A new office-based procedure for treatment of snoring: The S.I.Le.N.C.E. study.

OBJECTIVE: Demonstrate the safety and effectiveness of palatal foreshortening and stiffening in reducing snoring severity in nonobstructive sleep apnea (non-OSA) patients complaining of chronic disruptive snoring. METHODS: In a US-based 8-center, open-label, prospective, single-arm cohort study, 52 consenting adults with chronic disruptive snoring (snoring impacting a patient's life and causing patient or bed partner to seek medical intervention) were treated via office-based placement of resorbable, bidirectional, barbed suture implants into the soft palate under local anesthesia. Prior to intervention, home sleep tests (HSTs) were performed to rule out OSA and to document snoring noise level. Both subject and their bed/sleep partners (also consented) completed questionnaires including: bed/sleep partner's scored visual analog scale (VAS) for subjects' snoring severity, and subject scoring for Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Following intervention, HSTs, VAS, ESS and PSQI were repeated at 30, 90 and 180 days. RESULTS: Mean baseline bed/sleep partner VAS was 7.81 ± 1.59. Mean postimplant VAS scores decreased significantly at each measured interval; to 5.77±2.35 (P < .001) at 30 days, 4.48 ± 1.81 (P < .001) at 90 days, and 5.40 ± 2.28 (P < .001) at 180 days. Post treatment improvements in daytime sleepiness and QOL were also observed. Two partial extrusions were reported. No further adverse events were identified. CONCLUSION: The current study demonstrates the safety and efficacy of the Elevoplasty procedure in reducing snoring severity over a follow-up period of 6 months. LEVEL OF EVIDENCE: 2b.

Provent therapy for obstructive sleep apnea: Impact of nasal obstruction.

OBJECTIVES/HYPOTHESIS: Determine the impact of nasal obstruction on efficacy, success, and adherence of Provent therapy in patients with obstructive sleep apnea (OSA). STUDY DESIGN: Prospective, two-arm, clinical pilot study at a single clinical site. METHODS: Patients with OSA who failed continuous positive airway pressure therapy were divided into two treatment arms: arm 1 were patients with no complaints of nasal obstruction and <50% nasal obstruction on exam, and arm 2 were patients with occasional complaints of nasal obstruction and 50% to 80% nasal obstruction on exam. Sleep testing at home was performed prior to the trial and on day 10 of the study with the use of Provent. RESULTS: Apnea-hypopnea index (AHI) decreased significantly from 20.5 ± 14.8 to 11.5 ± 16.6 (P < .001) in our total patient population. Patients in arm 1 had statistically significant improvement in their AHI (18.1 ± 13.0 to 7.4 ± 10.1, P < .001), oxygen desaturation index (ODI) (16.3 ± 10.8 to 8.2 ± 9.0, P < .001), and minimum oxygen saturation (81.3% ± 6.7% to 86.9% ± 5.6%, P = 0.008) from baseline sleep study to sleep study 2. Patients in arm 2 had improvements in their AHI (23.4 ± 16.6 to 16.5 ± 21.4), ODI (21.5 ± 14.8 to 17.0 ± 16.0) and minimum 02 %. However, none of these reached statistical significance. CONCLUSIONS: In this study, Provent therapy had a high failure rate. Patients without nasal obstruction showed greater improvements using Provent than patients with obstruction. Correction of nasal obstruction may be a useful prerequisite for treatment with Provent.

Factors associated with hypertrophy of the lingual tonsils.

