Critical Upper Airway Edema After a Bee Sting to the Uvula.

Hymenoptera stings of the upper airway are rare events, but can result in rapid, life-threatening airway emergencies. The allergenic and toxic mediators that are released from the stings of bees, wasps, and hornets can cause local tissue inflammation and edema with subsequent upper airway obstruction. We report the case of a 15-y-old girl who suffered a bee sting to the uvula while zip-lining in Costa Rica. Shortly thereafter, she developed a choking sensation with associated dysphonia, odynophagia, drooling, and respiratory distress. She was brought to a rural emergency medical clinic where she was noted to have an erythematous, edematous, boggy uvula, with a black stinger lodged within it, as well as edema of the anterior pillars of the tonsils and soft palate. The stinger was removed with tweezers and she was treated with an intravenous corticosteroid and antihistamine. She had persistence of airway edema and symptoms until the administration of epinephrine, which resulted in clinical improvement shortly thereafter. In our review of this case and the existing literature, we emphasize the importance of early recognition and management of hymenoptera stings of the upper airway, which should always include immediate manual removal of the stinger, and in cases with significant upper airway edema, the administration of epinephrine should be considered.

About a "New" Technique for Uvular Repair.

This letter is about a recent publication in the Cleft Palate Craniofacial Journal titled: "The significance of uvula after palatoplasty: A new technique to improve the aesthetic outcome" published by Elsherbiny et al (Cleft Palate Craniofacial J 2018;55(3):451-455). The authors present the use of one hemi-uvula for uvular repair during primary palatoplasty as their "new technique." The method of primary uvuloplasty using one-hemiuvula was extensively used by different surgeons in south America and presented and published in different scientific meetings and indexed scientific journals since the 90s. The original concept was described by Carlos Navarro in Perú and published by me in different scientific indexed journals and a textbook.

Experiencia en pacientes operados de roncopatía y apnea obstructiva del sueño / Clinical experience in patients with surgery of rhonchopathy and obstructive sleep apnea syndrome

RESUMEN Introducción: La uvulopalatofaringoplastía (UPPP) es un procedimiento ampliamente difundido en el tratamiento del ronquido y el síndrome de apnea e hipopnea obstructiva del sueño (SAHOS), ya que permite aumentar el área de sección transversal de la vía aérea superior y eliminar tejidos obstructivos. Conocer el grado de satisfacción de los pacientes con la cirugía es importante para nuestro desempeño. Objetivo: Evaluar la satisfacción de los pacientes con el procedimiento UPPP con cirugía nasal con datos subjetivos mediante la aplicación de una encuesta para ser respondida de forma anónima. Material y método: Estudio observacional, descriptivo. Se envió vía email una encuesta de 4 preguntas cerradas creada en la plataforma online MonkeySurvey a los pacientes que fueron sometidos a UPPP (faringoplastía de relocalización) con cirugía nasal entre 2015 y 2016. Resultados: 27 pacientes respondieron la encuesta. Sesenta y seis coma seis por ciento tenían ronquido primario y/o SAHOS leve, 33,3% SAHOS severo. La edad media al momento de la cirugía fue 41 años. El tiempo de seguimiento medio fue 10 meses (324 meses). Noventa y dos coma cinco por ciento de los pacientes están satisfechos con la cirugía UPPP; 81,4% refieren que recomendarían la cirugía a otra persona. Noventa y dos coma cinco por ciento refieren mejoría en los ronquidos. Noventa y cinco coma seis por ciento de los pacientes con somnolencia diurna refiere mejoría. Conclusión: La cirugía UPPP con técnica faringoplastía de relocalización combinada con cirugía nasal en pacientes con ronquido primario y SAHOS ha demostrado una alta tasa de satisfacción según la percepción de los pacientes en el seguimiento desde los 3 meses hasta los 2 años posoperatorios.

