Ari DeRowe

Tongue-base suspension with a soft tissue-to-bone anchor for obstructive sleep apnea: preliminary clinical results of a new minimally invasive technique.

The Repose system is a new minimally invasive technique for tongue-base suspension in the treatment of sleep-disordered breathing caused by tongue-base collapse. It involves the insertion of a titanium miniscrew with attached suture into the anterior intraoral mandible and passing the suture through the tongue base. The procedure was performed in 16 patients with sleep-disordered breathing. Fourteen patients reported an improvement in daytime sleepiness, and their bed partners reported an improvement in snoring. The mean respiratory distress index before surgery was 35. Two months after surgery, the mean respiratory distress index was 17, an improvement of 51.4% (P = 0.001, 2-tailed t test). These preliminary results show the initial efficacy and safety of this new surgical procedure. (Otolaryngol Head Neck Surg 2000;122:100–3.)

The effect of tonsillectomy and adenoidectomy on inattention and impulsivity as measured by the Test of Variables of Attention (TOVA) in children with obstructive sleep apnea syndrome

OBJECTIVE: To evaluate children with obstructive sleep apnea syndrome (OSAS) for features of attention deficit disorder (ADD) using an objective test of inattention and impulsivity: Test of Variables of Attention (TOVA) and then to determine whether tonsillectomy and adenoidectomy (T+A) results in an improvement in TOVA scores. STUDY DESIGN AND SETTING: This study was a prospective interventional comparative trial in a tertiary care childrens hospital. Nineteen children ages 5 to 14 years with OSAS, and otherwise healthy, with a clinical indication for T+A. Preoperative and 2 months postoperative OSA-18, CBCL questionnaires, and TOVA scores were evaluated. RESULTS: The preoperative TOVA scores were in the abnormal range in 12/19 (63%) of the children. The mean preoperative TOVA score was −2.9 (± 3.1). The mean postoperative TOVA score was −0.4 (±2.8). The improvement in the TOVA scores was significant (P < 0.0001, t-test). CONCLUSION: This preliminary data suggests that treatment of OSAS with T+A results in significant improvement in objective parameters of inattention and impulsivity. SIGNIFICANCE: These findings may be important in understanding the impact of OSAS and therapeutic interventions on behavioral problems in children.

Pharyngeal suspension suture with Repose bone screw for obstructive sleep apnea

OBJECTIVE: Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This studys goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique. METHODS: A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep. RESULTS: Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure. CONCLUSION: A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Conservative management of acute mastoiditis in children

OBJECTIVE To review the current management of acute mastoiditis with critical emphasis on the role of myringotomy. DESIGN A retrospective chart review. SETTING Tertiary-care, university affiliated childrens hospital. PATIENTS One hundred and forty-four consecutive children hospitalized for acute mastoiditis between the years 1991 and 2002. INTERVENTIONS All children were treated with parenteral antibiotics (conservative management). Myringotomy was performed at the discretion of the otolaryngologist on-call. MAIN OUTCOME MEASURES Comparing outcomes of children with or without myringotomy regarding hospital stay, complications and the need for surgical interventions. RESULTS Myringotomy was performed in 34.6% of episodes. The children who underwent myringotomy were found to be significantly younger (22.4 compared to 28.8 months, p=0.028) and had more complications (n=17 vs. n=8, p<0.001). Complications overall occurred in 16.3% of episodes. Performing myringotomy had no significant effect on the duration of hospital stay. Children pretreated with antibiotics underwent significantly less myringotomies p=0.027. There were no significant differences between children who underwent myringotomy and those who did not with regard to WBC count, or ESR. CONCLUSIONS These findings suggest that myringotomy may not be required in all cases of acute mastoiditis. Parenteral antibiotics is sufficient in most cases. Criteria for myringotomy may include a younger age. Conservative management resulted in good outcomes in this series.

SKULL BASE APPROACHES IN THE PEDIATRIC POPULATION

This study aimed to examine the surgical, oncologic, and developmental results of infants and children undergoing extirpation of skull base tumors.

Fiber-optic sleep endoscopy in children with persistent obstructive sleep apnea: Inter-observer correlation and comparison with awake endoscopy

OBJECTIVE Evaluate the inter-observer correlation of sleep endoscopy findings in children with persistent obstructive sleep apnea (OSA) with awake office fiber-optic endoscopy. METHOD DESIGN retrospective case series; blinded review. SETTING tertiary care childrens hospital. PATIENTS Children with persistent obstructive sleep apnea. INTERVENTIONS Both awake and drug induced sleep endoscopy were performed. Endoscopy video recordings were mixed at random on a DVD. Two pediatric otolaryngologists and two pediatric pulmonologists independently scored each recording using an upper airway endoscopy scoring survey. MAIN OUTCOME MEASURES reviewers scored the following parameters: each structures contribution (nose, nasopharynx, lateral pharyngeal walls, tongue base, supraglottis) to the obstruction, the main site in which the obstruction occurs, the severity of OSA (mild, moderate, severe), the level of confidence of endoscopy findings (poor, fair, good). RESULTS When reviewing sleep endoscopy recordings for the upper airway obstruction site, the highest correlation among the four observers was found for the nasopharynx and the supraglottis (Kappa score: 0.6 and 0.5, respectively). Compared to awake endoscopy, sleep endoscopy demonstrated more cases of airway obstruction caused by collapse of lateral pharyngeal walls and base of tongue (McNemar test for symmetry, P value<0.05). Level of confidence among the four observers was higher in older children and lower in children with severe OSA. CONCLUSIONS Sleep endoscopy is a consistently reliable tool for identifying the site of obstruction in children with persistent OSA. Though anesthetic induced sleep is not a perfect model for real sleep, the technique demonstrably guides further therapy better than awake endoscopy.