OBJECTIVE: To identify factors that may be associated with lingual tonsil hypertrophy (LTH). STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Retrospective chart review identified 380 patients from August 2013 to April 2014 with graded lingual tonsils, documented during routine flexible laryngoscopy. Lingual tonsils were graded using a 0 to 4 scale: 0 = complete absence of lymphoid tissue, 1 = lymphoid tissue scattered over tongue base, 2 = lymphoid tissue covers entirety of tongue base with limited thickness, 3 = lymphoid tissue 5 to 10 mm in thickness, 4 = lymphoid tissue >1 cm in thickness (rising above the tip of epiglottis). Reflux symptom index (RSI collected during patient intake), presence of obstructive sleep apnea hypopnea syndrome (OSAHS; confirmed by polysomnogram), smoking habits, and basic demographics were gathered. Chi-square and linear multivariate regression analyses were used to identify significant relationships with LTH levels. RESULTS: Overall, 59.8% were male with a mean age of 50.2 ± 16.5 years and BMI of 30.1 ± 18.0. Chi-square analysis revealed no significant relationship between OSAHS and LTH (P = .059). When RSI was stratified to ≥ 10 or < 10, a Cochran-Armitage test supported the trend hypothesis that as RSI increases, lingual tonsil grading increases. Significant univariate correlates included younger age (r = -0.307, P < .001) and smoking (r = 0.186, P = .002). Multivariate regression revealed the combination of younger age, increasing RSI, and smoking (r = -0.297, P < .001) to be a significant correlate. CONCLUSION: LTH does not seem to be associated with OSAHS or BMI in this group of patients. High RSI, younger age, and gender may be factors associated with increased lingual tonsil thickness.

A standardized lingual tonsil grading system: interexaminer agreement.

OBJECTIVE: Comparisons among studies involving the tongue base are limited by lack of a universal system for grading lingual tonsils. The authors propose a new standardized clinical grading system for lingual tonsil hypertrophy (LTH). Validation was assessed via an interexaminer agreement study. STUDY DESIGN: Kappa interrater agreement study. SETTING: Tertiary academic center. SUBJECTS AND METHODS: Video assessment: The proposed grading system consists of a 0-to-4 scale: 0 = complete absence of lymphoid tissue; 1 = lymphoid tissue scattered over tongue base; 2 = lymphoid tissue covering entirety of tongue base with limited vertical thickness; 3 = significantly raised lymphoid tissue covering entirety of the tongue base, approximately 5 to 10 mm in thickness; 4 = lymphoid tissue rising above the tip of the epiglottis, ≥1 cm in thickness. The vertical height of the tonsils is a clinical approximate. A teaching video demonstrated identification of this grading system. Fourteen trained otolaryngologists graded 20 video clips of the tongue base, recorded during flexible laryngoscopy. Live assessment: A second study was performed by 2 examiners directly examining the tongue base of 23 patients using flexible laryngoscopy. RESULTS: Video assessment: The overall Fleiss kappa statistic was 0.775 (P < .0001). This denotes substantial agreement. Live assessment: The overall kappa for nominal data was 0.8665 (P < .0001). This denotes near perfect agreement. CONCLUSION: The substantial interexaminer correlation demonstrated during video assessment and perfect interexaminer correlation in live assessment indicate that the proposed grading system may be a valuable and useful tool in creating a common language to describe lingual tonsils.

Impact of mandibular advancement devices on C-reactive protein levels in patients with obstructive sleep apnea.

OBJECTIVES/HYPOTHESIS: To determine the effect of treatment of obstructive sleep apnea (OSA) with custom-made mandibular advancement devices (MADs) on C-reactive protein (CRP) levels in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN: Case series with chart review. METHODS: Charts of consecutive patients fitted with custom-made mandibular advancement devices for treatment of OSAHS between December 2011 and November 2012 were reviewed. Demographics such as age, sex, and body mass index (BMI) were collected. Prefitting and postfitting polysomnograms were reviewed. Pre- and posttreatment apnea-hypopnea index (AHI) and average O2 saturation were compared. Only patients with documented CRP levels determined prior to mandibular advancement device fitting and again after improvement of OSAHS symptoms were included. RESULTS: Forty-nine patients (77.6% male, age 47.4 ± 11.7 years, BMI 29.6 ± 5.0 kg/m(2)) were included in this study. Patients initially had elevated CRP levels (2.5 ± 1.8 mg/dl), which decreased significantly following use of their custom-made mandibular advancement device (1.9 ± 1.3 mg/dl, P = 0.006) by approximately 24%. AHI decreased significantly from 33.3 ± 21.7 pretreatment to 12.1 ± 22.3 posttreatment (P < 0.001). Treatment with MADs reduced AHI by approximately 69.3%. Minimum oxygen saturation significantly improved from 85.1% ± 5.9 pretreatment to 90.7% ± 3.6 posttreatment (P < 0.001). CONCLUSION: Treatment with custom-made mandibular advancement devices significantly reduced elevated CRP levels in patients with mild to severe OSAHS. Therapy achieves reasonable response and cure rates in the observed patients with a significant reduction in AHI.