ABSTRACT Introduction: Uvulopalatopharyngoplasty (UPPP) is a widely used surgical procedure for snoring and obstructive sleep apnea syndrome (OSAS), since it allows to increase of the cross-sectional area of the upper airway and elimination of obstructive tissues. Knowing the degree of satisfaction of patients with surgery is important for our performance. Aim: To evaluate patient satisfaction with UPPP procedure (relocation pharyngoplasty) with nasal surgery with subjective data through the application of a survey to be answered anonymously. Material and method: Observational, descriptive study. A survey of 4 closed questions created in the MonkeySurvey online platform was sent to patients who underwent UPPP with nasal surgery between 2015 and 2016 via email. Results: 27 patients answered the survey. 66.6% had primary snoring and/or mild OSAS, 33.3% severe OSAS. The average age at the time of surgery was 41 years. The mean follow-up time was 10 months (3-24 months). 92.5% of patients are satisfied with UPPP surgery; 81.4% reported that they would recommend surgery to another person. 92.5% reported improvement in snoring. 95.6% of patients with daytime somnolence reported improvement. Conclusion: UPPP surgery with relocation pharyngoplasty technique combined with nasal surgery in patients with primary snoring and OSAS has shown a high satisfaction rate according to the perception of patients at follow-up from 3 months to 2 years postoperative.

Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population / Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population

Abstract Introduction: Bifid uvula is a frequently observed anomaly in the general population and can be regarded as a marker for submucous cleft palate. Objective: In this study aimed to determine the frequency of bifid uvula and submucous cleft palate and their relationship with oral clefts in a Brazilian population. Methods: We conducted a transversal, descriptive and quantitative study of 1206 children between August 2014 and December 2015. A clinical examination of the children was conducted by means of inspection of the oral cavity with the aid of a tongue depressor and directed light. After the clinical examination in children, parents answered a questionnaire with questions about basic demographic information and their family history of oral clefts in their first-degree relatives. After application of the questionnaires, the information collected was archived in a database and analyzed by the statistical program SPSS® version 19.0, by applying Chi-Square tests. Values with p < 0.05 were considered statistically significant. Results: Of the 1206 children included in this study, 608 (50.40%) were female and 598 (49.60%) were male (p = 0.773). The average age of children was 3.75 years (standard deviation ± 3.78 years). Of the 1206 children studied, 6 (0.5%) presented with bifid uvula. Submucosal cleft palate was not found in any child. When the family histories of children were examined for the presence of nonsyndromic cleft lip and/or cleft palate, no first degree relatives presented with the congenital anomaly. Conclusion: This study revealed that the incidence of bifid uvula and submucous cleft palate in this population was quite similar to previously reported incidence rates. Our study suggests an intensification of new reviews, with broader and diverse populations, seeking to associate the occurrence of bifid uvula, submucous cleft palate and oral clefts.

Resumo: Introdução: A úvula bífida é uma anomalia frequentemente observada na população em geral e pode ser considerada como um marcador de fissura palatina submucosa. Objetivo: Determinar a frequência de úvula bífida e fissura palatina submucosa e sua relação com fissura orais em uma população brasileira. Método: Realizamos um estudo transversal, descritivo e quantitativo de 1.206 crianças entre agosto de 2014 e dezembro de 2015. O exame clínico das crianças foi realizado por meio da inspeção da cavidade oral com auxílio de um abaixador de língua e luz direcionada. Após o exame clínico nas crianças, os pais responderam a um questionário com perguntas sobre informações demográficas básicas e antecedentes de fendas orais em familiares de primeiro grau. As informações coletadas foram arquivadas em um banco de dados e analisadas pelo programa estatístico SPSS® versão 19.0, aplicando testes de Qui-Quadrado. Os valores com p < 0,05 foram considerados estatisticamente significativos. Resultados: Das 1.206 crianças incluídas neste estudo, 608 (50,40%) eram do gênero feminino e 598 (49,60%) do masculino (p = 0,773). A idade média das crianças foi de 3,75 anos (desvio-padrão ± 3,78 anos). Das 1.206 crianças estudadas, seis (0,5%) apresentavam úvula bífida. A fissura palatina submucosa não foi encontrada em nenhuma criança. Quando as histórias familiares de crianças foram examinadas quanto à presença de fissura de lábio e/ou palato não sindrômica, nenhum parente de primeiro grau apresentava esta anomalia congênita. Conclusão: Este estudo revelou que a incidência de úvula bífida e fissura palatina submucosa nesta população é bastante semelhante às taxas de incidência previamente relatadas. Nosso estudo sugere uma intensificação de novas revisões, com populações mais amplas e diversas, buscando associar a ocorrência de úvula bífida, fissura palatina submucosa e fissura orais.