Synchronous airway lesions in laryngomalacia.

OBJECTIVE Laryngomalacia is the most common cause of congenital stridor. Laryngomalacia may be associated with other structural and functional airway lesions. While previous studies suggested a 10-45% rate of synchronous airway lesions (SALs), the exact rate and its clinical significance is unknown. The purpose of this study was to determine the prevalence of SALs below the glottic level in congenital laryngomalacia, and to investigate possible relations with other clinical findings. METHODS A cohort of 228 infants with congenital stridor who underwent fiberoptic flexible bronchoscopy (FFB) was analyzed. Data was collected from the hospital records. All procedures were reevaluated from the video recordings. RESULTS SALs below the vocal cords were observed in 7.5% of the case (17/228). The most common SAL was tracheal bronchus followed by tracheomalacia and stenosis of the left main bronchus. No correlation was found between the presence of a SAL below the vocal cords and any other medical condition except for neurodevelopmental disorders. Except for one patient, all cases with SAL did not have any clinical symptoms or signs that would have suggested an accompanying airway lesion. CONCLUSIONS The rate of SALs in infants with congenital stridor due to laryngomalacia is low and most of the additional lesions are benign. The yield of discovering clinically significant SALs below the glottic level is low and the routine search for a synchronous lesion below the vocal cords should be questioned. Except for underlying neurodevelopmental problems, no clear risk factors for the existence of SALs were identified.

Fat graft myringoplasty: results of a long-term follow-up.

OBJECTIVE To evaluate the long-term results of fat graft myringoplasty in adult and pediatric populations. DESIGN Prospective case series study. MAIN OUTCOME MEASURES Patients with chronic tympanic membrane perforations were considered candidates for fat graft myringoplasty. Excluded were patients with purulent discharge, suspected ossicular disease, suspected cholesteatoma, or a perforation diameter greater than 6.5 mm. Fat was harvested from the ear lobule or subcutaneous tissue just posterior-inferior to the lobule. RESULTS The study population comprised 27 adults and 11 children. Twenty-eight perforations were small (73.7%) and 10 were large (26.3%). Altogether, 31 of 38 perforations were successfully repaired (81.6%), including 22 of 28 small perforations (78.6%) and 9 of 10 large perforations (90%). Assessment by age showed that 23 of 27 perforations of the adults (85.2%) and 8 of 11 perforations of the children (72.7%) successfully closed (p = .648). Follow-up ranged from 25 to 53 months (mean 40.6 +/- 8.3 months). No recurrence of the perforation during the follow-up period was recorded if the initial results were successful. The speech reception threshold improved significantly (18.5 +/- 7.7 dB vs 23.5 +/- 8 dB; p = .043). No significant sensorineural hearing loss occurred. CONCLUSIONS Fat graft myringoplasty is a reliable technique for the closure of small- and medium-sized perforations. The grafting results showed excellent long-term durability. Given the simplicity of the technique, its short duration, and the favourable hearing results, fat graft myringoplasty should be considered the procedure of choice in patients with suitable perforations and when not otherwise contraindicated.

Negative findings of esophagoscopy for suspected foreign bodies

PURPOSE Suspected impaction of esophageal foreign bodies may at times pose a diagnostic problem as to the decision to perform esophagoscopy. It is not unusual to perform a rigid esophagoscopy following a diagnostic work-up for an impacted foreign body and not to find one. This study attempts to delineate the clinical situations where negative esophagoscopies are more likely to occur. MATERIALS AND METHODS In a retrospective analysis of 98 rigid esophagoscopies performed for suspected foreign bodies in our department, an attempt was made to delineate the clinical and radiologic findings characteristic of the patients who had no foreign body at esophagoscopy compared with the patients in whom a foreign body was found. RESULTS Negative esophagoscopies were associated with suspected bone (mostly fish) impaction in 20 of the 22 negative esophagoscopies. Other parameters associated with negative findings were prolonged duration of symptoms and a positive finding at the physical examination. In suspected bone impaction, barium studies and neck x-rays were not helpful in determining the presence of a foreign body. CONCLUSION Clinical history is the main indicator in the decision to perform esophagoscopy for suspected foreign bodies.

Systemic corticosteroids for allergic fungal rhinosinusitis and chronic rhinosinusitis with nasal polyposis : A comparative study

Objectives To compare the effect of preoperative high-dose systemic corticosteroids on the radiographic and endoscopic appearance of allergic fungal rhinosinusitis (AFRS) and chronic rhinosinusitis with nasal polyposis (CRSwNP). Study Design and Setting Eight AFRS and 10 CRSwNP patients underwent computed tomographic (CT) scans and then received preoperative 1 mg/kg prednisone for 10 days. CT scans were repeated 1 day before surgery and compared with pretreatment scans (Lund-MacKay radiologic scoring system). The endoscopic appearance was recorded intraoperatively. Results The score dropped from 16 (66.4%) to 4.75 in the AFRS group and from 18.4 (23%) to 14.1 in the CRSwNP group (P = 0.0064). Intraoperatively, most sinus mucosal surfaces appeared normal in the AFRS patients but were markedly edematous in the CRSwNP patients. Conclusion Radiographic response of AFRS to systemic corticosteroids is significantly greater compared with CRSwNP. This finding is supported by endoscopic observation.