Transoral Versus Endoscopic Examination in Predicting Outcomes of Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea.

OBJECTIVES/HYPOTHESIS: To examine the correlation between transoral and awake endoscopic examination and investigate their respective ability to predict outcomes of hypoglossal nerve stimulation (HGNS). STUDY DESIGN: Retrospective cohort study at a US medical center. METHODS: Subjects were adults with apnea-hypopnea index (AHI) >15 events/hr who underwent HGNS according to standard indications. Eligible subjects had diagnostic preoperative sleep studies, full-night efficacy postoperative studies, as well as postoperative video recordings of transoral examination and awake endoscopy. Recordings were independently scored by two blinded reviewers. Cohen's κ coefficient, Student t test, and χ2 analyses were performed. RESULTS: Fifty-seven patients met all inclusion criteria. On average, patients were Caucasian, middle aged, and overweight. The mean preoperative AHI was 36.7 events/hr, which improved significantly to 18.3 events/hr following HGNS (P < .01). Overall, the response rate (defined as AHI reduction >50% and AHI < 20 events/hr) was 49%. There was slight correlation between transoral tongue protrusion and endoscopic tongue base movement (κ = 0.10). On transoral examination, patients with minimal/moderate tongue motion achieved a greater mean AHI reduction than patients with full motion (26.0 ± 18.0 vs. 12.8 ± 24.1, P = .02). In contrast, on awake endoscopy, patients with minimal/moderate tongue motion achieved a lesser mean AHI reduction than patients with full motion (8.7 ± 19.9 vs. 22.1 ± 22.7, P = .04). CONCLUSIONS: Transoral tongue protrusion bears an inverse relationship to HGNS success and correlates poorly with endoscopic tongue base movement. Endoscopic tongue base motion appears reflective of response to HGNS, with greater motion corresponding to greater AHI reduction. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:675-679, 2021.

Success of Hypoglossal Nerve Stimulation Using Mandibular Advancement During Sleep Endoscopy.

OBJECTIVES/HYPOTHESIS: Hypoglossal nerve stimulation (HGNS) effectively treats obstructive sleep apnea in select patients. Drug-induced sleep endoscopy (DISE) is required for HGNS candidacy. Data suggest that mandibular advancement (MA) devices and HGNS share similar target populations. We aimed to test the association between MA's effect on the velum and lateral walls during DISE in relation to the improvement in the apnea-hypopnea index (AHI) with HGNS. STUDY DESIGN: Prospective case series METHODS: All patients completed preoperative polysomnography or home sleep study, DISE with MA prior to HGNS implantation, and full-night efficacy sleep tests. Adult patients with body mass index (BMI) ≤ 35 and AHI ≥ 15 were included. Two independent reviewers scored DISE videos. RESULTS: Forty-six patients were included from October 2015 to January 2019. Mean BMI (standard deviation) was 28.5 (3.7) kg/m2 . Patients with a reduced airway response to MA had greater AHI improvement than patients with a robust response (21.7, 95% confidence interval [CI]: 14.4 to 29.0 vs. 4.9, 95% CI: -8.9 to 18.6; P = .03). Patients with complete baseline collapse at the velum and lateral walls (n = 11) had less response compared to those with partial collapse (n = 35) (AHI reduction of 4.4 [95% CI: -8.6 to 17.4] vs. 22.3 [95% CI: 15.1 to 29.6; P = .02]). CONCLUSIONS: Patients having significant airway improvement in the upper pharynx with MA during DISE appear less likely to succeed with HGNS. This phenomenon might be secondary to the worsened baseline obstruction of the upper pharynx in such patients. LEVEL OF EVIDENCE: 4 Laryngoscope, 2020.

Multilevel Palate and Tongue Base Surgical Treatment of Obstructive Sleep Apnea: A Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate multilevel palate and tongue base surgery as a method of treatment of obstructive sleep apnea by comparing the pre- and postoperative apnea-hypopnea index. METHODS: We conducted a systematic review. MEDLINE and Embase databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for conducting systematic reviews. Two authors screened all articles and performed methodological quality assessment. Relevant articles where reviewed in detail. Standard inclusion criteria were applied for article selection. Relevant data were extracted and summarized, a difference of means random-effects model was performed. Our primary outcome measure was change in apnea-hypopnea index pre-/postsurgical treatment. RESULTS: Of 1,172 studies identified from January 2006 to March 2017, 46 studies met inclusion criteria and were included in the systematic review. This included 11 surgical subgroups and 1,806 patients. Methodological quality and risk of bias assessments were completed. There was strong male predominance 86.8 (standard deviation [SD] = 10.3%), and the average age was 46.8 (SD = 4.0) years. All studies included overweight to obese patients (average body mass index = 29.1 [SD = 3.5]). The average preoperative apnea-hypopnea index was 39.0 (SD = 15.4), and the average postoperative apnea-hypopnea index decreased to 18.3 (SD = 7.5). Meta-analysis data yielded a decrease in apnea-hypopnea index of -23.67 with a 95% confidence interval of -27.27 to -20.06. CONCLUSIONS: Non-maxillomandibular advancement, multilevel surgical procedures for obstructive sleep apnea demonstrate significant improvements in reduction of apnea-hypopnea index following surgery in addition to improvement in many other sleep-specific outcomes. Future research should include larger, higher-level studies that compare surgical treatments and identify factors associated with outcomes. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1712-1721, 2019.

