Aviram Netzer

Implanted upper airway stimulation device for obstructive sleep apnea

Previous feasibility studies have shown that electrical stimulation of the hypoglossal nerve can improve obstructive sleep apnea (OSA). The current study examined the safety and preliminary effectiveness of a second generation device, the Upper Airway Stimulation (UAS) system, and identified baseline predictors for therapy success.

Tracheotomy: Changing indications and a review of 1130 cases

BACKGROUND Tracheotomy is one of the oldest known operations, dating back to ancient Egypt and India some 3000 years ago. The indications for tracheotomy have changed and expanded during the twentieth century. Today, owing to advancements in intensive care and the widespread use of mechanical ventilation, tracheotomy is one of the most commonly performed surgical procedures and is encountered on a regular basis by hospital physicians in all fields. We present one of the largest series of consecutive tracheotomies spanning one decade. We review and discuss the modern indications for tracheotomy and emphasize the changes in these indications over the past century. METHODS A retrospective study of 1,130 consecutive tracheotomies performed over one decade is presented. We studied the indications for surgery, the complications and mortality rate, and the various hospital departments requiring tracheotomies. RESULTS A total of 1,130 tracheotomies were performed: 859 to assist in mechanical ventilation, 124 as an adjunct to head and neck or chest surgery, and 68 to relieve upper airway obstruction. Major complications occurred in 49 of the cases, and there were 8 deaths directly attributed to the tracheotomies. The most common complication was tracheal stenosis, occurring in 21 cases. Hemorrhage was the second most common complication, occurring in 9 cases. CONCLUSION Tracheotomy, once used almost exclusively to bypass upper airway obstruction, is now a very common elective therapeutic procedure used mostly to facilitate prolonged intubation and ventilation of the critically ill. Today tracheotomy is not and should not be an emergency procedure owing to the huge complication and mortality rate of emergency tracheotomy and the existence of alternative routes to obtain immediate airway control in the acutely obstructed upper airway.

Paper patching for chronic tympanic membrane perforations.

OBJECTIVE This study was designed to evaluate the results of paper-patch myringoplasty in patients with chronic perforations of the tympanic membrane of different sizes. STUDY DESIGN AND SETTING A retrospective survey of paper-patch myringoplasties performed in a tertiary referral academic medical center on 77 patients with chronic perforations of the eardrum was carried out. Data consisted of the causes of the perforations, time the perforations had been present, their size, number of patch applications, duration of application, and number of successfully closed perforations. RESULTS Closure rate was 63.2%, 43.5%, and 12.5% for small, medium, and large perforations, respectively. Small perforations needed the least number of repeated applications and the least time for closure. CONCLUSIONS AND SIGNIFICANCE Paper patching is technically simple, time saving, safe to perform, cost effective, and suitable as an outpatient procedure and has a good success rate, It should be tried in perforations smaller than 5 mm before a patient is referred for surgery.

EFFECTS OF MIDDLE EAR EFFUSION ON THE VESTIBULAR SYSTEM IN CHILDREN

Vertigo and dizziness are not common in childhood, but are probably present more often than was formerly thought. These symptoms caused mainly by otitis media and middle ear effusion, two of the most common diseases in children, have been neglected for a long time, both in the literature and in practice, until recently. The purpose of this study was to determine objectively the incidence of balance-related symptoms in children with long-lasting middle ear effusion and to discover whether these symptoms resolve after the insertion of ventilation tubes. One hundred thirty-six children, ages 4 to 9 years, were given electronystagmographic tests and the Bruininks-Oseretsky tests for motor proficiency before and after tube ventilation of the middle ear. The results were compared with those in 74 healthy children with no history of middle ear diseases. Pathologic findings were found in 58% of the children with chronic middle ear effusion, as compared with only 4% of the control group. The symptoms and signs of balance disturbances resolved in 96% of the children after ventilation tube insertion. The results of this study indicate that balance-related symptoms often encountered in young children may result from chronic middle ear effusion and that these symptoms will resolve after evacuation of the effusion and ventilation of the middle ear.

VENTILATION TUBES AND PERSISTING TYMPANIC MEMBRANE PERFORATIONS

Surgical management of otitis media with effusion and recurrent acute otitis media includes myringotomy and the use of ventilation tubes. Since this procedure was reintroduced by Armstrong in 1954, it has become one of the most commonly performed operations in otolaryngology. In most series perforation of the tympanic membrane in some patients has been reported after spontaneous extrusion or removal of the tympanostomy tubes. We present a retrospective review designed to examine the incidence of persisting perforations of the tympanic membrane in our series of 2604 operated ears. The study also identifies and analyzes the variables and the contributing risk factors. Perforations occurred in 3.06% of the ears: with a greater incidence in children younger than 5 years, when the indication was recurrent purulent otitis media, with the use of long-term Goode T tubes, in cases with repeated insertions of ventilation tubes, and in cases in which postoperative otorrhea was frequent.

Magnesium: a new therapy for idiopathic sudden sensorineural hearing loss.