Head elevation improves laryngeal exposure with direct laryngoscopy.

STUDY OBJECTIVE: The aim of this study was to examine the effect of changing head position on the laryngeal view in the same subject. DESIGN: Prospective, randomized, crossover comparison of laryngeal views. SETTING: Operating suite at a university-affiliated, community hospital. PATIENTS: One hundred sixty-seven consenting adult patients scheduled to undergo elective surgery with general anesthesia. INTERVENTIONS: After anesthesia induction and muscle relaxation and the head in extended position, the laryngeal view was graded in 3 different head height positions. A special inflatable pillow was placed under the subject's head before induction and was deflated to produce no head elevation or inflated to produce either 6.0cm (sniffing position), or 10.0cm elevation (elevated sniffing position) in random order. MAIN RESULTS: The incidence of difficult laryngoscopy (grade ≥3) was 8.38% with no head elevation, 2.39% in the sniffing position, and 1.19% in the elevated sniffing position. Head elevation was not associated with a worse grade in any single patient. CONCLUSIONS: Sniffing position improves glottic exposure when the laryngoscopic grade is greater than 1 in the head-flat position. The elevated sniffing position improves the view to a better grade in some patients. Because head elevation was not associated with a worse grade in any subject, the elevated sniffing position should be considered as the initial head position before direct laryngoscopy when a difficult exposure is anticipated.

Effect of continuous positive airway pressure on C-reactive protein levels in sleep apnea: a meta-analysis.

OBJECTIVE: Evaluate the effects of continuous positive airway pressure (CPAP) on C-reactive protein (CRP) levels, reported either as a primary or secondary end point among patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) based on a meta-analysis of published studies. DATA SOURCES: English-language searches of PubMed, Ovid, and the Cochrane databases were completed. Reference sections of identified studies were also examined for additional relevant articles to review. REVIEW METHODS: Studies of adult patients with OSAHS who reported pre- and post-CPAP treatment CRP were reviewed and analyzed. Two independent reviewers extracted data from 10 peer-reviewed studies, which were combined using a random effects meta-analysis model. RESULTS: The CPAP treatment was found to lead to a significant reduction in CRP levels (17.8%, P = .002). This corresponds to an effect size of -0.485 (-0.731, -0.240). Sensitivity analysis was done to determine the impact of study design. Both case-control studies and case-series studies yielded a significant effect. Sensitivity analysis also yielded a significant effect for studies with average body mass index <30, studies where CPAP was employed over automatic positive airway pressure, and studies treating patients ≤ 3 months. Analysis of publication bias, however, revealed a likelihood of "missing" studies. CONCLUSION: Although there is a significant lack of high-quality studies addressing this question, this analysis suggests that treatment with CPAP leads to a statistically significant reduction in CRP levels. However, the mean pre- and posttreatment CRP levels observed are considered "high risk" for cardiovascular morbidity. The clinical significance of this finding as it relates to cardiovascular risk reduction and the relationship between CRP and OSAHS requires further study.

Dead Sea salt irrigations vs saline irrigations with nasal steroids for symptomatic treatment of chronic rhinosinusitis: a randomized, prospective double-blind study.

