Evaluation and validation of four translated Chinese questionnaires for obstructive sleep apnea patients in Hong Kong.

BACKGROUND: The present study validates and evaluates the sensitivity and specificity of four internationally popular questionnaires, translated into Chinese, for assessing suspected obstructive sleep apnea (OSA) patients, namely, the Berlin questionnaire, the ASA checklist, the STOP questionnaire and the STOP-BANG questionnaire. Their predictive values in OSA risks in patients presenting with OSA symptoms are examined. Questionnaires may be helpful in prioritizing polysomnography (PSG) and in treatment for the more severe cases. METHODS: All patients attending our sleep laboratory for overnight PSG were recruited. They were asked to complete three questionnaires (Berlin, ASA checklist and STOP) 2 weeks before and on the same night as the PSG. STOP-BANG questionnaire, an extended STOP with demographic data, 'B'-body mass index (BMI), 'A'-age, 'N'-neck circumference and 'G'-gender was completed by our technologists using the patient's completed STOP. RESULTS: A number of 141 patients were recruited. The sensitivities and specificities for STOP-BANG with cutoffs at PSG's RDI=5, RDI=15 and RDI=30 were 81% to 86% and 34% to 57%, respectively. The high-risk group patients identified by STOP-BANG had significantly higher respiratory disturbance index and lower minimum oxygen saturation than the low-risk group patients. CONCLUSION: Among the four questionnaires studied, STOP-BANG, with only eight questions and the highest sensitivity, is the best questionnaire of the four for OSA screening. This can potentially assist in prioritizing PSG and can be helpful in clinical or self-evaluation by the general public.

A Hybrid Auricular Framework of Autologous Rib Cartilage and a Porous Polyethylene Implant for Reconstruction of Congenital Microtia: A Modification of Nagata's Technique.

Background: An implant (porous polyethylene) is an alternative to rib cartilage for microtia reconstruction but carries a risk of extrusion. Objective: To evaluate the outcome of a hybrid framework of implant with rib cartilage for microtia reconstruction. Methods: Patients who underwent Nagata's technique for microtia reconstruction were reviewed for complications and aesthetic score. In stage 1, a rib cartilage framework or a hybrid framework of implant with rib cartilage was used. In stage 2, the framework was elevated and supported by an implant for projection. Postoperative outcomes were reported for both groups. Results: Forty-four ears of 40 patients underwent surgery. Eleven ears received a rib auricular framework and 33 ears a hybrid auricular framework. The mean postoperative follow-up for the rib and hybrid groups was 76.3 and 43.1 months, respectively. No supporting postauricular implant extruded, whereas stainless-steel wires extruded in seven ears (15.9%). Five (15.2%) hybrid frameworks were removed due to infection or extrusion. Mean operating time was 2 h shorter in the hybrid group. Aesthetic outcomes were similar for both groups. Conclusion: A hybrid framework of rib and implant that requires less harvested cartilage is feasible for microtia reconstruction, but caution should be used due to its higher explantation rate.

The prevalence of gastroesophageal reflux disease and laryngopharyngeal reflux in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: The prevalence of gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) in post-irradiated patients with nasopharyngeal carcinoma (NPC) is unknown. MATERIALS AND METHODS: In a cross-sectional study, 31 NPC and 12 control patients completed questionnaires for GERD/LPR before esophageal manometry and 24-h pH monitoring. The DeMeester score and reflux finding score (RFS) were used to define GERD and LPR, respectively. Risk factors were identified. RESULTS: 51.6% of NPC and 8.3% of control patients, and 77.4% of NPC and 33% of control patients, were GERD-positive and LPR-positive, respectively. The GERD/LPR questionnaire failed to identify either condition in patients with NPC. No parameter differences in esophageal manometry or pneumonia incidence were noted between GERD/LPR-positive and GERD/LPR-negative patients. Post radiotherapy duration, high BMI, lack of chemotherapy, and dysphagia were positive risk factors for GERD/LPR. CONCLUSIONS: A high prevalence of GERD/LPR in patients with post-irradiated NPC exists, but reflux symptoms are inadequate for diagnosis.

