Risk of cancer in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study.

PURPOSE: This study aimed to obtain a comprehensive view of the risk of developing cancer in patients with obstructive sleep apnea (OSA) and to compare this risk between patients receiving continuous positive airway pressure (CPAP) therapy versus upper airway surgery (UAS). METHODS: We used both local data and a global-scale federated data research network, TriNetX, to access electronic medical records, including those of patients diagnosed with OSA from health-care organizations (HCOs) worldwide. We used propensity score matching and the score-matched analyses of data for 5 years of follow-up, RESULTS: We found that patients who had undergone UAS had a similar risk of developing cancer than those who used CPAP [hazard ratio of 0.767 (95% CI 0.559-1.053; P = 0.100)]. CONCLUSION: Analysis of the large data sets collected from HCOs in Europe and globally lead us to conclude that in patients with OSA, neither CPAP nor UAS were associated with the development of cancer better than in non-treated patients.

Reply to: Letter to the Editor of Journal of Otolaryngology regarding "Risk of diabetes in patients with sleep apnea: comparison of surgery versus CPAP in a long-term follow-up study".

A recent Letter published, in the Journal of Otolaryngology-Head & Neck Surgery in response to our original article "Risk of diabetes in patients with sleep apnea: comparison of surgery versus Continous Positive Airway Pressure in a long-term follow-up study" raised some issues we would like to address here. However, we thank the authors for their effort and time in analyzing our manuscript and we want to facilitate a balanced discussion on this topic with our reply.

Evaluation of the Muscle Strength of the Tongue with the Tongue Digital Spoon (TDS) in Patients with Obstructive Sleep Apnea.

Myofunctional therapy (MT) is a recent treatment option for obstructive sleep apnea (OSA). The Iowa Oral Performance Instrument (IOPI) is a useful but expensive tool for measuring tongue strength in patients with OSA. We validated the Tongue Digital Spoon (TDS) to monitor tongue hypotonia in patients with OSA. Measurements with the IOPI and TDS were compared in patients with OSA before and after MT for tongue hypotonia. Baseline mean tongue strength measured with the IOPI in patients with moderate and severe OSA were 35.36 ± 9.05 and 33.83 ± 12.05, respectively, and that with the TDS were 168.55 ± 42.8 and 129.61 ± 53.7, respectively. After MT, mean tongue strength significantly improved: measured with the IOPI in patients with moderate and severe OSA were 53.85 ± 10.09 and 55.50 ± 9.64 (p = 0.8), and that with the TDS were 402.36 ± 52.92 and 380.28 ± 100.75 (p = 0.01), respectively. The correlation between the IOPI and TDS was high (r = 0.74; p = 0.01 pre-treatment, and r = 0.25; p = 0.05 post-treatment). The TDS is a useful tool for monitoring the efficacy of MT in patients with short-term OSA. Future randomized studies will determine the effectiveness of MT for the treatment of OSA.

Comparison Between two Surgical Techniques for Increasing Vocal Pitch by Endoscopic Shortening of the Vocal Folds.

OBJECTIVE: To compare two surgical techniques, the Wendler glottoplasty (GP) and its modification, the vocal fold shortening, and retrodisplacement of the anterior commissure (VFSRAC) associated with laser assisted voice adjustment (LAVA) cordotomy, used to feminize the voice of transgender women by increasing the fundamental frequency (F0). METHODS: A retrospective study of 22 trans-women (20-62 years-old) was carried out. 12 of them were treated with GP and 10 with the VFSRAC+LAVA technique. They were evaluated before surgery and 6 months after surgery and the postoperative speech therapy. Laryngostroboscopy examination, F0 measurements, Transgender Woman Voice Questionnaire (TWVQ) assessment and the perceptual assessment using a visual analog scale (PA-VAS) were obtained from all patients. RESULTS: Laryngostroboscopic findings showed normal vocal folds before surgery and a shortening of the vocal folds, due to the anterior glottic synechia, after surgery. Significant increases of F0 were found in both groups but they were higher in the VFSRAC+LAVA group (47.75Hz in GP group vs 69.70Hz in VFSRAC+LAVA group). TWVQ scores showed a significant decrease in both groups although the difference was greater in the VFSRAC+LAVA group. Similarly, PA-VAS scores lowered significantly in both groups but VFSRAC+LAVA group presented the biggest decreases. CONCLUSION: Both surgical techniques produce the shortening of the vocal folds through an endoscopic approach and result in voices with higher vocal pitch. Of the two techniques presented, the VFSRAC+LAVA produces better results although when compared with previous studies it seems that the LAVA technique may not significantly contribute to the postoperative results. So, the VFSRAC technique followed by postoperative speech therapy could be recommended for trans-women who wish to feminize their voice.