BACKGROUND: Intranasal steroids are 1 of the most frequently prescribed medications for the treatment of chronic rhinosinusitis (CRS), and saline irrigations are commonly used as an adjunct to medical therapy. We aimed to compare the efficacy of Dead Sea salt (DSS) irrigations and DSS nasal spray vs saline irrigations and topical nasal steroid spray in the treatment of symptoms of CRS. METHODS: A total of 145 symptomatic adult patients without acute infection were initially enrolled and 114 completed the study. Patients completed a Sino-Nasal Outcomes Test 20 (SNOT-20) survey (primary outcome metric) and underwent endonasal examination, acoustic rhinometry, and smell testing (secondary outcome metrics). Patients were randomized to 2 groups. The experimental group (n = 59) self-administered hypertonic DSS spray and DSS irrigation; the control group (n = 55) self-administered fluticasone spray and hypertonic saline irrigation and spray. Patients and staff were blinded to group assignment. Outcomes were reassessed at 4 weeks. RESULTS: The 2 groups were homogeneous with respect to pretreatment primary and secondary outcome metrics. Dropout rates were 30% in the DSS group and 36.6% in the control group. Both groups showed significant improvement in mean SNOT-20 scores following treatment; however, the degree of improvement was not significantly different between groups (p = 0.082). There were no significant changes in secondary outcome metrics between the 2 groups. CONCLUSION: For patients with CRS, treatment with DSS irrigations and sprays appears as effective for symptom reduction as a combination of hypertonic saline irrigations and sprays and a topical steroid spray.

Induced hypocapnia is effective in treating pulmonary hypertension following mitral valve replacement.

BACKGROUND: Mitral valve stenosis is often associated with increased pulmonary vascular resistance resulting in pulmonary hypertension, which may lead to or exacerbate right heart dysfunction. Hypocapnia is a known pulmonary vasodilator. The purpose of this study was to evaluate whether induced hypocapnia is an effective treatment for pulmonary hypertension following elective mitral valve replacement in adults. METHODS: In a prospective, crossover controlled trial, 8 adult patients with mitral stenosis were studied in the intensive care unit following elective mitral valve replacement. Hypocapnia was induced by removal of previously added dead space. Normocapnic (baseline), hypocapnic and recovery hemodynamic parameters including cardiac output, pulmonary vascular resistance, pulmonary artery pressure and systemic oxygen delivery and consumption were recorded. RESULTS: Moderate hypocapnia (an end-tidal carbon dioxide concentration reduced to 28 +/- 5 mmHg) resulted in decreases in pulmonary vascular resistance and mean pulmonary artery pressure of 33% and 25%, respectively. Hypocapnia had no other hemodynamic or respiratory effects. The changes in pulmonary vascular resistance and mean pulmonary artery pressure were reversible. CONCLUSION: Moderate hypocapnia was effective in decreasing pulmonary vascular tone in adults following mitral valve replacement. The application of this maneuver in the immediate postoperative period may provide a bridge until pulmonary vascular tone begins to normalize following surgery.

Otolaryngology office-based treatment of obstructive sleep apnea-hypopnea syndrome with titratable and nontitratable thermoplastic mandibular advancement devices.

OBJECTIVE: 1) Share our experiences treating patients with obstructive sleep apnea-hypopnea syndrome (OSAHS) with titratable and nontitratable thermoplastic mandibular advancement devices (MADs) fitted in our otolaryngology clinic. 2) Compare these devices in terms of objective response (OR), as defined by a > or = 50 percent decrease in baseline apnea-hypopnea index (AHI) and an AHI < 20, and subjective parameters, including adherence. 3) Determine overall success, as defined by OR plus adherence at two months follow-up. STUDY DESIGN: Cohort study. SETTING: Tertiary care center. SUBJECTS AND METHODS: Patients with OSAHS who tried and failed or refused both continuous positive airway pressure (CPAP) and surgical therapy were fitted with a nontitratable Snore Guard (n = 38), nontitratable SomnoGuard 2.0 (n = 8), or titratable SomnoGuard AP (n = 41). Pre- and post-treatment assessment included: 1) Epworth Sleepiness Scale, 2) snoring level, 3) polysomnogram. Patients were contacted at two months follow-up to assess adherence and subjective parameters. RESULTS: OR was achieved in 62.1 percent of patients. Overall mean reduction in AHI was from 39.96 +/- 23.70 to 14.86 +/- 13.46 (P = 0.000). Adherence at two months was 58.5 percent. No significant differences were observed in OR or adherence according to MAD type, though improvements in AHI and minimum oxygen saturation were significantly better for the SomnoGuard AP than for the nontitratable devices. Overall success was 38.6 percent. CONCLUSION: Thermoplastic MADs are a relatively inexpensive treatment alternative for patients with OSAHS who fail/refuse CPAP and upper airway surgery. They can be easily fitted in the otolaryngology clinic. Long-term compliance, efficacy, and safety are unknown at this time.