Quality of life and swallowing outcomes after early proactive swallowing rehabilitation by either transcutaneous neuromuscular electrical stimulation or exercise-based swallowing training in patients with nasopharyngeal carcinoma after radiotherapy.

Background: Exercise-based swallowing training (EBST) and transcutaneous neuromuscular electrical stimulation (TNMES) are common modalities used to treat late dysphagia after radiotherapy for nasopharyngeal carcinoma (NPC). We aimed to investigate and compare the efficacies of EBST and TNMES as proactive treatments administered early after radiotherapy. Methods: Patients with early post-radiotherapy NPC (n = 120) underwent either TNMES or EBST. Flexible endoscopic evaluation of swallowing (FEES), quality of life (QOL), and swallowing function questionnaires were completed before the intervention as well as immediately, 6, and 12 months after the intervention. Outcome measures included the scores for the swallowing function score (SFS), penetration and aspiration scale (PAS), dynamic imaging grade of swallowing toxicity (DIGEST), functional oral intake scale (FOIS), swallowing performance status scale (SPSS), pharyngeal motor impairment (PMI), pharyngeal function impairment (PFI), and functional assessment after cancer therapy-nasopharyngeal (FACT-NP) questionnaire. Results: Three months after radiotherapy, 31 and 34 patients underwent TNMES and EBST, respectively, and completed swallowing assessments at all four assessment timepoints. All patients showed post-radiotherapy impairments in the SFS, PAS, DIGEST, PMI, and PFI. Compared with the EBST group, the TNMES group showed significant improvements in the PFI and PMI scores, with small-to-medium effect sizes. Additionally, compared with the EBST group, the TNMES group demonstrated a trend toward slightly better improvements in the PAS, DIGEST, FOIS, and SPSS scores immediately and 6 months after the intervention. The SFS scores improved from baseline in both groups; however, the TNMES group showed an earlier improvement. Finally, the TNMES group showed better QOL according to the FACT-NP than the EBST group. Conclusion: Proactive TMNES and EBST are safe and feasible modalities for improving swallowing in patients with NPC when administered early after radiotherapy. Although TNMES showed better results than EBST, these results should be interpreted with caution given the study limitations. Level of evidence: 1B.

Recommendations for Epstein-Barr virus-based screening for nasopharyngeal cancer in high- and intermediate-risk regions.

A meeting of experts was held in November 2021 to review and discuss available data on performance of Epstein-Barr virus (EBV)-based approaches to screen for early stage nasopharyngeal carcinoma (NPC) and methods for the investigation and management of screen-positive individuals. Serum EBV antibody and plasma EBV DNA testing methods were considered. Both approaches were found to have favorable performance characteristics and to be cost-effective in high-risk populations. In addition to endoscopy, use of magnetic resonance imaging (MRI) to investigate screen-positive individuals was found to increase the sensitivity of NPC detection with minimal impact on cost-effectiveness of the screening program.

Otitis media with effusion and hearing loss in Chinese children with cleft lip and palate.

OBJECTIVE: To determine the incidence of otitis media with effusion and the associated hearing loss, the rate of ventilation tube insertion, and complications of ventilation tube insertion in Chinese cleft palate patients. DESIGN: Retrospective review in a tertiary care hospital in Hong Kong. PATIENTS: A total of 104 consecutive patients with cleft lip and/or cleft palate who were born between January 1996 and January 2006. RESULTS: The incidence of otitis media with effusion in Chinese cleft palate patients for the first 2 years after birth was 76.1%. Of these patients, 16.9% had otitis media with effusion associated with a moderate hearing loss (>40 decibels hearing level [dBHL]). Approximately half (53.2%) of our patients had ventilation tube insertion. Complications including retraction, tympanosclerosis, and perforation of the tympanic membrane were found in 15.7% of all ears with otitis media with effusion and ventilation tube insertion. CONCLUSIONS: The high incidence of otitis media with effusion in cleft palate infants found in this study is consistent with that reported in the Western literature. A small but significant proportion of otitis media with effusion was associated with moderate hearing loss that truly required surgical treatment. Cleft palate children are much more likely to develop otitis media with effusion than normal children, and they develop the condition at an earlier age. A protocol for the treatment of otitis media with effusion in cleft palate patients and further prospective studies are warranted.