Does Frenotomy Modify Upper Airway Collapse in OSA Adult Patients? Case Report and Systematic Review.

Ankyloglossia (tongue-tie) is a condition of the oral cavity in which an abnormally short lingual frenulum affects the tongue's mobility. Literature on the correlation between ankyloglossia and obstructive sleep apnea (OSA) is scarce. The main objective of this study was to report our preliminary experience in adult OSA patients before and after ankyloglossia treatment, using drug-induced sleep endoscopy (DISE) to evaluate the upper airway modifications resulting after treatment, and to present a systematic review of the impact of ankyloglossia and its treatment on OSA adults. We found that, after frenotomy, regarding the DISE findings, and according to the VOTE classification, two of the three patients showed an improvement in tongue level, from 2A-P (complete anteroposterior collapse) to 1ap (partial anteroposterior collapse). The third patient showed no changes in his UA after frenotomy, neither worsening nor showing improvement. Thus, the results of this study suggest that frenotomy in OSA patients with ankyloglossia could reduce tongue collapse, probably by allowing the tongue to take into the physiological position in the oral cavity. These patients should undergo speech therapy and oropharyngeal exercises prior to any surgical procedure, in order to avoid glossoptosis and to improve the quality of life and sleep apnea results.

Improving Adherence to Myofunctional Therapy in the Treatment of Sleep-Disordered Breathing.

Myofunctional therapy (MT) is used to treat sleep-disordered breathing. However, MT has low adherence-only ~10% in most studies. We describe our experiences with MT delivered through a mobile health app named Airway Gym®, which is used by patients who have rejected continuous positive airway pressure and other therapies. We compared ear, nose, and throat examination findings, Friedman stage, tongue-tie presence, tongue strength measured using the Iowa oral performance instrument (IOPI), and full polysomnography before and after the 3 months of therapy. Participants were taught how to perform the exercises using the app at the start. Telemedicine allowed physicians to record adherence to and accuracy of the exercise performance. Fifty-four patients were enrolled; 35 (64.8%) were adherent and performed exercises for 15 min/day on five days/week. We found significant changes (p < 0.05) in the apnoea-hypopnoea index (AHI; 32.97 ± 1.8 to 21.9 ± 14.5 events/h); IOPI score (44.4 ± 11.08 to 49.66 ± 10.2); and minimum O2 saturation (80.91% ± 6.1% to 85.09% ± 5.3%). IOPI scores correlated significantly with AHI after the therapy (Pearson r = 0.4; p = 0.01). The 19 patients who did not adhere to the protocol showed no changes. MT based on telemedicine had good adherence, and its effect on AHI correlated with IOPI and improvement in tongue-tie.

Desarrollo y validación de la versión abreviada del Transsexual Voice Questionnaire for Male-to-Female Transsexuals en español / Development and validation of the Spanish abbreviated version of the Transsexual Voice Questionnaire for Male-to-Female Transsexuals