Measurements of adult lingual tonsil tissue in health and disease.

OBJECTIVES: To report computed tomography (CT) measurements of lingual tonsil tissue (LTT) in patients with laryngopharyngeal reflux (LPR), obstructive sleep apnea-hypopnea syndrome (OSAHS), both LPR and OSAHS, or neither disease. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care center. SUBJECTS AND METHODS: Ninety-eight patients with CT scans including the tongue base and complete historical data regarding the presence or absence of symptoms, signs, and laboratory confirmation of LPR and/or OSAHS were included. LTT was measured on CT. Charts of patients meeting inclusion criteria were subsequently reviewed and patients were divided into four groups: 1) those without LPR or OSAHS, 2) those with LPR only, 3) those with OSAHS only, and 4) those with both LPR and OSAHS. Statistical analysis focused on correlating LTT thickness with the presence or absence of LPR and/or OSAHS. RESULTS: The mean LTT thickness for group 1 (21 patients without reflux or OSAHS) was 0.937 mm (range 0-2.67 mm). The mean for group 2 (29 patients with LPR only) was 3.35 mm (range 0-7.4 mm). The mean for group 3 (16 patients with OSAHS only) was 4.29 mm (range 0-9 mm). The mean for group 4 (32 patients with LPR and OSAHS) was 4.00 mm (range 0-19.2 mm). The mean for group 1 was lower than the other 3 groups (P < 0.001). CONCLUSION: CT images including the tongue base allow precise measurement of LTT thickness. LTT > 2.7 mm was not identified in patients without OSAHS or LPR. The mean LTT for patients with LPR and/or OSAHS was significantly greater than for patients without either disease.

Screening for obstructive sleep apnea/hypopnea syndrome: subjective and objective factors.

OBJECTIVES: To determine the sensitivity and specificity of the Berlin Questionnaire and the Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) score for individually predicting a diagnosis of OSAHS, and to propose a method for OSAHS screening incorporating objective and subjective factors. STUDY DESIGN: Cross-sectional survey. SETTING: Tertiary care center. METHODS: Charts were reviewed from 223 consecutive patients for whom complete data regarding the Berlin questionnaire, OSAHS score (Friedman tongue position + tonsil size + body mass index grade), Epworth Sleepiness Scale, and visual analog scale for snoring were obtained prior to polysomnography (PSG). Sensitivity and specificity were determined for the Berlin questionnaire and OSAHS score for predicting an apnea hypopnea index (AHI) >or= 5. Patient data were subjected to multivariate stepwise discriminant analysis and used to construct a screening system based on the Fisher's linear classification equation. Results were cross-validated by PSG findings. RESULTS: In predicting an AHI >or= 5, the sensitivity and specificity, respectively, were 0.615 and 0.226 for the Berlin questionnaire, 0.863 and 0.468 for OSAHS score, and 0.82 and 0.834 for our predictive equation. When applied case-wise to the study population, this equation correctly predicted 82.5 percent of diagnoses. Accuracy was highest for severe OSAHS (87.4%) and lowest for mild disease (77.0%). Sensitivity was lowest for mild OSAHS (0.50). CONCLUSIONS: Neither the Berlin questionnaire nor the OSAHS score alone was both highly sensitive and specific for diagnosing OSAHS. By incorporating subjective and objective metrics into a single predictive equation, sensitivity and specificity were maximized, and 82.5 percent of diagnoses were accurately predicted.

Successful treatment of meralgia paresthetica with pulsed radiofrequency of the lateral femoral cutaneous nerve.