Tubed Supraglottic Laryngeal Closure to Treat Chronic Aspiration After Radiotherapy for Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: To evaluate the long-term swallowing outcomes after surgical treatment for chronic aspiration in patients treated with radiotherapy for head and neck cancer. STUDY DESIGN: This was a retrospective study. METHODS: The data of patients who underwent radiotherapy for head and neck cancer and who subsequently required a laryngectomy or a tubed supraglottic laryngeal closure (TSLC) for recurrent aspiration pneumonia between 2004 and 2017 were retrieved from a tertiary referral hospital dysphagia clinic. The Functional Oral Intake Scale (FOIS) and the Swallowing Performance and Status Scale (SPSS) were used to assess swallowing function. RESULTS: Of the 17 patients who required surgery for chronic aspiration secondary to radiotherapy for head and neck cancer, two underwent a laryngectomy and 15 a TSLC. During a mean follow-up of 77 months, the FOIS and SPSS scores significantly improved at 12, 24, and 36 months after laryngectomy and TSLC relative to the baseline (P < .05). Both patients who underwent laryngectomy and 11 of the 15 (73.3%) who underwent a TSLC resumed oral feeding. Both laryngectomy patients had episodes of recurrent aspiration pneumonia after surgery due to leakage through the tracheoesophageal puncture or prosthesis, whereas none of the TSLC patients had these episodes. CONCLUSION: A tubed supraglottic laryngeal closure, which is a reversible procedure that preserves the larynx and allows for natural phonation, should be considered an alternative to laryngectomy for the control of chronic aspiration. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1234-E1243, 2021.

Perceptual Voice and Speech Analysis after Supraglottic Laryngeal Closure for Chronic Aspiration in Head and Neck Cancer.

OBJECTIVES/HYPOTHESIS: To evaluate the voice and speech outcomes after tubed supraglottic laryngeal closure (TSLC) surgery to treat chronic aspiration after radiotherapy for head and neck cancer. STUDY DESIGN: A retrospective case-control study. METHODS: The data of patients who underwent radiotherapy for head and neck cancer and who later required total laryngectomy or TSLC for chronic aspiration between 2004 and 2017 were retrieved from a dysphagia clinic. Preoperative and postoperative voice and speech were assessed by the GRBAS and INFVo rating scales. Control subjects who underwent radiotherapy alone or total laryngectomy with a tracheoesophageal prosthesis for other indications were recruited for comparison. RESULTS: Of 15 patients who underwent a TSLC with a mean age of 57.3 years (45-75 years), 13 were male and 2 female. All patients had a history of nasopharyngeal carcinoma. The success rate of speech production using their own larynx following an intact TSLC was 64%. There was no statistically significant difference in voice and speech ratings between preoperative and TSLC subjects on the GRBAS (P = .32) and INFVo scales (P = .57), although the quality of voice appeared to deteriorate after TSLC. However, the INFVo scale for impression, intelligibility and unsteadiness of the voice after TSLC was statistically significantly better than for laryngectomy with tracheoesophageal speech. CONCLUSIONS: A tubed supraglottic laryngeal closure controls chronic aspiration while preserving the larynx for phonation, and results in a better voice and speech quality than a laryngectomy with a voice prosthesis. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E1616-E1623, 2021.

Assessment of pharyngeal motor function using a novel velopharyngeal squeeze maneuver and a novel endoscopic pharyngeal contraction grade scale in patients with dysphagia after radiotherapy for nasopharyngeal carcinoma.

BACKGROUND: To investigate a novel velopharyngeal squeeze maneuver (VPSM) and novel endoscopic pharyngeal contraction grade (EPCG) scale for the evaluation of pharyngeal motor function. METHODS: During endoscopic examination of 77 post-irradiated nasopharyngeal carcinoma patients and control subjects, VPSM was rated and lateral pharyngeal wall movement graded with EPCG scale during swallowing. Pharyngeal constriction ratio (PCR) measured by videofluoroscopy was used for correlation. RESULTS: VPSM and EPCG scale showed almost perfect intra-rater and inter-rater reliability (Kappa: >0.90). VPSM was present in 61% of patients suggesting good pharyngeal motor function. VPSM was predictive of EPCG scale (Wald statistic = 29.99, p < 0.001). EPCG scale also correlated strongly with PCR (r: 0.812) and was predictive for aspiration (odds ratio: 22.14 [95% CI 5.01-97.89, p < 0.001]). CONCLUSIONS: VPSM and EPCG scale are two novel tools to assess pharyngeal motor function, and both correlate well with pharyngeal contractility and aspiration.