Optimal detection of hypothyroidism in early stage laryngeal cancer treated with radiotherapy.

BACKGROUND: Hypothyroidism following radiation therapy (RT) for treatment of Head and Neck Cancer (HNC) is a common occurrence. Rates of hypothyroidism following RT for Early Stage Laryngeal Squamous Cell Carcinoma (ES-LSCC) are among the highest. Although routine screening for hypothyroidism is recommended; its optimal schedule has not yet been established. We aim to determine the prevalence and optimal timing of testing for hypothyroidism in ES-LSCC treated with RT. METHOD: We conducted a population-based cohort study. Data was extracted from a prospective provincial head and neck cancer database. Demographic, survival data, and pre- and post-treatment thyroid stimulating hormone (TSH) levels were obtained for patients diagnosed with ES-LSCC from 2008-2012. Inclusion criteria consisted of patients diagnosed clinically with ES-LSCC (T1 or 2, N0, M0) treated with curative intent. Patients were excluded if there was a history of hypothyroidism before the treatment or any previous history of head and neck cancers. RESULTS: Ninety-five patients were included in this study. Mean age was 66.1 years (range: 44.0-88.0 years) and 82.3% of patients were male. Glottis was the most common subsite at 77.9% and the average follow-up was 40 months (Range: 12-56 months). Five-year overall survival generated using the Kaplan-Meier method was 79%. Incidence of hypothyroidism after RT was found to be 46.9%. The greatest frequency of developing hypothyroidism was at 12 months. CONCLUSIONS: We found a high prevalence of hypothyroidism for ES-LSCC treated with RT, with the highest rate at 12 months. Consequently, we recommend possible routine screening for hypothyroidism using TSH level starting at 12 months. To our knowledge, this is the first study to suggest the optimal timing for the detection of hypothyroidism.

Immunoglobulin G4-related diseases in the head and neck: a systematic review.

BACKGROUND: Immunoglobulin G4 related disease (IgG4-RD) is a poorly understood chronic inflammatory disorder affecting the middle-aged and elderly that can present to the otolaryngologist. We aim to summarize the current literature regarding the manifestations and management of IgG4-RD in the head and neck. METHODS: Pubmed and EMBASE were searched using the term relevant search algorithm utilizing keywords such as: IgG4 related disease, head and neck, orbit, salivary glands, sialadenitis, Kuttner, angiocentric eosinophilic fibrosis, submandibular, lacrimal, thyroid, dacryoadenitis, nasal, sinus, and Mikulicz's. Reference lists were searched for identification of relevant studies. Case reports, original research and review articles published in English from 1964 to 2014 whose major topic was IgG4-RD affecting the head and neck were included. Data regarding patient demographics, presentation, histopathology, management and treatment outcomes of IgG4-RD were extracted. Level of evidence was also assessed and data were pooled where possible. Three independent reviewers screened eligible studies; extracted relevant data and discrepancies were resolved by consensus, where applicable. Descriptive and comparative statistics were performed. RESULTS: Fourty-three articles met our inclusion criteria. IgG4-RD most often presents as a mass lesion in the head and neck region. Common diagnostic features include: (1) elevated serum IgG4 level, (2) marked infiltration of exocrine glands by IgG4-positive plasma cells with fibrosis, and (3) marked improvement with corticosteroid therapy and additional immunosuppressive therapy in corticosteroid refractory cases. Early diagnosis and involvement of rheumatology is important in management. CONCLUSIONS: IgG4-RD is a challenging non-surgical disease that has multiple manifestations in the head and neck. It must be distinguished from various mimics including malignancy, systemic diseases, and infectious. Otolaryngology-Head and Neck surgeons should be aware of this condition and its management.