OBJETIVO: El objetivo de este estudio es crear y validar un cuestionario abreviado de la versión española del Transsexual Voice Questionnaire for Male-to-Female Transsexuals (VeTVQMtF). METODOLOGÍA: El estudio fue dirigido por 2 hospitales de referencia para la feminización quirúrgica de la voz y por un departamento universitario de psicología y rehabilitación vocal, todos ellos en España. MATERIAL Y MÉTODOS: Se realizó un estudio prospectivo de 51 mujeres transexuales a las que se les intervino de feminización quirúrgica de la voz entre enero 2017 y diciembre 2018. La VeTVQMtF fue rellenada por las mujeres transexuales antes y después de la cirugía y los 10 ítems de este cuestionario que más variaron fueron seleccionados por un grupo de expertos en feminización de la voz, para desarrollar la versión abreviada de la VeTVQMtF (VeTVQMtF-10). Se estudió la correlación entre la puntuación total y la puntuación de cada ítem en la VeTVQMtF y en la VeTVQMtF-10. Se analizó la consistencia interna de la VeTVQMtF-10. RESULTADOS: Se encontró una buena correlación entre los 2 cuestionarios (coeficiente de Pearson > 0,90), una buena correlación entre la puntuación total y la puntuación de cada ítem de la VeTVQMtF-10 y una correlación negativa entre la de la VeTVQMtF y la frecuencia fundamental de la voz tras la cirugía. El alfa Cronbach fue de 0,79. CONCLUSIÓN: La VeTVQMtF-10 es una versión abreviada válida de la VeTVQMtF y podría usarse para valorar la calidad de vida relacionada con la voz en mujeres transexuales en el idioma español

OBJECTIVE: The aim of this study was to create and validate an abbreviated version of the Spanish Transsexual Voice Questionnaire for Male-to-Female Transsexuals (SvTVQMtF). SETTING: The study was conducted by two referral hospitals for voice feminization surgery and by a university department of psychology and speech therapy, all in Spain. Subjects and methods: We prospectively studied 51 male-to-female transsexuals who underwent voice feminization surgery between January 2017 and December 2018. The SvTVQMtF was completed before and after surgery, and the 10 items with the greatest variation were selected by clinical consensus of an expert panel to develop the short version of the SvTVQMtF (SvTVQMtF-10). The correlation between the total score and the score for each item on the SvTVQMtF and the SvTVQMtF-10 was studied. The internal consistency of the SvTVQMtF-10 was analysed. RESULTS: Good correlation (Pearson coefficient above .90) was found between the two questionnaires. A significant correlation was found between the total SvTVQMtF-10 score and the score for each item. A significant negative correlation was found between the SvTVQMtF and fundamental frequency after voice feminization surgery. Cronbach's Alpha was .79. CONCLUSION: The SvTVQMtF-10 is a valid short version of the SvTVQMtF and can be used to quantify voice-related quality of life in MtF transsexuals

Development and validation of the Spanish abbreviated version of the Transsexual Voice Questionnaire for Male-to-Female Transsexuals. / Desarrollo y validación de la versión abreviada del Transsexual Voice Questionnaire for Male-to-Female Transsexuals en español.

OBJECTIVE: The aim of this study was to create and validate an abbreviated version of the Spanish Transsexual Voice Questionnaire for Male-to-Female Transsexuals (SvTVQMtF). SETTING: The study was conducted by two referral hospitals for voice feminization surgery and by a university department of psychology and speech therapy, all in Spain. SUBJECTS AND METHODS: We prospectively studied 51 male-to-female transsexuals who underwent voice feminization surgery between January 2017 and December 2018. The SvTVQMtF was completed before and after surgery, and the 10 items with the greatest variation were selected by clinical consensus of an expert panel to develop the short version of the SvTVQMtF (SvTVQMtF-10). The correlation between the total score and the score for each item on the SvTVQMtF and the SvTVQMtF-10 was studied. The internal consistency of the SvTVQMtF-10 was analysed. RESULTS: Good correlation (Pearson coefficient above .90) was found between the two questionnaires. A significant correlation was found between the total SvTVQMtF-10 score and the score for each item. A significant negative correlation was found between the SvTVQMtF and fundamental frequency after voice feminization surgery. Cronbach's α was .79. CONCLUSION: The SvTVQMtF-10 is a valid short version of the SvTVQMtF and can be used to quantify voice-related quality of life in MtF transsexuals.

Myofunctional Therapy App for Severe Apnea-Hypopnea Sleep Obstructive Syndrome: Pilot Randomized Controlled Trial.