Epidemiology of obstructive sleep apnoea syndrome in Chinese children: a two-phase community study.

OBJECTIVE: To determine the prevalence and risk factors of obstructive sleep apnoea syndrome (OSAS) in Chinese children using a two-phase community-based study design. METHODS: Children from 13 primary schools were randomly recruited. A validated OSAS screening questionnaire was completed by their parents. Children at high risk of OSAS and a randomly chosen low-risk group were invited to undergo overnight polysomnographic study and clinical examination. The the sex-specific prevalence rate was measured using different cutoffs (obstructive apnoea hypopnoea index ≥ 1, ≥ 1.5, ≥ 3 and ≥ 5 and obstructive apnoea index ≥ 5) and risk factors associated with OSAS were evaluated with logistic regression. RESULTS: 6447 completed questionnaires were returned (out of 9172 questionnaires; 70.3%). 586 children (9.1%; 405 boys and 181 girls) children belonged to the high-risk group. A total of 619 (410 and 209 from the high and low-risk group, respectively) subjects underwent overnight polysomnagraphy. Depending on the cutoffs, the prevalence rate of childhood OSAS varied from 4.8% to 40.3%. Using the International Criteria of Sleep Disorders version II, the OSAS prevalence for boys and girls was 5.8% and 3.8%, respectively. Male gender, body mass index z-score and increased adenoid and tonsil size were independently associated with OSAS. CONCLUSIONS: The prevalence rate of OSAS in children was contingent on the cutoff used. The inclusion of symptoms as a part of the diagnostic criteria greatly reduced the prevalence. A further prospective and outcome study is needed to define a clinically significant diagnostic cutoff for childhood OSAS.

There is no routine head and neck exam during the COVID-19 pandemic.

Head and neck examinations are commonly performed by all physicians. In the era of the COVID-19 pandemic caused by the SARS-CoV-2 virus, which has a high viral load in the upper airways, these examinations and procedures of the upper aerodigestive tract must be approached with caution. Based on experience and evidence from SARS-CoV-1 and early experience with SARS-CoV-2, we provide our perspective and guidance on mitigating transmission risk during head and neck examination, upper airway endoscopy, and head and neck mucosal surgery including tracheostomy.

Pearls of experience for safe and efficient hospital practices in otorhinolaryngology-head and neck surgery in Hong Kong during the 2019 novel coronavirus disease (COVID-19) pandemic.

The 2019 novel coronavirus disease (COVID-19) epidemic originated in Wuhan, China and spread rapidly worldwide, leading the World Health Organization to declare an official global COVID-19 pandemic in March 2020. In Hong Kong, clinicians and other healthcare personnel collaborated closely to combat the outbreak of COVID-19 and minimize the cross-transmission of disease among hospital staff members. In the field of otorhinolaryngology-head and neck surgery (OHNS) and its various subspecialties, contingency plans were required for patient bookings in outpatient clinics, surgeries in operating rooms, protocols in wards and other services. Infected patients may shed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) particles into their environments via body secretions. Therefore, otolaryngologists and other healthcare personnel in this specialty face a high risk of contracting COVID-19 and must remain vigilant when performing examinations and procedures involving the nose and throat. In this article, we share our experiences of the planning and logistics undertaken to provide safe and efficient OHNS practices over the last 2 months, during the COVID-19 pandemic. We hope that our experiences will serve as pearls for otolaryngologists and other healthcare personnel working in institutes that serve large numbers of patients every day, particularly with regard to the sharing of clinical and administrative tasks during the COVID-19 pandemic.

COVID-19 Viral Load in the Severity of and Recovery From Olfactory and Gustatory Dysfunction.