Hiperplasia de la úvula: presentación de un caso clínico / Hyperplasia of the uvula: report of a clinical case

La hiperplasia de la úvula es una entidad poco frecuente. Puede tener diversas causas, tales como: surgir a partir de un proceso infeccioso; por reacciones alérgicas; angioedema hereditario (HANE) (14,16); inhalación de sustancias psicoactivas (7); traumatismos ocasionados por procedimientos como intubación o extubación endotraqueal, así como durante la aspiración de los líquidos de la cavidad oral en procedimientos quirúrgicos. (7,14,16) El alargamiento de la úvula, en algunos casos, se manifiesta asintomático. Este trabajo tiene como objetivo la descripción de esta entidad, la presentación de un caso clínico, y su manejo clínico-quirúrgico (AU)

The hyperplasia of the uvula is a rare entity, it can have diverse causes, such as: of an infectious process, allergic reactions, hereditary angioedema (HANE), (14 16) inhalation of psychoactive substances (7) traumatisms caused by procedures such as, intubation or endotracheal extubation, as well as during the aspiration of liquids from the oral cavity in surgical procedures (7,14,16). The lengthening of the uvula, in some cases, is asymptomatic. The aim of this work is the description of this entity, the presentation of a clinical case, and the clinical and surgical management (AU)

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.

Incidence of bifid uvula and its relationship to submucous cleft palate and a family history of oral cleft in the Brazilian population.

INTRODUCTION: Bifid uvula is a frequently observed anomaly in the general population and can be regarded as a marker for submucous cleft palate. OBJECTIVE: In this study aimed to determine the frequency of bifid uvula and submucous cleft palate and their relationship with oral clefts in a Brazilian population. METHODS: We conducted a transversal, descriptive and quantitative study of 1206 children between August 2014 and December 2015. A clinical examination of the children was conducted by means of inspection of the oral cavity with the aid of a tongue depressor and directed light. After the clinical examination in children, parents answered a questionnaire with questions about basic demographic information and their family history of oral clefts in their first-degree relatives. After application of the questionnaires, the information collected was archived in a database and analyzed by the statistical program SPSS® version 19.0, by applying Chi-Square tests. Values with p<0.05 were considered statistically significant. RESULTS: Of the 1206 children included in this study, 608 (50.40%) were female and 598 (49.60%) were male (p=0.773). The average age of children was 3.75 years (standard deviation±3.78 years). Of the 1206 children studied, 6 (0.5%) presented with bifid uvula. Submucosal cleft palate was not found in any child. When the family histories of children were examined for the presence of nonsyndromic cleft lip and/or cleft palate, no first degree relatives presented with the congenital anomaly. CONCLUSION: This study revealed that the incidence of bifid uvula and submucous cleft palate in this population was quite similar to previously reported incidence rates. Our study suggests an intensification of new reviews, with broader and diverse populations, seeking to associate the occurrence of bifid uvula, submucous cleft palate and oral clefts.

Quiste epidermoide de úvula palatina: presentación de un caso: revisión de la literatura / Epidermoid cyst of uvula: presentation of case: review of the literature

El quiste epidermoide es una entidad dermatológica frecuente, siendo muy rara su ubicación en la cavidad oral, con una mayor prevalencia a nivel de la cavidad oral. Es considerada de etiología congénita, aunque se presenta predominantemente en adulto jóvenes. Generalmente son masas bien circunscritas, decrecimiento lento y asintomáticos, aunque los ubicados en la cavidad oral y orofaringe pueden provocar trastornos fonatorios, deglutorios y respiratorios. El diagnóstico es clínico, siendo el diagnóstico diferencial con los quistes dermoides y teratoides solo posible con el estudio histopatológico. El tratamiento es quirúrgico y elpronóstico favorable sin recidivas. Se presenta un caso de quiste epidermoide localizado en la úvula palatina, en un varón de 6 meses de vida, tratado quirúrgicamente, con la excéresis del tumor por un abordaje trasoral

The epidermoid cyst is a frequent dermatological entity, being very rare its location in theoral cavity, with a higher prevalence at the level of the floor of the oral cavity. It is considered of congenitaletiology, although it occurs predominantly in young adults. They are generally well circumscribed, slowgrowing and asymptomatic masses, although those located in the oral cavity and oropharynx can causephonatory, swallowing and respiratory disorders. The diagnosis is clinical, being the differential diagnosiswith the dermoid and teratoid cysts only possible with the histopathological study. The treatment is surgicaland the prognosis is favorable without relapses. We present a case of epidermoid cyst located in uvula, in amale of 6 months of life, treated surgically, with the tumor excision by a transoral approach

Vowel Height Allophony and Dorsal Place Contrasts in Cochabamba Quechua.

