Swallowing evaluation after surgery for obstructive sleep apnea syndrome: uvulopalatopharyngoplasty vs. expansion pharyngoplasty.

PURPOSE: To evaluate the effect of pharyngeal surgery on swallowing pattern in patients with obstructive sleep apnea syndrome (OSAS), and to compare two surgical techniques: uvulopalatopharyngoplasty (UPPP) and expansion pharyngoplasty (EP), through videofluoroscopy. METHODS: Longitudinal prospective cohort, in a tertiary referral center. 17 adult patients were enrolled this study, divided into two groups: patients who underwent UPPP (n = 10) or EP (n = 7). Swallowing videofluoroscopy (for both liquid and pasty consistences) was assessed at three different periods: before surgery, and at 14 and 28 days following surgery. Comparisons were performed between pre- and post-operative (PO) swallowing conditions in the same patient, and between surgical techniques. RESULTS: Asymptomatic OSAS patients already presented altered swallowing pattern before surgery. Both surgical procedures led to an increased hyoid movement time and an increased frequency of laryngeal penetration in early PO during liquid ingestion. For pasty consistency, both techniques reduced velum movement time and increased pharyngeal transit time and the rate of stasis in hypopharynx. All these parameters reached or tended to reach the pre-operative indices at day PO 28. CONCLUSIONS: OSAS patients show sub-clinical changes in swallowing pattern before surgery. Both surgical techniques are related to transitory changes in swallowing biomechanics. Complete or partial reversal to pre-operative swallowing parameters occurs 1 month after both surgery techniques.

Clasificación de las resecciones transorales en la orofaringe: propuesta del grupo de trabajo de la Sociedad Catalana de Otorrinolaringología / Transoral oropharyngeal resection classification: Proposal of the SCORL working group

Introducción y objetivos: La cirugía mínimamente invasiva ha presentado una expansión muy importante en la última década. Con el objetivo de aportar un lenguaje común tras cirugía transoral de la orofaringe, se ha creado un sistema de clasificación de las resecciones en esta zona, independientemente de la instrumentalización utilizada. Métodos: Desde el Grupo de Trabajo en Oncología de la Sociedad Catalana de Otorrinolaringología, se presenta una propuesta de clasificación basada en una división topográfica de las diferentes zonas de la orofaringe, así como en la afectación de las estructuras anexas según las vías anatómicas de extensión de estos tumores. Resultados: La clasificación se inicia utilizando la letra D o I según la lateralidad sea derecha (D) o izquierda (I). A continuación se coloca el número del área resecada. Esta numeración define las zonas iniciando a nivel craneal donde el área I sería el paladar blando, el área II lateral en la zona amigdalina, el área III en la base de lengua, el área IV en los repliegues glosoepiglóticos, la epiglotis y repliegues faringoepiglóticos, el área V pared orofaríngea posterior y VI el trígono retromolar. Se añade el sufijo p si la resección afecta profundamente al plano submucoso de la zona comprometida. Las diferentes áreas propuestas tendrían, de una forma teórica, diferentes implicaciones funcionales. Conclusiones: Propuesta de sistema de clasificación por áreas que permite definir diferentes tipos de cirugía transoral de la orofaringe así como compartir los resultados y ayudar en la docencia de este tipo de técnicas (AU)

Introduction and goals: There has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. Methods: From the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. Results: The classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone. The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. Conclusions: Proposal for a system of classification by area to define different types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique (AU)

Transoral oropharyngeal resection classification: Proposal of the SCORL working group. / Clasificación de las resecciones transorales en la orofaringe: propuesta del grupo de trabajo de la Sociedad Catalana de Otorrinolaringología.

INTRODUCTION AND GOALS: There has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. METHODS: From the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. RESULTS: The classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone. The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. CONCLUSIONS: Proposal for a system of classification by area to definedifferent types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique.

Surgical scheduling categorization system (SSCS): A novel classification system to improve coordination and scheduling of operative cases in a tertiary pediatric medical system.

