Andrew Victores

Usefulness of Sleep Endoscopy in Predicting Positional Obstructive Sleep Apnea

Objectives The aim of the study was to (1) evaluate whether position affects drug-induced sleep endoscopy (DISE) findings in positional and nonpositional patients and (2) determine which areas of the upper airway obstruct in different body positions. Study Design Prospective, case-controlled study. Setting Academic tertiary care center. Subjects and Methods Twenty-two patients with obstructive sleep apnea (OSA) were enrolled. Two groups were individually recruited to make 11 consecutive patients with positional OSA and 11 consecutive patients with nonpositional OSA. Positional OSA was defined by nonsupine 50% reduction in apnea-hypopnea index. DISE was performed with patients in both lateral and supine sleep positions. Upper airway collapse was compared between the sleep positions and between the 2 groups. Results Most patients (77%) demonstrated multilevel obstruction on DISE. Nearly all patients with positional OSA (91%) had at least a partial improvement in collapse while in the lateral sleep position. Most of the reduction in collapse involved the tongue base and epiglottis (P < .05). Sleep position did not significantly alter the upper airway morphology of patients with nonpositional OSA. Apnea-hypopnea index and body mass index were not significantly different between the 2 groups. Conclusions Sleep position can change upper airway morphology on DISE, particularly positional OSA patients. Hypopharyngeal collapse was the primary site that improved with change in position. DISE in multiple sleep positions should be considered as part of a minimally invasive approach to surgical therapy of OSA.

Effects of nasal surgery on the upper airway: A drug‐induced sleep endoscopy study

To evaluate the impact of nasal surgery on the oropharyngeal and hypopharyngeal anatomy of patients with obstructive sleep apnea (OSA) by comparing drug‐induced sleep endoscopy (DISE) data prior to and following nasal surgery.

Electronic health records and resident workflow: A time-motion study of otolaryngology residents

To evaluate the impact of electronic health records (EHRs) on the workflow of otolaryngology residents.

Otolaryngology Resident Workflow: A Time-Motion and Efficiency Study

Objective. To investigate workflow in an otolaryngology–head and neck surgery residency program over 1 year and identify areas for improvement in the efficiency of resident education and training. Study Design. Time-motion study. Setting. An urban, county hospital and a Veterans Affairs medical center hospital. Subjects and Methods. Eight otolaryngology residents (4 residents at postgraduate year [PGY] 2 and 4 at PGY 4) were studied using direct observations early and late in the 2008-2009 academic year. Resident activities were categorized, and a database program was generated for a handheld computer to facilitate time entry. Resident activities were classified into a taxonomy of tasks and their educational value was assessed. For each PGY level studied, observations were made for clinic and operative days. Results. Residents spent their day on direct patient care (43.5%), indirect patient care (33.7%), didactic education (9.6%), personal activities (7.5%), and transit (5.8%), with activities of marginal educational value consuming 16% of their time. Major inefficiencies included managing administrative tasks, scheduling, and technical difficulties. On average, residents devoted significantly more time to marginal tasks on clinic days (19%) than on operative days (12%; P < .001). These data were compared with previously published data obtained during the pre–Accreditation Council for Graduate Medical Education (ACGME) duty hour mandates era. Conclusion. This study evaluates resident workflow and efficiency over the course of a PGY in an ACGME-accredited otolaryngology residency program. By understanding the time motion of residents, interruptions and inefficiencies in workflow can be identified to direct future changes to enhance resident education and training in the era of the ACGME duty hours mandate.

Recurrent Onodi cell mucocele: rare cause of 2 different ophthalmic complications.

The paranasal sinuses are prone to ostium obstruction by surgery, inflammation, or trauma. Sinus obstruction can trigger formation of a mucocele, which is a cyst lined by respiratory epithelium and filled with mucoid secretions. When mucoceles become infected, a mucopyocele develops. Mucoceles of posterior ethmoid cells, known as Onodi cells, are particularly prone to ocular disturbances because of proximity to the optic nerve. This case report represents the second published account of a recurrent Onodi cell mucocele and the only account demonstrating recurrence with different ophthalmic complications. Approval by the Institutional Review Board of Baylor College of Medicine (Houston, Texas) was obtained.

