Efficacy of expansion pharyngoplasty and hypoglossal nerve stimulation in treating sleep apnea.

OBJECTIVE: We investigated whether a palatal conversion procedure combined with a second-stage hypoglossal nerve stimulator (HGNS) insertion can be beneficial for those patients who have a complete concentric velopharyngeal collapse and may initially not meet the criteria for use of HGNS. METHODS: A retrospective chart review included all patients who underwent a planned multi-level sleep surgery including expansion sphincter pharyngoplasty (ESP) followed by HGNS. All patients had a complete concentric collapse (CCC) of the velopharynx (VP) on pre-intervention drug-induced sleep endoscopy (DISE) and were initially not a candidate for HGNS. These patients then underwent ESP followed by a DISE to confirm elimination of the CCC of the VP. They then went on to HGNS implantation several months later followed by a sleep study. RESULTS: A total of 20 patients were identified and included in the retrospective chart analysis. All patients who underwent ESP successfully converted their VP from CCC to an anterior-posterior collapse pattern and thus met inclusion criteria for HGNS. After the HGNS was implanted, patients showed a significant reduction of the mean AHI from 53.9 before ESP to 8.2 after ESP and HGNS and a decrease in the Epworth Sleep Score (ESS) from a mean of 13.3 to 5.7. CONCLUSION: ESP can be effective in eliminating the CCC of the VP thus making patients become HGNS candidates. In selected OSA patients, who have multilevel upper airway obstruction with complete concentric VP collapse, the combination of ESP and HGNS insertion should be considered as a planned 2-staged approach.

Pectoralis Major Onlay vs Interpositional Reconstruction Fistulation After Salvage Total Laryngectomy: Systematic Review and Meta-analysis.

OBJECTIVE: To evaluate the difference in pharygocutaneous fistula (PCF) development between pectoralis major flap onlay and interpositional reconstructions after salvage total laryngectomy (STL). DATA SOURCES: Medline, Cochrane, Embase, Web of Science, CINAHL, and ClinicalTrials.gov. REVIEW METHODS: A systematic review was performed during January 2020. English articles were included that described minor and major PCF rates after STL reconstructed with pectoralis major onlay or interposition. PCFs were classified as major when conservative therapy was unsuccessful and/or revision surgery was needed. Articles describing total laryngopharyngectomies were excluded. Meta-analyses of the resulting data were performed. RESULTS: Twenty-four articles met final criteria amassing 1304 patients. Three articles compared onlay with interposition, and 18 compared onlay with primary closure. Pectoralis interposition demonstrated elevated odds ratio (OR) of PCF formation as compared with onlay (OR, 2.34; P < .001). Onlay reconstruction reduced overall (OR, 0.32; P < .001) and major (OR, 0.21; P < .001) PCF development as compared with primary pharyngeal closure alone. Data were insufficient to compare interposition against primary closure. CONCLUSIONS: This research shows evidence that pectoralis onlay after STL diminishes the odds of total and major PCF development. Pectoralis interposition reconstruction showed elevated odds of PCF formation as compared with pectoralis onlay.

KTP Laser Treatment of Early Glottic Cancer: A Multi-Institutional Retrospective Study.

OBJECTIVES: The primary objectives were to report oncologic outcomes of transoral laser microsurgery with potassium-titanyl-phosphate (KTP) laser (TLM-KTP) ablation of early glottic cancer (EGC). The secondary objectives were to report vocal outcomes and to analyze factors that might influence outcomes. METHODS: A multi-institutional, retrospective analysis of consecutive patients treated for T1 or T2 glottic squamous cell carcinoma undergoing TLM-KTP ablation with at least 2 years of follow-up was performed. Patients with prior radiation or surgery for laryngeal disease were excluded. PRIMARY OUTCOME MEASURES INCLUDED: surgical failures requiring radiation or laryngectomy, disease-specific survival (DSS), and overall survival (OS). Secondary outcome measures included: pre- and postoperative Voice Handicap Index-10 (VHI-10) scores. The effects of smoking status, stage, and anterior commissure involvement on outcomes were analyzed. RESULTS: Overall 88 patients met inclusion criteria (83% male, 79.5% current or former smokers). Mean age was 68 (standard deviation (SD): 12). Mean follow-up was 39.5 months (SD: 15.3). Staging included 50 T1a, 21 T1b, and 20 T2 tumors, including three metachronous second primaries. Radiation and/or laryngectomy avoidance was achieved in 87/88 (98.9%) of patients, inclusive of 24 patients requiring KTP re-treatments. Two patients had biopsy-proven recurrence (2.3%), but only 21 of 24 re-treated patients received a formal biopsy. No patients died from laryngeal cancer. DSS and OS were 100% and 92.3%, respectively. The mean VHI-10 scores were 19.3 preoperatively, 3.8 at 6-months postop, and 3.8 at 2-years postop. Smokers had a longer interval to re-treatment (P = .03), patients with T2 lesions had a shorter interval to re-treatment (0.02), and patients with T2 lesions presented with worse initial VHI-10 scores (0.002). CONCLUSIONS: A multi-institutional, retrospective case series of TLM-KTP ablation of EGC demonstrated excellent oncologic outcomes when close surveillance and proactive re-treatments were utilized. Disease-specific survival, overall survival, and vocal function were excellent. Additional studies are necessary to further analyze the merits and risks of this treatment approach.

Scaffold-free tissue-engineered cartilage implants for laryngotracheal reconstruction.

OBJECTIVES/HYPOTHESIS: Donor site morbidity, including pneumothorax, can be a considerable problem when harvesting cartilage grafts for laryngotracheal reconstruction (LTR). Tissue engineered cartilage may offer a solution to this problem. This study investigated the feasibility of using autologous chondrocytes to tissue-engineer scaffold-free cartilage grafts for LTR in rabbits to avoid degradation that often arises from an inflammatory reaction to scaffold carrier matrix. STUDY DESIGN: Animal study. METHODS: Auricular cartilage was harvested from seven New Zealand white rabbits, the chondrocytes expanded and loaded onto a custom-made bioreactor for 7 to 8 weeks to fabricate autologous scaffold-free cartilage sheets. The sheets were cut to size and used for LTR, and the rabbits were sacrificed 4, 8, and 12 weeks after the LTR and prepared for histology. RESULTS: None of the seven rabbits showed signs of respiratory distress. A smooth, noninflammatory scar was visible intraluminally; the remainder of the tracheal lumen was unremarkable. Histologically, the grafts showed no signs of degradation or inflammatory reaction, were covered with mucosal epithelium, but did show signs of mechanical failure at the implantation site. CONCLUSIONS: These results show that autologous chondrocytes can be used to fabricate an implantable sheet of cartilage that retains a cartilage phenotype, becomes integrated, and does not produce a significant inflammatory reaction. These findings suggest that with the design of stronger implants, these implants can be successfully used as a graft for LTR.