OBJECTIVE: To describe a surgical categorization system to create a universal nomenclature, delineating patient complexity as a first step toward developing a true risk stratification system. METHODS: Retrospective database review of all otolaryngology surgical procedures performed in a tertiary pediatric hospital system over one academic year (July 2012-June 2013). All otolaryngology surgical procedures were reviewed, encompassing 8478 procedures on 5711 patients. The attending otolaryngologist assigned surgical scheduling category (SSCS) at the time of case booking based on an institution specific guidelines. The guidelines are as follow: Category I was assigned to American Society of Anesthesiologists physical status classification (ASA) I/II patients, designating them appropriate for institution's suburban ambulatory surgery centers; Category II was ASA I/II patients with social or transportation issues; Category III was ASA I/II patients who required case coordination with other medical or surgical departments; Category IV was reserved for patients of any ASA class whom the surgeon designated to be of a higher complexity. RESULTS: 8478 total procedures analyzed with 7198 having complete records. 48% were Category I, 13.6% were Category II, 1.9% were Category III and 36.5% were Category IV. The ASA were 34.7% ASA I, 50% ASA II, 13.39% ASA III, and 1.9% ASA IV. Although the largest proportion of patients were ASA II (50%), 39.6% of all ASA II were Category IV. Category IV was split into 54.2% ASA II and 34% ASA III and shows that peri-operative surgical concerns were not encompassed by the ASA system. CONCLUSION: This surgical categorization system streamlines surgical scheduling in a tertiary pediatric hospital system, particularly with respect to the designation of cases as ambulatory surgery center or main operating room appropriate. The case mix complexity is also readily apparent, enhancing recognition of the coordination and attention required for the perioperative management of high complexity patients. The SSCS helps convey concerns not addressed by ASA physical status alone.

The International Classification of the radiological Complexity (ICC) of frontal recess and frontal sinus.

BACKGROUND: The frontal sinus is considered the most challenging sinus to address surgically. There are no current classifications of the degree of surgical complexity of different frontal sinus configurations. The aim of this study is to develop a classification system of the degree of complexity of frontal recess surgery based on preoperative computed tomography (CT) scans. METHODS: Authors were asked to submit a classification system. These were circulated to all authors. Selection of the final 3 classifications was based on a majority consensus. These classifications were compared further for time-taken, ease-of-use, and interrater agreement. These were assessed by the authors on 10 CT scans representing a range of anticipated surgical difficulty. RESULTS: Out of 3 compared classifications, classification A was the quickest to score (1.44 minutes vs 1.57 minutes and 2.25 minutes), subjectively easiest (3.23 vs 4.07 and 5 on a visual analogue scale [VAS]), and had a moderate interrater agreement (0.52 vs 0.42 and 0.79). In addition, the grading of complexity was as good whether measurements were taken on the CT scans or whether size of the frontal ostium was visually estimated. CONCLUSION: We propose a fast, easy classification to anticipate the complexity of surgery in the frontal sinus and recess, for patients undergoing primary surgery.

Mastoidectomia: parâmetros anatômicos x dificuldade cirúrgica / Mastoidectomy: anatomical parameters x surgical difficulty

INTRODUÇÃO: A meninge temporal rebaixada e o/ou seio sigmoide anteriorizado são condições que podem determinar dificuldades cirúrgicas na realização da mastoidectomia. OBJETIVO: Correlacionar a medida do prolapso do seio sigmoide e da meninge temporal na tomografia com a dificuldade cirúrgica na mastoidectomia. MÉTODO: As medidas tomográficas de prolapso sigmóideo e da meninge temporal foram correlacionadas com presença ou não de dificuldade cirúrgica observados durante o procedimento mastoidectomia de pacientes com otomastoidite crônica (n=30). FORMA DE ESTUDO: Coorte contemporânea com corte transversa. RESULTADOS: Em 10 pacientes, observou-se dificuldade cirúrgica assim distribuída: devido ao prolapso do seio sigmoide (n = 2) ou prolapso da meninge temporal (n = 7) ou ambos (n = 1). Nos pacientes cuja dificuldade cirúrgica foi devido ao prolapso do seio sigmoide, a distância na tomografia da borda anterior do seio sigmoide à parede posterior do canal auditivo externo foi menor que 9 mm. Nos pacientes cuja dificuldade cirúrgica foi devido ao prolapso da meninge temporal, a distância tomográfica desta ao plano superior do osso petroso foi 7 mm. CONCLUSÃO: A distância na tomografia computadorizada entre a meninge temporal e o plano superior do osso petroso 7 mm e uma distância do bordo anterior do seio sigmoide à parede posterior do canal auditivo externo inferior a 9 mm são preditivos de dificuldades cirúrgicas durante a mastoidectomia.

INTRODUCTION: The lowered temporal meninges and/ or anterior sigmoid sinus are contiditions that can determine surgical difficulties in performing mastoidectomy. OBJECTIVE: To correlate in the tomography the extent of the prolapse of the sigmoid sinus and of temporal meninges with the surgical difficulty in the mastoidectomy. METHOD: The tomographic measurements of prolapse sigmoid and of temporal meninges were correlated with the presence or non-presence of the surgical difficulty observed during the mastoidectomy procedure in patients with ostomatoiditis chronic (n=30). FORM OF STUDY: Contemporary cohort transverse. RESULTS: In 10 patients were observed surgical difficulty distributed as: due to prolapse of the sigmoid sinus (n = 2) or temporal meninges prolapse (n = 7) or both (n = 1). In patients in which the surgical difficulty was due to sigmoid sinus prolapse, the tomography distance of the anterior border of the sigmoid sinus to posterior wall of external auditory canal was lower than 9 mm. In patients in which surgical difficulty was due to temporal meninges prolapse, the tomographic distance to the upper plane of the petrous bone was 7 mm. CONCLUSION: The computerized tomography distance between the temporal meninges and the upper plane of the petrous bone 7 mm and the distance of the anterior border of the sigmoid sinus to posterior wall of external auditory canal was lower than 9 mm are predictive to the surgical difficulties to perform mastoidectomy.