OBJECTIVES/HYPOTHESIS: This study investigated olfactory and gustatory dysfunction in the 2020 novel coronavirus disease (COVID-19) patients, and their correlations with viral load evaluation. STUDY DESIGN: Prospective cross-sectional cohort study. METHODS: One hundred forty-three symptomatic patients being screened for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) were invited to participate. The clinical data of 83 confirmed COVID-19 subjects were collected, with 60 patients who were symptomatic but negative for COVID-19 recruited as controls. The prevalence and severity of and recovery time for olfactory and gustatory dysfunction, and cycle threshold (Ct) values from a SARS-CoV-2 polymerase chain reaction assay of nasopharyngeal and deep throat swabs were collected. Their correlations with Ct values were reported. RESULTS: Thirty-nine (47.0%) and 36 (43.4%) COVID-19 patients reported olfactory and gustatory dysfunction, respectively. The results of one-way analysis of variance did not show statistically significant relationships between the Ct values and severity of olfactory and gustatory dysfunction (P = .780 and P = .121, respectively). Among the COVID-19 patients who reported smell and taste loss, 28/39 (71.8%) and 30/36 (83.3%) experienced complete recovery, respectively. The mean recovery time was 10.3 ± 8.1 days for olfactory dysfunction and 9.5 ± 6.8 days for gustatory dysfunction. The recovery time was not correlated with the Ct values (Pearson correlation coefficient, smell: -0.008, P = .968; taste: -0.015, P = .940). CONCLUSIONS: There is a high prevalence of olfactory and gustatory dysfunction in COVID-19. However, the severity of and recovery from these symptoms have no correlations with the viral load of SARS-CoV-2. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:2680-2685, 2020.

Genioglossus Advancement and Hyoid Surgery.

The structure and dimensions of the mandible, tongue, and hyoid complex are important variables in the pathophysiology of obstructive sleep apnea at the hypopharyngeal level. Genioglossus advancement is based on mandibular osteotomy, which brings the genioglossus muscle (GGM) forward and prevents posterior collapse during sleep. The genioglossus advancement technique has recently undergone several modifications; each has attempted to minimize surgical morbidity while improving the incorporation and advancement of the GGM. The hyoid bone has been of interest in sleep apnea and apnea-related surgical procedures because of its integral relationship with the tongue base and hypopharynx. Hyothyroidopexy is illustrated.

Advances in Box Surgery for Obstructive Sleep Apnea: Genioglossus Advancement, Hyoid Suspension, and Maxillomandibular Advancement.

Box surgery for obstructive sleep apnea (OSA) patients consists of mandibular surgery, including genioglossus advancement, hyoid suspension, and maxillomandibular advancement, as an airway reconstruction. This surgery was developed in the early 1980s. Thereafter, techniques were modified in each surgery for the enhancement of outcome and prevention of complications. However, the indication for surgery remains poorly defined due to the dynamicity of the upper airway, variability of the phenotype in OSA patients, and absence of a representative method for the obstruction site in the upper airway. As a result, box surgery is performed restrictively. On the development of an evaluation method including radiologic and endoscopic examination during sleep, the indications and surgical outcomes of each box surgery should be standardized and reevaluated. In this review, the development and limitations of box surgery will be discussed for the positive future of this surgery.

Management of drooling for children with neurological problems in Hong Kong.

OBJECTIVES: To share our experience in the management of drooling in Hong Kong, to describe the clinical profile of children with this problem, and to report the clinical outcome of oro-motor training. METHODS: Children attending the Drooling Clinic of Alice Ho Miu Ling Nethersole Hospital, Hong Kong between January 2000 and June 2003 were included. Multidisciplinary assessment was performed to ascertain the medical condition, functional status and oro-motor difficulties of each child. Intervention might include optimization of medical condition, oro-motor training and surgery. Severity of drooling was rated by a 10-point visual analogue scale (VAS). The outcome of oro-motor training was assessed by the change in VAS from baseline. RESULTS: Eight children, with a mean age of 11.9 years, were included. Six children suffered from cerebral palsy and two had syndromal diagnoses. All had moderate or severe mental retardation. Poor lip closure, inadequate jaw control and delay in swallowing were common oro-motor difficulties. All children received oro-motor training. The mean duration of follow-up for seven children was 17 months. The mean baseline VAS was 7.1. When compared with the baseline, VAS rating during the training period decreased with a mean difference of 3.0. The difference remained at 1.9 at 4 months after training had stopped. Other functional gains, such as improved sucking and swallowing, were identified. Six caregivers declined surgery. One child improved and did not require surgery. CONCLUSIONS: Short-term follow-up of oro-motor training suggested beneficial outcome.