BACKGROUND: Meralgia paresthetica is a rarely encountered sensory mononeuropathy characterized by paresthesia, pain or sensory impairment along the distribution of the lateral femoral cutaneous nerve caused by entrapment or compression of the nerve as it crosses the anterior superior iliac spine and runs beneath the inguinal ligament. OBJECTIVE: We describe the first reported use of pulsed radiofrequency neuromodulation to relieve the intractable pain associated with meralgia paresthetica. CASE REPORT: A 33-year-old morbidly obese female with a history of lower back pain and previous spinal fusion presented with sensory dysesthesias and paresthesias in the right anterolateral thigh, consistent with meralgia paresthetica. Temporary relief occurred with multiple lateral femoral cutaneous nerve and fascia lata blocks at 2 different institutions. The patient expressed dissatisfaction with her previous treatments and requested "any" therapeutic intervention that might lead to long-lasting pain relief. At this time, we located the anterior superior iliac spine and reproduced concordant dysesthesia. Pulsed radiofrequency was then undertaken at 42 degrees C for 120 seconds followed by dexamethasone and bupivicaine. The patient reported exceptional and prolonged pain relief at 6-month follow-up. LIMITATIONS: Since this case report is not a prospective, randomized, controlled or blinded study, no conclusions may be drawn from the results attained on behalf of this single individual. Additional, larger group analyses studying this technique while eliminating bias from patient variables would be essential prior to assuming any validity to using pulsed radiofrequency techniques of neuromodulation for managing peripheral neuropathic pain processes. CONCLUSION: The patient had experienced long-standing pain that was recalcitrant to conservative/pharmacologic therapy and multiple nerve blocks with local steroid instillations. A single treatment with pulsed radiofrequency resulted in complete and sustained cessation of pain. No side effects were evident. Pulsed radiofrequency of the LFCN may offer an effective, low risk treatment in patients with meralgia paresthetica who are refractory to conservative medical management or are unwilling or unfit to undergo surgery.

Intracapsular coblation tonsillectomy and adenoidectomy for the treatment of pediatric obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: To report the findings of five years' experience using standardized coblation intracapsular tonsillectomy with adenoidectomy for treatment of pediatric sleep apnea. STUDY DESIGN: Case series. METHODS: A five-year retrospective analysis of coblation tonsillectomy performed by a single department for sleep apnea was completed. RESULTS: A total of 159 tonsillectomy and adenoidectomy (T&A) cases performed with coblation technique were reviewed. The mean preoperative apnea-hypopnea index (AHI) was 17.8 and mean postoperative AHI was 3.3. Polysomnogram (PSG) normalization (AHI < 1), was achieved in 54.7% patients. Normalization of PSG data was achieved in only 42.2% of overweight patients (body mass index [BMI] >or= 85th percentile). Based on regression analysis, Friedman tongue position (III and IV) and elevated AHI were determined to be independent predictors of poor response to T&A. CONCLUSIONS: Contrary to popular belief, a review of 159 cases demonstrates that T&A does not always result in normalization of polysomnographic data. Although complete resolution is not achieved in most cases, T&A offers significant improvements in AHI. Predictive variables such as BMI, FTP, and AHI should be taken into account when designing a treatment plan. It is important to recognize the need for close follow-up and early detection of residual disease in the pediatric population.

Metoclopramide does not attenuate cricoid pressure-induced relaxation of the lower esophageal sphincter in awake volunteers.

BACKGROUND: The authors examined the influence of metoclopramide on cricoid pressure-induced relaxation of the lower esophageal sphincter (LES) in awake human volunteers. METHODS: With local institutional review board approval, measurements of LES and intragastric pressures were made in 10 consenting volunteers before cricoid pressure application, during 15 s of cricoid pressure application, and after release of cricoid pressure. The measurements were repeated after 0.15 mg/kg intravenous metoclopramide. Cricoid pressure was applied by one investigator trained to consistently apply a force of 44 N. RESULTS: Cricoid pressure resulted in immediate decrease in LES and barrier pressures from 14.1 +/- 2.9 mmHg to 3.2 +/- 3.7 mmHg and from 9.6 +/- 3.4 mmHg to -1.8 +/- 2.9 mmHg, respectively. These pressures promptly returned to baseline values after release of cricoid pressure. LES and barrier pressures increased after metoclopramide from 14.5 +/- 3.1 to 19.6 +/- 4.7 mmHg and from 10.2 +/- 3.6 to 14.1 +/- 5.5 mmHg, respectively. Cricoid pressure applied after metoclopramide resulted in immediate decreases in LES and barrier pressures to levels comparable to cricoid pressure before metoclopramide, but immediately returned to precricoid values after release of pressure. CONCLUSIONS: The current investigation demonstrates that cricoid pressure reflexly decreases LES tone and barrier pressure in awake subjects. Although metoclopramide increased LES and barrier pressures, it did not attenuate cricoid pressure-induced relaxation of the LES and barrier pressures and thus seems to have no value in preventing gastroesophageal reflux during cricoid pressure. Metoclopramide may be useful in preventing reflux when there is need to release or discontinue cricoid pressure.