Tiroplastia tipo III para el tratamiento de la disfonía por elevación del tono / Type III thyroplasty for the treatment of high-pitched voice disorder

La tiroplastia tipo III es una técnica quirúrgica que disminuye la frecuencia fundamental de la voz. Presentamos el caso de un paciente con disfonía por elevación del tono en relación con el sexo tratado mediante tiroplastia tipo III, y se realiza una revisión actualizada de la técnica quirúrgica y sus resultados (AU)

Type III thyroplasty is a surgical technique which diminishes the fundamental frequency of the voice. We present the case of a patient with dysphonia by tone elevation in relation to gender, treated by type III thyroplasty and an updated review of the surgical technique and its outcome (AU)

[Type III thyroplasty for the treatment of high-pitched voice disorder]. / Tiroplastia tipo III para el tratamiento de la disfonía por elevación del tono.

Type III thyroplasty is a surgical technique which diminishes the fundamental frequency of the voice. We present the case of a patient with dysphonia by tone elevation in relation to gender, treated by type III thyroplasty and an updated review of the surgical technique and its outcome.

[ENT medicine and head and neck surgery in the G-DRG system 2008]. / Die HNO-Heilkunde, Kopf- und Hals-Chirurgie im G-DRG-System 2008.

BACKGROUND: Further developments in the German DRG system have been incorporated into the 2008 version. For ENT medicine and head and neck surgery significant changes concerning coding of diagnoses, medical procedures and concerning the DRG-structure were made. METHODS: Analysis of relevant diagnoses, medical procedures and G-DRGs in the versions 2007 and 2008 based on the publications of the German DRG institute (InEK) and the German Institute of Medical Documentation and Information (DIMDI). RESULTS: Changes for 2008 focussed on the development of DRG structure, DRG validation and codes for medical procedures. The outcome of these changes for German hospitals may vary depending on the range of activities. CONCLUSION: The G-DRG system has gained in complexity again. High demands are made on correct and complete coding of complex ENT and head and neck surgery cases. Quality of case allocation within the G-DRG system has been improved. For standard cases quality of case allocation is adequate. Nevertheless, further adjustments of the G-DRG system especially for cases with complex neck surgery are necessary.

Defining phonosurgery: a proposal for classification and nomenclature by the Phonosurgery Committee of the European Laryngological Society (ELS).

The term phonosurgery (PS) refers to any operation designed primarily for the improvement or restoration of voice. It is defined by the intended operative goal, which pertains to quality of life rather than its preservation, and informed consent needs to account for this emphasis. Since the aim is improvement or maintenance of vocal function, it is essential to document voice accurately pre-operatively. As important as the surgery itself is a team approach to perioperative care and rehabilitation. Although not a new concept, the PS portfolio of operations continues to grow rapidly, making this one of the most dynamic field in Laryngology. However, this has also led to confusion regarding terminology and classification, with the result that it is presently difficult to compare results between institutions. The aim of this paper is to establish a practical classification system for PS and to thereby establish a common language for reporting results. We propose four groups of operation: vocal fold surgery (VFS), laryngeal framework surgery (LFS), neuromuscular surgery (NHS) and reconstructive surgery (RCS) (for either partial or total laryngeal replacement).

[Case allocation of extensive operations on head and neck within the German DRG system 2004-2007: what is the net result of the continued developments in case allocation?]. / Analyse der Abbildungsqualität grosser operativer Eingriffe an Kopf und Hals in den G-DRG-Systemen 2004-2007: Was hat die Weiterentwicklung der Fallpauschalen gebracht?

BACKGROUND: When the German DRG system was implemented there was some doubt about whether patients with extensive head and neck surgery would be properly accounted for. Significant efforts have therefore been invested in analysis and case allocation of those in this group. The object of this study was to investigate whether the changes within the German DRG system have led to improved case allocation. METHODS: Cost data received from 25 ENT departments on 518 prospective documented cases of extensive head and neck surgery were compared with data from the German institute dealing with remuneration in hospitals (InEK). Statistical measures used by InEK were used to analyse the quality of the overall system and the homogeneity of the individual case groups. RESULTS: The reduction of variance of inlier costs improved by about 107.3% from the 2004 version to the 2007 version of the German DRG system. The average coefficient of cost homogeneity rose by about 9.7% in the same period. Case mix index and DRG revenues were redistributed from less extensive to the more complex operations. Hospitals with large numbers of extensive operations and university hospitals will gain most benefit from this development. CONCLUSION: Appropriate case allocation of extensive operations on the head and neck has been improved by the continued development of the German DRG system culminating in the 2007 version. Further adjustments will be needed in the future.