BACKGROUND: Myofunctional therapy has demonstrated efficacy in treating sleep-disordered breathing. We assessed the clinical use of a new mobile health (mHealth) app that uses a smartphone to teach patients with severe obstructive sleep apnea-hypopnea syndrome (OSAHS) to perform oropharyngeal exercises. OBJECTIVE: We conducted a pilot randomized trial to evaluate the effects of the app in patients with severe OSAHS. METHODS: Forty patients with severe OSAHS (apnea-hypoxia index [AHI]>30) were enrolled prospectively and randomized into an intervention group that used the app for 90 sessions or a control group. Anthropometric measures, Epworth Sleepiness Scale (0-24), Pittsburgh Sleep Quality Index (0-21), Iowa Oral Performance Instrument (IOPI) scores, and oxygen desaturation index were measured before and after the intervention. RESULTS: After the intervention, 28 patients remained. No significant changes were observed in the control group; however, the intervention group showed significant improvements in most metrics. AHI decreased by 53.4% from 44.7 (range 33.8-55.6) to 20.88 (14.02-27.7) events/hour (P<.001). The oxygen desaturation index decreased by 46.5% from 36.31 (27.19-43.43) to 19.4 (12.9-25.98) events/hour (P=.003). The IOPI maximum tongue score increased from 39.83 (35.32-45.2) to 59.06 (54.74-64.00) kPa (P<.001), and the IOPI maximum lip score increased from 27.89 (24.16-32.47) to 44.11 (39.5-48.8) kPa (P<.001). The AHI correlated significantly with IOPI tongue and lip improvements (Pearson correlation coefficient -0.56 and -0.46, respectively; both P<.001). The Epworth Sleepiness Scale score decreased from 10.33 (8.71-12.24) to 5.37 (3.45-7.28) in the app group (P<.001), but the Pittsburgh Sleep Quality Index did not change significantly. CONCLUSIONS: Orofacial exercises performed using an mHealth app reduced OSAHS severity and symptoms, and represent a promising treatment for OSAHS. TRIAL REGISTRATION: Spanish Registry of Clinical Studies AWGAPN-2019-01, ClinicalTrials.gov NCT04438785; https://clinicaltrials.gov/ct2/show/NCT04438785.

Tongue peak pressure: a tool to aid in the identification of obstruction sites in patients with obstructive sleep apnea/hypopnea syndrome.

Purpose of this study was to evaluate whether tongue peak pressure measured using the Iowa Oral Performance Instrument is correlated with the topographic site of obstruction in patients with obstructive sleep apnea/hypopnea syndrome observed during drug-induced sleep endoscopy. Thirty-five consecutive adult patients (29 men, 6 women) were prospectively enrolled after having been diagnosed with severe obstructive sleep apnea/hypopnea syndrome by polysomnography. An apnea-hypopnea index > 30 was confirmed, and age, gender, and body mass index were recorded by Epworth Sleepiness Scale questionnaire, and a thorough evaluation of the upper airway by video-flexible endoscopy. Twenty healthy controls according to age and sex were chosen for IOPI measurements. After drug-induced sleep endoscopy, a topographic diagnosis was done using the VOTE classification. Tongue and lip peak pressures were both measured using the Iowa Oral Performance Instrument in all patients and in 20 healthy controls. Main outcomes and measures: the correlations between office findings, Iowa Oral Performance Instrument measures, and the VOTE tongue classification during drug-induced sleep endoscopy (T0, T1, T2) were then investigated. RESULTS: The average Iowa Oral Performance Instrument tongue and lip pressure were 44.02 ± 12.29 and 15.03 ± 3.71 kPa, respectively. The Iowa Oral Performance Instrument scores were both significantly lower than values in healthy controls (P < 0.001). The VOTE classification referring to the tongue position was T0 in 13 cases (37.1%), T1 in 12 cases (34.3%), and T2 in 10 cases (28.6%). A significant correlation was found between the Iowa Oral Performance Instrument tongue pressure and the T size during drug-induced sleep endoscopy (Kruskal-Wallis χ2 25.82; P ≤ 0.001). CONCLUSIONS: In our experience, the Iowa Oral Performance Instrument is a useful tool for evaluating tongue collapse for the topographic diagnosis of patients with obstructive sleep apnea/hypopnea syndrome.