Interventional Drug-Induced Sleep Endoscopy: A novel technique to guide surgical planning for obstructive sleep apnea

STUDY OBJECTIVE One of the challenges of surgery for obstructive sleep apnea (OSA) is identifying the correct surgical site for each patient. The objective of this study was to use drug-induced sleep endoscopy (DISE) and nasopharyngeal tube (NPT) placement to determine the effect of eliminating palatal collapse on the obstruction seen on other segments of the upper airway. METHODS Forty-one OSA patients were enrolled in this prospective study. All patients had a polysomnogram followed by DISE. DISE findings were recorded and compared with and without placement of a NPT. Obstruction was graded with a scale that incorporates location, severity, and interval of obstruction. RESULTS Most patients (83%) demonstrated multilevel obstruction on initial DISE. With the nasopharyngeal airway in place, many patients with multilevel obstruction had at least a partial improvement (74%) and some a complete resolution (35%) of collapse (p < 0.05). Reduction in collapse was observed at the lateral walls (86%), epiglottis (55%), and tongue base (50%). NPT placement did not significantly alter upper airway morphology of patients with incomplete palatal obstruction or mild OSA. CONCLUSIONS To our knowledge, this is the first study to evaluate the effect of soft palatal stenting on downstream pharyngeal obstruction during DISE. Our study provides evidence that reducing soft palatal collapse can reduce negative pharyngeal pressure and thereby alleviate other sites of upper airway obstruction. Taken together, these findings provide a means to identify appropriate candidates for isolated palatal surgery and better direct a minimally invasive approach to the surgical management of OSA.

Thyroid Eye Disease: Optic Neuropathy and Orbital Decompression.

Thyroid eye disease (TED) is an orbital condition that has a strong association with thyroid autoimmune diseases. Most cases of TED are associated with Graves disease; however, the condition has also been linked with other thyroid diseases such as Hashimoto thyroiditis. Between 25% and 50% of patients with Graves disease exhibit clinical features of TED, making it the most common extrathyroidal manifestation of Graves disease. TED can present with both cosmetic disfigurement and functional deficits, including exophthalmos, diplopia, and vision loss. Hyperthyroidism in Graves disease has a relatively well-understood pathogenesis. Thyroid stimulating hormone is a hormone secreted by the pituitary and functions to bind to thyrotropin receptors on the thyroid gland and stimulate thyroid hormone production. Hyperthyroidism in Graves disease results from overstimulation of these receptors by thyrotropin-receptor antibodies. Although still controversial, it seems that Graves-associated orbitopathy may be a result of a different process. Genetic and environmental factors have both been implicated in the pathogenesis of the disease. Studies suggest that antibodies, other than thyrotropin-receptor antibodies, may have a direct effect on orbital cells leading to the clinical expression of the disease. Given the inconclusive pathogenesis of the disease, no directed therapy has been formulated. TED has both an active, progressive phase and a stable phase. During the active phase, orbital inflammation drives enlargement of the extraocular muscles (EOMs) and orbital fat. Unfortunately, disease activity can be difficult to determine. Some tools, such as the Clinical Activity Score, have been devised to more consistently predict the active

Chondrosarcoma of the Epiglottis: A Case Report and Literature Review

BACKGROUND Laryngeal chondrosarcoma (LCS) is an exceedingly rare malignancy and least frequently reported in the epiglottis. METHODS AND RESULTS We report a case of a 71-year-old male smoker who presented with sore throat, dysphagia, and odynophagia for 3 months. Computed tomography scan revealed an inhomogeneously enhancing necrotic mass emanating from the right epiglottis and traveling along the aryepiglottic fold. The mass was removed via endoscopic en bloc laser resection. Histopathological examination of the biopsied specimen confirmed low-grade LCS of the epiglottis. CONCLUSION Differentiating low-grade LCS from laryngeal chondroma is a challenging task with an increased risk of potential misdiagnosis. This case study reinforces the need for a histopathological examination in forming the basis for ongoing management and follow-up observations. Timely surgery remains the optimal, primary means of treatment notwithstanding the rarity of LCS.

Management of Acute Rhinosinusitis

Acute rhinosinusitis is a common disease of the pediatric and adult population. While most patients improve either spontaneously or with nonsurgical measures, complications can develop when the infection extends into the orbit or into the intracranial space. This chapter provides insight into the pathophysiology, diagnosis, and medical and surgical management of sinusitis.

OTO Resident Workflow

EORTC QoL Head and Neck35, Karnofky performance status, Visual Analog Scales for dysphonia, dysphagia, dysmorphism and Goodenough-Harris Draw a Person Test (DAP). RESULTS: After a median follow-up of 63 months, moderate-severe DISCHE score in S RT vs CT RT was: taste impairment (64% vs 89%), salivary function (59% vs 79%), subcutaneous fibrosis (97% vs 75%). Concerning long term dysphagia: some discomfort (22% vs 39%), soft diet required (42% vs 28%), fluids only and naso-gastric tube feeding (11% vs 4%); patients with severe dysphagia and taste impairment showed higher levels of anxiety (p 0.05): dysphagia influences the QoL, fatigue and physical-social functioning. Severe salivary function impairment is related only with troubles in social eating and contacts, without effects on QoL. MADRS depression was 56% vs 46%, HADS anxiety was 22% vs 21%. CONCLUSION: A different pattern of long term toxicity was observed in S RTvsCT RT. Anxiety rate is lower, depression is present in half of patients and is statistically related with dysphagia.