This paper reports on the results of two studies investigating the role of allophony in cueing phonemic contrasts. In Cochabamba Quechua, the uvularvelar place distinction is often cued by additional differences in the height of the surrounding vowels. An acoustic study documents the lowering effect of a preceding tautomorphemic or a following heteromorphemic uvular on the high vowels /i u/. A discrimination study finds that vowel height is a significant cue to the velar-uvular place contrast. These findings support a view of contrasts as collections of distinguishing properties, as opposed to oppositions in a single distinctive feature.

Characteristics and surgical and clinical outcomes of severely obese children with obstructive sleep apnea.

STUDY OBJECTIVES: To describe characteristics and surgical and clinical outcomes of obese children with obstructive sleep apnea (OSA). METHODS: At our institution from 2000 to 2010, 143 obese children with an overnight polysomnography (OPSG) diagnosis of OSA, excluding children with comorbidities, were identified. Relationships between demographics, clinical findings, and the severity of OSA were assessed. Presurgery and postsurgery OPSG indices were compared. We defined cure as an apneahypopnea index (AHI) < 1.5/h on the postsurgery OPSG, and we compared the cure rates of different surgeries. RESULTS: A total of 143 children, median age 12.4 y (interquartile range [IQR] 9.6-14.9) and BMI z-scores 2.8 (IQR 2.6-2.9), were included. Seventy-eight (55%) (Median age 12 y [IQR 9-15]) underwent surgery: 1 had tonsillectomy; 1 tonsillectomy + uvulopharyngopalatoplasty (UPPP); 23 adenotonsillectomy (AT); 27 AT + UPPP; 11 adenoidectomy + UPPP; 8 UPPP; and 7 AT + turbinate trim ± tongue base suspension. Overall, surgery cured 19 children (26%), but AHI improved in the majority of children (p = 0.001). Similarly, the arousal index, PETCO2, and SpO2 nadir improved significantly (p < 0.002, p = 0.019, p < 0.001, respectively). AHI improved significantly in children with mild-to-moderate OSA in comparison to severe OSA (p < 0.001). Children with enlarged tonsils and no history of prior surgery benefitted more often from surgery (p < 0.004 and p = 0.002, respectively). AT was the only surgery reducing the AHI significantly (p = 0.008). Children did not lose weight despite intervention. Adherence with PAP was poor. CONCLUSIONS: Surgery improved OPSG indices in the majority of obese children with OSA.

Nuevas manifestaciones orales del síndrome branquio-óculo-facial: Caso clínico / New oral manifestations of Branchio-oculo-facial syndrome: Case report

El síndrome branquio-óculo-facial es una condición autosómica dominante con expresividad variable y que afecta particularmente las estructuras de la cara y cuello por un desarrollo inadecuado del primero y segundo arco branquial; presenta malformaciones de los ojos y oídos, con características faciales distintivas. Está asociado con alteraciones en el gen TFAP2A. Se presenta una paciente de 9 años con fenotipo de síndrome branquio-óculo-facial y la presencia de dos nuevas manifestaciones orales, la úvula bifida y la lengua con hendidura central parcial, no descritas hasta ahora en esta condición clínica.

The branchio-oculo-facial syndrome is a dominant autosomic condition with variable expressivity that affects particularly the facial and neck structures by an inadequate development of the first and second branchial arch. It is characterized by malformations of eyes and ears, with distinct facial characteristics. It is associated with alterations in TFAP2A gene. We present a patient with 9 years of age with phenotype of the branchio-oculo-facial syndrome and the presence of 2 new oral manifestations, the bifid uvula and the tongue with partial central cleft, not yet described in this clinical condition.

Clinical and genetic study on 356 Brazilian patients with a distinct phenotype of cleft lip and palate without alveolar ridge involvement.

Oral clefts include cleft lip (CL), cleft lip with cleft palate (CLP) and cleft palate (CP), with wide variations in clinical presentation and degree of severity. We described a sample of individuals with CL and CP without alveolar arch involvement (CL + CP) to verify if the characteristics of this group are distinct from those with CL with or without CP (CL/P) described in literature. The sample was composed of 356 patients with CL + CP, registered at HRCA-USP, Bauru-SP-Brazil. The following characteristics were investigated: sex ratio, parental age at the time of conception, parental consanguinity, familial recurrence, laterality of the cleft and associated anomalies. A subgroup of 30 individuals with microforms of CL and CP were taken from the sample and compared with the remaining cases. Statistical differences were found between this CL + CP sample and the literature data for groups with CL/P regarding laterality, sex ratio, consanguinity, familial recurrence, and the presence of associated anomalies. The microform sample showed a statistical difference in paternal age. In most evaluated aspects, this sample presents similar characteristics to the consulted literature data for CL/P; as do the group of microform cleft cases when compared with the remaining CL + CP sample in this study. Microforms of cleft can represent a target group for investigation into the embryogenetic mechanisms of oral clefts and their phenotypic variability.