Floppy Closing Door Epiglottis Treated Successfully with an Mhealth Application Based on Myofunctional Therapy: A Case Report.

We introduce the first case reported to date of a floppy closing door epiglottis in an OSA (obstructive sleep apnea) patient treated successfully with an Mhealth smartphone application based on myofunctional therapy.

Procedimientos para la integración de una Unidad de Voz en el funcionamiento de un Servicio/Área de ORL y sus resultados / Procedures for Integrating a Voice Unit in an ENT area/service and its results

Objetivos(I): Servir de modelo para aquellos Servicios de ORL que se encuentren en proceso de creación de una Unidad de Voz. (II) Exponer los resultados que hemos obtenido en nuestra Unidad de Voz a lo largo de los últimos 12 meses. Material y método: Se desarrollan los apartados: Funciones de la Unidad de Voz; Organización de la Unidad de Voz y Procedimientos de la Unidad de Voz. Se han estudiado 122 pacientes: valoración de autopercepción mediante el Índice de Incapacidad Vocal, categoría diagnóstica, diagnóstico de la Unidad, tratamientos previos y tratamientos propuestos por la Unidad. Resultados: Entre los resultados destacamos: tendencia en las puntuaciones del Voice Handicap Index a valoración leve y moderada; el grupo patológico más frecuente son las lesiones exudativas del espacio de Reinke; la existencia de más de un 50% de discrepancias diagnósticas entre las Consultas de ORL Generales y la Unidad de Voz; la terapia más habitual es el tratamiento logopédico (45%) seguido de la fonocirugía con un 28%. Conclusiones: El objetivo principal de la Unidad de Voz será obtener la máxima efectividad y calidad en sus diferentes funciones. Un diagnóstico y tratamiento correcto aumenta la efectividad y permite un mejor aprovechamiento de los recursos. Para alcanzarlo se requiere un equipamiento mínimo e imprescindible: laringoestroboscopio, protocolo multidimensional y trabajo interdisciplinar (AU)

Objectives(I): To serve as a model for ENT services in the process of creating a Voice Unit and (II) to show the results obtained in our Voice Unit over the past 12 months. Methods: Sections on Voice Unit Functions, Organisation, and Procedures are presented, as well as the study of 122 patients: an assessment of patient self-perception using the Voice Handicap Index, diagnostic category, Voice Unit diagnosis, previous treatments, and treatments proposed by the Unit. Results: The results highlight that Voice Handicap Index scores tend towards mild and moderate evaluations; that the most frequent pathological group are exudative lesions affecting Reinke's space; that there are diagnostic discrepancies of more than 50% between the general ENT consultations and the Voice Unit; and that the most common treatment is speech and language therapy (45%), followed by phonosurgery (28%). Conclusions: The main aim of the Voice Unit is to achieve maximum effectiveness and quality in its various functions. Correct diagnosis and treatment increase effectiveness and allow better use of resources; achieving this requires a minimal, essential setup: laryngostroboscope, a multidimensional protocol and interdisciplinary work (AU)

[Procedures for integrating a voice unit in an ENT area/service and its results]. / Procedimientos para la integración de una Unidad de Voz en el funcionamiento de un Servicio/Área de ORL y sus resultados.

OBJECTIVES: (I) To serve as a model for ENT services in the process of creating a voice unit and (II) to show the results obtained in our Voice Unit over the past 12 months. METHODS: Sections on Voice Unit Functions, Organisation and Procedures are presented, as well as the study of 122 patients: an assessment of patient self-perception using the Voice Handicap Index, diagnostic category, Voice Unit diagnosis, previous treatments and treatments proposed by the Unit. RESULTS: The results highlight that Voice Handicap Index scores tend towards mild and moderate evaluations; that the most frequent pathological group are exudative lesions affecting Reinke's space; that there are diagnostic discrepancies of more than 50% between the general ENT consultations and the Voice Unit; and that the most common treatment is speech and language therapy (45%), followed by phonosurgery (28%). CONCLUSIONS: The main aim of the Voice Unit is to achieve maximum effectiveness and quality in its various functions. Correct diagnosis and treatment increases effectiveness and allows better use of resources; achieving this requires a minimal, essential setup: laryngostroboscope, a multidimensional protocol and interdisciplinary work.

