwent the procedure with standard endotracheal intubation using a wire-reinforced tube. Of these, four patients required subsequent tracheostomy- 2 for laryngeal edema postoperatively, one for airway management during a postoperative bleeding event, and one for laryngeal edema following initiation of adjuvant chemoradiation. Twenty patients (32%) underwent tracheostomy at the time of transoral resection for airway management, 17 of whom were decannulated an average of 12.2 weeks following surgery. Those who underwent tracheostomy at the time of surgery had a higher percentage of tumors involving multiple supraglottic subsites (p = 0.031), 85 vs. 54% in the group who did not undergo tracheostomy. No difference in age, BMI, clinical T-stage, or clinical N stage was found between the two groups. Conclusion: Performing a tracheostomy at the time of surgery should be considered for those patients with more extensive malignant disease (≥T2 tumors). While avoiding tracheostomy is often preferred by the patient, the maintenance of the patent airway peri-operatively should be first priority when considering airway management. Furthermore, as the majority of those patients receiving tracheostomy are decannulated within 4 months of surgery, the tracheostomy could be considered a short-term adjunct to the procedure.

Upper airway stimulation therapy and prior airway surgery for obstructive sleep apnea.

OBJECTIVE: To determine if patients with prior airway surgery for obstructive sleep apnea (OSA) had increased benefit following implantation with hypoglossal nerve stimulator. STUDY DESIGN: Retrospective chart review at a single institution tertiary academic care center. METHODS: Following implantation with hypoglossal nerve stimulator device, the outcomes of patients who underwent prior airway surgery for OSA were compared with those who did not. Primary outcome measures included apnea-hypopnea index (AHI) and nadir oxyhemoglobin saturation (NOS) as measured by polysomnography. Secondary outcome measures included Epworth Sleepiness Scale. RESULTS: Forty-seven patients underwent implantation with hypoglossal nerve stimulator. Of these, 30 patients had undergone prior airway surgery for OSA, whereas 16 did not. Mean preoperative AHI and NOS were 39.3 ± 2.8 and 78% ± 1.8% for all patients, 39.4 ± 3.7 and 79% ± 14% for patients with prior airway surgery, and 39.1 ± 4.0 and 77% ± 2.6% for patients without prior surgery. Mean postoperative AHI and NOS were 3.9 ± 1.2 and 91% ± 0.4% for all patients, 4.2 ± 1.7 and 91% ± 0.5% for patients with prior surgery, and 3.4 ± 1.5 and 93% ± 0.6% for patients without prior surgery (P = 0.756 and 0.053, respectively). CONCLUSION: Overall, patients had significant improvement following implantation with hypoglossal nerve stimulator. Prior airway surgery had no statistically significant effect on postoperative AHI or NOS. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1486-1489, 2018.

Speech perception performance as a function of age at implantation among postlingually deaf adult cochlear implant recipients.

OBJECTIVE: We seek to determine the extent of age-related decline in speech perception performance among cochlear implant recipients as quantified by various metrics. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: The records of 70 postlingually deafened adults who received cochlear implants between 2004 and 2013 were reviewed. INTERVENTION(S): Unilateral cochlear implantation. MAIN OUTCOME MEASURE(S): Postoperative AzBio and Consonant-Nucleus-Consonant (CNC) scores at greater than 3 months postactivation. Group analyses comparing patients aged 65 years and older (elderly) with younger adult patients (control). In addition, multivariate linear regression analyses were performed that incorporated preoperative pure-tone audiograms, duration of deafness, duration of follow-up, sex, and laterality of the implanted ear to quantitate the dependence of AzBio and CNC results on age at implantation (AAI). RESULTS: Performance on AzBio for the control and elderly groups were 74.6% ± 4.1% and 59.5% ± 4.5% (p = 0.032), respectively. Performance on CNC scores were 63.9% ± 3.4% and 55.3% ± 3.3% (p = 0.098), respectively. Multiple linear regression showed a significant correlation of AzBio with AAI, whereas CNC did not correlate significantly (correlation coefficients = -0.006 and -0.003, p = 0.019 and 0.081, respectively). CONCLUSION: Patients implanted at a later age performed more poorly on AzBio sentences. A similar trend was noted with CNC scores although not significant. The variability in correlation coefficients and significance between both speech perception tests and AAI suggests that, as patients age, their performance on each individual test will be affected to a varying degree.

Safety, efficacy, and hearing preservation using an integrated electro-acoustic stimulation hearing system.

OBJECTIVE: To determine the safety, efficacy, and potential for hearing preservation of an electroacoustic hearing system in patients with severe high-frequency and moderate low-frequency hearing loss. PATIENTS: Five patients were included in this study with steeply down-sloping sensorineural hearing loss. All patients had a history of hearing aid use and similar hearing in the contralateral ear. Ages ranged from 48 to 69 years. INTERVENTION: All participants were implanted with an electro-acoustic stimulation (EAS) device using a hearing preservation technique. This device integrates electric and acoustic stimulation into a single processor for simultaneous ipsilateral bimodal stimulation. MAIN OUTCOME MEASURE(S): Pure-tone audiograms (PTA) and speech reception thresholds (SRTs) during preoperative evaluation; initial cochlear implant (CI) stimulation; initial EAS stimulation; and at 3, 6, and 12 months poststimulation. Consonant-Nucleus-Consonant (CNC) monosyllables preoperatively and at 3, 6, and 12 months poststimulation. RESULTS: All participants showed preserved hearing in the surgical ear after implantation as measured by PTA and SRT. Significant improvement in speech recognition testing over hearing aid was observed at 3 months with EAS versus 6 months with CI-only stimulation. Facial stimulation occurred in 1 patient and resolved after reprogramming. CONCLUSION: There were no significant complications in this cohort of patients. Adequate hearing preservation was achieved. EAS and CI aided conditions both showed significant improvement over hearing aid with EAS condition achieving significance sooner.