Prediction of obstructive sleep apnea: comparative performance of three screening instruments on the apnea-hypopnea index and the oxygen desaturation index.

PURPOSE: To evaluate the performance of the NoSAS (neck, obesity, snoring, age, sex) score, the STOP-Bang (snoring, tiredness, observed apneas, blood pressure, body mass index, age, neck circumference, gender) questionnaire, and the Epworth sleepiness score (ESS) as a screening tool for obstructive sleep apnea (OSA) severity based on the apnea-hypopnea index (AHI) and the oxygen desaturation index (ODI). METHODS: Data from 235 patients who were monitored by ambulant polysomnography (PSG) were retrospectively analyzed. OSA severity was classified based on the AHI; similar classification categories were made based on the ODI. Discrimination was assessed by the area under the curve (AUC), while predictive parameters were calculated by four-grid contingency tables. RESULTS: The NoSAS score and the STOP-Bang questionnaire were both equally adequate screening tools for the AHI and the ODI with AUC ranging from 0.695 to 0.767 and 0.684 to 0.767, respectively. Both questionnaires perform better when used as a continuous variable. The ESS did not show adequate discrimination for screening for OSA (AUC ranging from 0.450 to 0.525). Male gender, age, and BMI proved to be the strongest individual predictors in this cohort. CONCLUSION: This is the first study to evaluate the predictive performance of three different screening instruments with respect to both the AHI and the ODI. This is important, due to increasing evidence that the ODI may have a higher reproducibility in the clinical setting. The NoSAS score and the STOP-Bang questionnaire proved to be equally adequate to predict OSA severity based on both the AHI and the ODI.

Long-term results of external upper esophageal sphincter myotomy for oropharyngeal Dysphagia.

The aim of this work was to assess the efficacy of external myotomy of the upper esophageal sphincter (UES) for oropharyngeal dysphagia. In the period 1991-2006, 28 patients with longstanding dysphagia and/or aspiration problems of different etiologies underwent UES myotomy as a single surgical treatment. The main symptoms were difficulties in swallowing of a solid-food bolus, aspiration, and recurrent incidents of solid-food blockages. Pre- and postoperative manometry and videofluoroscopy were used to assess deglutition and aspiration. Outcome was defined as success in the case of complete relief or marked improvement of dysphagia and aspiration and as failure in the case of partial improvement or no improvement. Initial results showed success in 21 and failure in 7 patients. The best outcomes were observed in patients with dysphagia of unknown origin, noncancer-related iatrogenic etiology, and neuromuscular disease. No correlation was found between preoperative constrictor pharyngeal muscle activity and success rate. After follow-up of more than 1 year, 20 patients were marked as success and 3 as failure. All successful patients had full oral intake with a normal bolus consistency without clinically significant aspiration. We conclude that in select cases of oropharyngeal dysphagia success may be achieved by UES myotomy with restoration of oral intake of normal bolus consistency.

Endoscopic carbon dioxide laser Zenker's diverticulotomy revisited.

OBJECTIVES: We assessed the efficacy of endoscopic Zenker's diverticulotomy with the carbon dioxide (CO2) laser and Acuspot and compared it with the historical results of using a CO2 laser without Acuspot and electrocautery diverticulotomy. METHODS: Between 1976 and 2005, a total of 229 endoscopic Zenker's diverticulotomies in 189 patients were performed in our institution. Since 1995, micro-endoscopic diverticulotomy with the CO2 laser and Acuspot (MEDCO2A) has been performed in 61 cases. Between 1984 and 1995, micro-endoscopic diverticulotomy with the CO2 laser (MEDCO2) was performed in 113 cases. Before 1984, endoscopic diverticulotomy with electrocautery (EDE) was performed in 55 cases. All patients had radiologically proven Zenker's diverticula. We recorded preoperative and postoperative complaints of dysphagia, the frequency of recurrence in long-term follow-up, postoperative tube feeding, non-oral intake, days of admission, and complications. RESULTS: After operation, dysphagia was absent in 84.6% of MEDCO2A cases, 78.4% of MEDCO2 cases, and 72.0% of EDE cases. Repeat surgery was required in 13.0% of MEDCO2A cases, 19.6% of MEDCO2 cases, and 24.3% of EDE cases. Five patients developed mediastinitis (2 MEDCO2 cases and 3 EDE cases); none died as a consequence. In 1 patient, squamous cell carcinoma was found in the diverticulum. CONCLUSIONS: The technological improvement of the CO2 laser with Acuspot has further increased the efficacy of its use over that of methods previously used in our institution. The results and complications rate are comparable to those reported for endoscopic stapler diverticulotomy in the literature.

Long-term results of laryngeal suspension and upper esophageal sphincter myotomy as treatment for life-threatening aspiration.

OBJECTIVES: We evaluated the long-term results of laryngeal suspension and upper esophageal sphincter (UES) myotomy in patients with life-threatening aspiration. METHODS: In the period 1995 to 2004, 17 patients with severe aspiration caused by insufficient laryngeal elevation and absent or negligible pharyngeal constrictor muscle activity during deglutition resulting in aspiration pneumonia were surgically treated with a laryngeal suspension procedure and UES myotomy. Preoperative and postoperative videofluoroscopy was performed to assess swallowing and aspiration. RESULTS: In 9 of the 17 patients, long-term (more than 1 year) full oral intake without aspiration was achieved. Three other patients demonstrated improvement of deglutition with partial restoration of oral intake with adjusted food consistency, but remained partly dependent on gastrostomy feeding for adequate nutrition. Two patients no longer had cases of aspiration pneumonia, but were unable to achieve even modified oral intake. Three patients finally underwent total laryngectomy--2 of them after initial successful full oral intake without aspiration but with recurrent aspiration as a result of progression of neuromuscular disease. None of the patients succumbed to aspiration pneumonia. CONCLUSIONS: In most of our patients, life-threatening aspiration was successfully treated by UES myotomy and laryngeal suspension with restoration of oral intake.