The combined olfactory test in a Chinese population.

OBJECTIVE: To establish an olfactory test in the Hong Kong Chinese population. STUDY DESIGN: Prospective analysis of the results of a combined olfactory test (COT) for patients with olfactory dysfunction and for normal subjects attending a secondary and tertiary ear, nose and throat centre. METHOD: Our COT was based on and modified from the Connecticut Chemosensory Research Centre test. It consisted of an odour identification test involving nine substances and a threshold test using a series of threefold dilutions of 1-butanol. From September 1998 to June 2002, 188 Hong Kong Chinese patients with olfactory dysfunction and subjects with normal olfaction were prospectively recruited. The subjects were categorized into normal, hyposmic and anosmic groups. The olfactory function of the main group of subjects (n = 153) was assessed with the COT by a blinded observer and also quantified with a visual analogue scale; the results were analysed to validate the discriminative ability of the COT. Another subgroup of subjects (n = 35) was tested with the COT twice with a two-week interval to evaluate test-retest reliability. RESULTS: There were 42 normal, 68 hyposmic and 43 anosmic subjects within the main group (total n = 153). The identification scores, threshold scores and combined olfactory scores were statistically significantly different between the anosmic, hyposmic and normal groups of subjects (p < 0.001). The combined olfactory score correlated with the visual analogue score and the correlation coefficient was 0.56 (p < 0.01). The mean time spent on each COT was 8.6 minutes (standard deviation = 3.4 minutes). The test-retest reliability of the COT was satisfactory, with a one-way model intraclass correlation coefficient of 0.87 (n = 35). CONCLUSION: The satisfactory discriminative ability and test-retest reliability of the COT have been demonstrated in this study. The COT is a feasible method for assessing sense of smell in the Hong Kong Chinese population.

Ultrasound, CT and MRI Appearances of a Rare Symptomatic Laryngeal Chondrometaplasia: A Case Report.

Symptomatic laryngeal chondrometaplasia is rare. To the best of our knowledge, there are only few case reports on laryngeal chondrometaplasia. The imaging appearance of this uncommon disease is even more rarely described. There are only two case reports describing its appearances in computed tomography (CT) and magnetic resonance imaging (MRI). Ultrasound (US) features have not been reported so far. This case report is to show the US, CT and MRI features of this disease entity to stress the role of imaging in this disease.

Tracheobronchial stenting for tuberculous airway stenosis.

We reviewed the results of the use of the Dumon silicone stents in patients experiencing tuberculous tracheobronchial stenosis since 1994, using a retrospective case review in a university teaching hospital with 1,450 beds serving a population of > 1.8 million. Between February 1994 and September 2001, seven patients with tuberculous tracheobronchial stenosis (mean age, 43 years) underwent a total of 11 dilatations with placement of 10 straight stents and 1 Y stent. Under general anesthesia, all patients underwent rigid bronchoscopy and dilatation of the stenosis with placement of a Dumon stent. There were no deaths. One patient developed a pneumothorax. Two patients experienced migration of the stent, which required reintervention for adjustment of position of the stent. The stents were left in situ for a mean period of 32 months. There was marked improvement in dyspnea in all patients after the procedure, as determined by visual analog scale. Endoscopic dilatation with placement of a silicone stent is an effective treatment for patients with tuberculous tracheobronchial stenosis.

External jugular vein vascular malformation: sonographic and MR imaging appearances.

Vascular malformations arising from the wall of the external jugular vein are rare. This case series discusses the sonographic and MR imaging appearances of four such cases and reviews the literature. The diagnosis should be suggested preoperatively particularly because of the close relationship such malformations to the external jugular vein, as this helps surgeons to plan the operative procedure. The imaging appearances are similar to those of other vascular malformations elsewhere in the head and neck.