Interexaminer agreement of Friedman tongue positions for staging of obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: To determine if strong interexaminer agreement exists in identifying Friedman tongue positions (FTPs) for staging of obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN AND METHODS: Twenty-six digital video clips of oropharyngeal examinations were prepared to demonstrate FTPs I through IV. Specific parameters for each FTP were provided to 126 examiners (otolaryngology residents, attendings, and fellows). The video clips were then presented to the examiners to determine the FTP. Kappa statistical analysis was used to evaluate the degree of intergrader agreement or disagreement. RESULTS: A generalized kappa statistic of 0.8 is considered the upper limits of substantial agreement. Thus, the overall kappa value (0.82) as well as all the subgroup kappa values for attendings (0.84), fellows (0.87), and residents (0.84) represented "very good" agreement. CONCLUSION: The strong interexaminer correlation of FTP demonstrated by this study indicates that FTP may be a useful adjunct in describing hypopharyngeal anatomy in patients with OSAHS.

Functional endoscopic dilatation of the sinuses: patient satisfaction, postoperative pain, and cost.

BACKGROUND: The purpose of this study was to determine how functional endoscopic dilatation of the sinuses (FEDS) compares with functional endoscopic sinus surgery (FESS) in a select group of patients with respect to (1) elimination of symptoms, (2) patient satisfaction, (3) postoperative narcotic use, and (4) cost. A retrospective study was performed of 70 patients with chronic rhinosinusitis who underwent FEDS or FESS as primary or revision treatment. METHODS: Symptoms and satisfaction based on the Sino-Nasal Outcome Test (SNOT-20) questionnaires and global patient assessment, postoperative narcotic use, and costs were compared after 3-month follow-up. RESULTS: SNOT-20 change scores indicated that both FEDS and FESS had clinically meaningful treatment responses. Patient satisfaction was higher and postoperative narcotics usage was less with FEDS. The cost for primary procedures was similar, whereas the cost for revision surgery using FEDS was considerably less. Turbinate lateralization and scarring was more common in the FEDS group, particularly early in the study. The incidence of recurrent sinus infections during the follow-up period was similar for both groups. Only one patient in the FEDS group required a repeat intervention within the short-term follow-up period. CONCLUSION: Both FEDS and FESS resulted in significant improvement in SNOT-20 scores for selected patients with mild disease. Patient satisfaction and postoperative narcotic use of FEDS compare favorably with FESS. Cost of FEDS was comparable with FESS for primary procedures but was less than FESS for revision procedures. Long-term efficacy and final cost of FEDS remain to be addressed, taking into account the need for revision procedures after initial FEDS, by means of long-term studies and objective outcome measures.

Palatal implants for the treatment of snoring and obstructive sleep apnea/hypopnea syndrome.

OBJECTIVE: Randomized, double-blinded, placebo-controlled, clinical trial to determine the effectiveness of palatal implants for treatment of mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDY DESIGN AND SETTING: Sixty-two non-obese adults with history of snoring, daytime sleepiness, and mild/moderate OSAHS, were randomized to receive palatal implants (n = 31) or placebo procedure (n = 31). Complete follow-up including quality of life (QOL, SF-36), snoring visual analog scale (VAS), and Epworth Sleepiness Scale (ESS) data were obtained in 62 patients. Seven patients refused follow-up polysomnography for a total of 55 patients (29 implant and 26 placebo). RESULTS: The treatment group (change in score of -7.9 +/- 7.7) was significantly improved compared with the placebo group (change in score of 0.9 +/- 4.3) for apnea/hypopnea index (AHI) (P < 0.0001), QOL, SF-36 (P < 0.0001), snoring VAS (P < 0.0001), and ESS (P = 0.0002). CONCLUSIONS: Palatal implants improve AHI, QOL, snoring intensity, and daytime sleepiness for selected patients with mild/moderate OSAHS.