Resultado funcional de las miringoplastias / Functional results in myringoplasties

Objetivo: Determinar la mejoría de los umbrales auditivos tras la realización de una miringoplastia. Material y métodos: Utilizamos un estudio restrospectivo con un total de 119 casos intervenidos de miringoplastia en nuestro servicio analizando los umbrales aéreos pre- y posquirúrgicos a los 6 meses de la intervención. Se realiza un análisis de varianzas para las distintas variables y un contraste de hipótesis utilizando una T-Student. Resultados: Se obtuvo una mejoría en umbrales aéreos en todas las frecuencias, excepto en 8.000Hz, en los que la cirugía empeora la audición sensiblemente. La ganancia auditiva es mayor cuanto más baja es la frecuencia, con lo que se obtuvo el resultado máximo en 250Hz, donde la mejoría auditiva media llegó hasta los 13,49dB. Conclusiones: La miringoplastia es una técnica eficaz en la recuperación de umbrales auditivos secundarios a un defecto de la membrana timpánica (AU)

Goal: The aim of this study was to assess hearing improvement after myringoplasty. Material and methods: We present a retrospective study with a total of 119 cases undergoing myringoplasty at our Department analyzing the air conduction thresholds before and 6 months after surgery. We conducted an analysis of variance for the different variables and contrasted hypotheses using Student's T-test. Results: We obtained a hearing improvement at all frequencies, except at 8.000Hz, at which surgery noticeably worsens hearing. The lower the frequency, the higher the hearing improvement, with the best results at 250Hz, where the mean hearing improvement reached 13.49dB. Conclusions: Myringoplasty is an effective technique in the recovery of hearing thresholds secondary to a tympanic membrane perforation (AU)

[Functional results in myringoplasties]. / Resultado funcional de las miringoplastias.

GOAL: The aim of this study was to assess hearing improvement after myringoplasty. MATERIAL AND METHODS: We present a retrospective study with a total of 119 cases undergoing myringoplasty at our Department analyzing the air conduction thresholds before and 6 months after surgery. We conducted an analysis of variance for the different variables and contrasted hypotheses using Student's T-test. RESULTS: We obtained a hearing improvement at all frequencies, except at 8.000 Hz, at which surgery noticeably worsens hearing. The lower the frequency, the higher the hearing improvement, with the best results at 250 Hz, where the mean hearing improvement reached 13.49 dB. CONCLUSIONS: Myringoplasty is an effective technique in the recovery of hearing thresholds secondary to a tympanic membrane perforation.

Snoring surgery with palatal implants after failed uvulopalatopharyngoplasty.

The aim of this study was to assess the efficacy and morbidity in the use of the palatal implant technique (PITs) in patients with failed uvulopalatopharyngoplasty (UPPP) after a 6-month follow-up period. This was a prospective, nonrandomized study. Sixteen patients who underwent UPPP by the same Institution with Fujita's technique with initial success but developed posterior residual apnea or snoring who fulfilled the inclusion criteria were enrolled. Responses of all patients and their partners were assessed using the visual analogue scale (VAS) and the Epworth sleepiness scale (ESS). Objective data were recorded using ambulatory polysomnography before and at 6 months after surgery. Postoperative VAS and ESS scores significantly improved by 180 days after surgery (P < 0.005). VAS snoring score was reduced from 8.3 +/- 0.8 to 5.5 +/- 1.7 (P < 0.005) and ESS score decreased from 13.3 +/- 5.9 to 10.25 +/- 4.6 (P< 0.005). The apnea-hypopnea index (AHI) decreased from 18.08 +/- 6.02 to 16.8 +/- 5.05 events/h (P = 0.03). The PIT is an effective treatment for snoring and daytime sleepiness of patients with failed UPPPs.