A prospective, randomized, double-blind clinical trial study to evaluate a method for uvular repair during primary palatoplasty.

The purpose of this study was to evaluate the efficacy of a new technique for uvular repair in patients with cleft palate. This is a prospective, randomized, double blind controlled trial study with Ethical Committee approval between two groups of 30 patients each with cleft palate who were operated on using the conventional and proposed method of uvular repair from 2005-2007. Data was from the Outreach Surgical Center Program, Lima, Peru. Two groups of 30 patients each with cleft palate were operated on using the new technique by the Outreach Surgical Center Program Lima since 2007. Data collection was accomplished by physical exam to evaluate the appearance of the constructed uvula, as well as the presence or absence of a fistula and by a speech therapist. This comparative study did not find a statistically significant association between the conventional and the proposed method for uvular repair or the presence of postoperative hypernasal speech determined at 1-5 years of age during follow-up (p = 0.640). This study observed no increase in the rate of fistulas and/or VPI between these two groups so it was concluded that the use of the proposed method for uvular reconstruction does not affect the closure of the velopharyngeal sphincter and, thus, the development of VPI is not increased.

Analysis of the dynamic changes in the soft palate and uvula in obstructive sleep apnea-hypopnea using ultrafast magnetic resonance imaging.

Apnea and the respiratory cycle are dynamic processes in obstructive sleep apnea-hypopnea (OSAH), which occur only during sleep. Our study aimed to observe the dynamic changes in the soft palate and the uvula during wakefulness and sleep using ultrafast magnetic resonance imaging (UMRI) to provide reference data for the pathogenesis and treatment of OSAH. The dynamic changes in the soft palate and uvular tip of 15 male patients (average age: 50.43 ± 9.82 years) with OSAH were evaluated using UMRI of the upper airway while asleep and awake after 1 night of sleep deprivation. A series of midline sagittal images of the upper airway were obtained. The distance from the center of the soft palate to the x-axis (an extended line from the anterior nasal spine to the posterior nasal spine), from the uvular tip to the x-axis, from the center of the soft palate to the y-axis (a perpendicular line from the center of the pituitary to the x-axis), and from the uvular tip to the y-axis (designated as PX, UX, PY, and UY, respectively) were measured during sleep and wakefulness. The minimum PX, PY, UX, and UY were shorter during sleep than during wakefulness, whereas the maxima were longer during sleep (P < 0.01), the differences between the maximum and minimum PX, PY, UX, and UY were larger during sleep (P < 0.01). The upward, downward, forward, and backward ranges of movement of the soft palate and the uvular tip were larger during sleep in OSAH patients. This increased compliance may trigger each airway obstructive event.

Predictors of uvulopalatopharyngoplasty success in the treatment of obstructive sleep apnea syndrome.

OBJECTIVE: Uvulopalatopharyngoplasty (UPPP) has been described as an option for treating obstructive sleep apnea syndrome (OSAS), with variable success rates. The main purpose of our study was to correlate UPPP success to craniofacial bony structure and orofacial muscles function. METHODS: Clinical variables, including body mass index (BMI), age, and preoperative apnea-hypopnea index (AHI); cephalometric measurements of the craniofacial region and hyoid bone position; and muscle function variables including clinical protocol and tongue strength measures were evaluated in 54 patients who underwent UPPP in the last 7years. The measurements were related to the success or failure of UPPP based on the results of preoperative and postoperative polysomnography (PSG). RESULTS: The variables BMI, preoperative AHI, and cephalometric measurements showed no influence on surgical success. The clinical muscle protocol also was similar between groups. However, the muscle strength of the anterior portion of the tongue was significantly greater in the group that showed surgical success compared to those with surgical failure. CONCLUSION: OSAS is a multifactorial disease and diagnostic symptom assessments should be individualized. In addition, special attention should be given to functional muscle alterations of the airways, as they might influence the evolution of the disease.