Guidelines for radioguided parathyroid surgery.

OBJECTIVE: To confirm or refute the notion that only parathyroid adenomas have radioactivity higher than 20% of background. DESIGN: Retrospective analysis of a prospective patient data set. SETTING: Tertiary care referral center. PATIENTS: Forty-six patients (9 men and 37 women; mean +/- SD age, 53.7 +/- 12.1 years) underwent thyroid and parathyroid surgery between December 2005 and December 2006 to collect data on ex vivo radioactivity percentages on a variety of tissues. INTERVENTIONS: Patients were injected with 296 to 925 MBq of technetium Tc 99m sestamibi 1(1/2) to 3(1/2) hours before surgery. Biopsy specimens were taken of normal parathyroid glands, normal thyroid tissue, and lymph nodes and ex vivo radioactivity was recorded. Hyperplastic parathyroid glands and adenomatous glands were excised. Finally, some enlarged glands were cut into segments, and radioactivity counts were recorded and compared with the weight of the tissue. MAIN OUTCOME MEASURES: All counts were compared with radioactivity percentages in the surrounding tissues, and results were expressed as a function of these background radioactive counts. RESULTS: The mean +/- SD ex vivo background radioactivity of parathyroid adenomas was 148.5% +/- 83.1% of background activity (range, 40.1%-388.9% but never less than 40%). The mean +/- SD ex vivo background radioactivity of hyperplastic parathyroid glands was 74.6% +/- 18.0% (range, 49.5%-109.1% but never less than 40%). A significant difference was found in ex vivo background radioactivity between pathologic parathyroid tissue and the other tissue specimens studied (normal parathyroid glands [2.4% +/- 1.8%], thyroid tissue [4.5% +/- 2.8%], lymph nodes [1.6% +/- 0.8%], and fat [0.4% +/- 0.3%]). CONCLUSIONS: Ex vivo radioactivity percentages can differentiate hyperactive parathyroid tissue from any other tissue, but they cannot differentiate adenoma from hyperplasia and thus are not helpful in ruling out multiglandular disease. Interpretation of ex vivo radioactivity percentages should take into consideration the size of the specimen.

Impact of treatment of gastroesophageal reflux on obstructive sleep apnea-hypopnea syndrome.

OBJECTIVES: We test the hypothesis that treatment of gastroesophageal reflux disease (GERD) can improve obstructive sleep apnea-hypopnea syndrome (OSAHS). METHODS: One hundred forty-six patients with OSAHS underwent a complete history-taking, physical examination, and laboratory testing, including questions related to GERD symptoms. Full-night attended polysomnography, 24-hour wireless pH study at the upper esophagus, snoring level evaluation, Epworth Sleepiness Scale, and quality-of-life surveys were completed for each patient. Patients who tested positive for GERD were treated with esomeprazole magnesium 40 mg once daily for 2 to 12 months. The 24-hour pH study was repeated, and those patients with elimination of GERD were reevaluated by polysomnography, snoring level evaluation, Epworth Sleepiness Scale, quality-of-life surveys, and subjective data collection. RESULTS: Forty-one patients completed single-dose treatment with esomeprazole, but the repeat 24-hour pH study showed that 9 patients had persistent GERD. In the 29 patients who completed phase 2 with normal pH study findings, the snoring level decreased from 9.7 +/- 0.5 to 7.9 +/- 1.3 (p < .0001), the Epworth Sleepiness Scale score decreased from 14.2 +/- 2.5 to 11.1 +/- 2.4 (p < .0001), the apnea-hypopnea index decreased from 37.9 +/- 19.1 to 28.8 +/- 11.5 (p = .006), and the minimum saturation of oxygen increased from 84.1% +/- 7.8% to 86.9% +/- 5.0% (p = .055). CONCLUSIONS: Treatment of GERD had a significant impact on the reduction of the apnea-hypopnea index, snoring, and daytime sleepiness. Elimination of GERD should be part of a comprehensive treatment plan for patients with OSAHS.