[ENT and head and neck surgery in the German DRG system 2007]. / HNO-Heilkunde, Kopf- und Hals-Chirurgie im G-DRG-System 2007.

BACKGROUND: The German DRG system has been further developed into version 2007. For ENT and head and neck surgery, significant changes in the coding of diagnoses and medical operations as well as in the the DRG structure have been made. RESULTS: New ICD codes for sleep apnoea and acquired tracheal stenosis have been implemented. Surgery on the acoustic meatus, removal of auricle hyaline cartilage for transplantation (e. g. rhinosurgery) and tonsillotomy have been coded in the 2007 version. In addition, the DRG structure has been improved. Case allocation of more than one significant operation has been established. CONCLUSION: The G-DRG system has gained in complexity. High demands are made on the coding of complex cases, whereas standard cases require mostly only one specific diagnosis and one specific OPS code. The quality of case allocation for ENT patients within the G-DRG system has been improved. Nevertheless, further adjustments of the G-DRG system are necessary.

[ENT relevant changes in the German OPS Procedure Classification System for 2006]. / HNO-relevante Anderungen des Operations- und Prozedurenschlüssels (OPS) ab 2006.

BACKGROUND: Classification of surgical and medical procedures is of increasing relevance for health care financing. From this viewpoint, classification according to the German "Operations- und Prozedurenschlüssel" (OPS) was frequently inadequate so far. METHODS: In the course of a comprehensive DRG evaluation project, deficits of the economic classification of ENT-medicine were identified. Based on these findings, proposals for further improvement of the OPS were developed. RESULTS: An improper medical economic classification was identified for common surgical procedures on middle ear, nose and paranasal sinuses, and for coding of prosthetic voice restoration. In agreement with the German Institute for Medical Documentation and Information (DIMDI) the OPS was revised accordingly. CONCLUSIONS: Significant modifications of the OPS will take place at January 1 (st) 2006, which are of great impact for health care financing by the G-DRG-System and in the context of outpatient surgery.

[G-DRG System 2005. Analysis and evaluation of significant changes from the viewpoint of HNO medical science]. / G-DRG-System 2005. Analyse und Bewertung wesentlicher Anderungen aus Sicht der HNO-Heilkunde.

With the release of the new Global Case Agreement by Self Administration in Public Health on the 16 September 2004, the adjustment of the G-DRG System for the year 2005 was completed. Otorhinolaryngology, and head and neck surgery face several changes in the fields of diagnosis and procedural coding (ICD-10-GM 2005, OPS-301 2005), G-DRG case allocation, and extra reimbursements for special interventions. Despite some considerable improvements, substantial problems remain unsolved. This paper presents and comments on the key points of the G-DRG System for 2005 for otorhinolaryngology, and head and neck surgery.

[Thought-provoking adaptation of otorhinolaryngologic surgery]. / Tankevekkende tilpasning av øre-nese-hals-kirurgi.

BACKGROUND: Global budgeting was partially replaced by activity-based funding in 1999 in order to improve productivity and reduce waiting lists. The aim of this study is to estimate otolaryngologic surgery rates after the introduction of Diagnosis Related Groups funding. MATERIAL AND METHOD: National data on outpatient and inpatient otolaryngologic surgical procedures over the period 1999 to 2002 were provided by the Norwegian Patient Register; an estimate was made of the proportion undergoing uvuloplasty for sleep apnea or snoring. RESULTS: From 1999 to 2002, there was an overall increase in otolaryngologic procedures of 12%. Inter-procedural variation ranged from a 110% increase in uvuloplasties to a 12 % decrease in tonsillectomies. There was a particular increase in procedures requiring neither general anaesthesia nor a highly specialised surgeon. In spite of the increased rates of uvuloplasty, the proportion of patients selected for surgery remained unchanged. INTERPRETATION: The substantial increase in certain procedures may give rise to several interpretations: better medical technology, reallocation of surgical resources to disorders that had been inadequately covered, or a shift towards procedures for which marginal costs do not exceed treatment costs.

[Crystotomy with use of surgical ultrasonic instruments]. / Kristotomiia s ispol'zovaniem khirurgicheskikh ul'trazvukovykh instrumentov.

The authors propose to make crystotomy using energy of low-frequency ultrasound (the device URSK 7N 22, frequency - 26.5-30 kHz, amplitude - 40-50 mcm). The working part of the waveguide was designed in specific geometric shape. Indications to ultrasonic crystotomy and surgical techniques are outlined. A total of 29 patients were operated on. Good results were achieved in 25 patients, satisfactory results in 4 patients.