Objective To determine whether treatment with Mg2+ improves the outcome of idiopathic sudden hearing loss and to investigate which variables influence its prognosis. Study Design Prospective randomized study. Setting Department of Otolaryngology–Head and Neck Surgery, Rambam Medical Center, Haifa, Israel. Patients The study group included 133 patients. Sixty patients were treated with carbogen inhalation, and 73 were treated with a combination of carbogen inhalation and intravenous MgSO4. Results The mean improvement rate was 66.4% in the Mg2+ group and 49.9% in the carbogen group (p < 0.01). Recovery was achieved in 35 patients (48%) in the Mg2+ group and only in 19 patients (31.6%) in the carbogen group (p < 0.01). Significant improvement was seen in 20 patients (27.4%) in the Mg2+ group and in 14 patients (23.3%) in the carbogen group. Partial improvement was seen in eight patients (10.9%) in the Mg2+ group and in 12 patients (20%) in the carbogen group. No improvement was achieved in 10 patients (13.6%) in the Mg2+ group and in 15 patients (25%) in the carbogen group. Patients with vestibular symptoms had a poorer hearing outcome compared to those without vertigo (p < 0.04). Patients who commenced the treatment 8 days or more after onset had poorer recovery as compared with those who started treatment earlier (p < 0.03), regardless of the treatment regimen. Age, sex, and tinnitus had no significant impact on hearing recovery. Conclusion We found that Mg2+ improved hearing recovery in cases of idiopathic sudden hearing loss. Vertigo and treatment delay beyond 8 days were poor prognostic factors for recovery.

Laser Partial Epiglottidectomy as a Treatment for Obstructive Sleep Apnea and Laryngomalacia

Obstructive sleep apnea (OSA) and laryngomalacia are two different entities. Occasionally, they may have a common etiology: an elongated, flaccid, and lax epiglottis that is displaced posteriorly during inspiration causing airway obstruction. Twenty-seven adults with a diagnosis of airway obstruction or OSA of various degrees, and 12 infants with severe stridor associated with frequent apneas due to laryngomalacia, who on fiberoptic examination were found to have a posteriorly displaced epiglottis, underwent partial epiglottidectomy with a CO2 laser. Their postoperative recovery was uneventful. Polysomnographic studies performed after operation in the adult patients demonstrated statistically significant improvement in 85% of the patients. In all the cases of laryngomalacia, stridor ceased permanently after surgery, together with complete cessation of the apneic episodes. This study demonstrates that similar pathophysiological mechanisms may be involved in both laryngomalacia and in OSA. Effective and relatively safe treatment can be achieved by partial resection of the epiglottis with a microlaryngoscopic CO2 laser.

Effect of middle ear effusion on the vestibular labyrinth

Although middle ear effusion was once described as the most common cause of vestibular disturbance in children, the association between glue ear and symptoms of dysequilibrium has never been quantified objectively. In this study the effect of middle ear effusion on the vestibular system of the inner ear was studied in a select group of children suffering from long lasting effusion in the middle ear with no evidence of infection at least one year prior to the study. The results were compared with results obtained from otitis free children, as well as from examinations of children after the insertion of ventilating tubes. The results of this study confirm the assumption that middle ear effusion has an adverse effect on the vestibular system, which can be resolved following the insertion of ventilation tubes. This effect may also contribute to the adverse effect that otitis media has on a childs development.

Plastipore Implants in the Surgical Treatment of Atrophic Rhinitis: Technique and Results

BACKGROUND Atrophic rhinitis is a distressing and socially crippling disease. Surgical treatment has been used for patients with severe disease that is unresponsive to medical therapy. METHODS Eight patients with primary atrophic rhinitis were treated surgically by narrowing of the nasal fossae with implantation of 2 Plastipore plates per affected side into submucosal pockets into the floor of the nose and septum, thus reducing the volume of the nasal fossae. RESULTS Excellent results were obtained in 6 patients, with complete resolution of symptoms and good results and only minor crusting in 2 patients. One implant was extruded spontaneously 18 months after implantation and was reimplanted. Results in this patient before and after reimplantation were excellent. There were no cases of infection and no other complications. CONCLUSION We implanted Plastipore, a high-density polyethylene sponge with micropores, which enables tissue ingrowth, anchoring the implants to the surrounding tissue. The surgical technique is performed with the patient under local anesthesia and is relatively easy and avoids complicated flap procedures, allogeneic bone harvesting, and the discomfort of nostril closure for prolonged periods.

Stapedius muscle myoclonus.

Myoclonus of the middle ear is a very rare condition. We present the case of a 20-year-old soldier who was exposed to intense artillery noise during a fierce battle and immediately afterward complained of an incapacitating tinnitus in both ears. Microscopic examination of the ears demonstrated rapid rhythmic movements of the tympanic membrane coinciding with the tinnitus, which was also easily heard by the examiner. There was no evidence of palatal myoclonus, and thus the diagnosis of middle ear myoclonus was made. Exploratory tympanotomy confirmed the diagnosis of stapedial muscle myoclonus. Bilateral sectioning of the stapedial tendons brought immediate relief of the tinnitus to the patient. We review the literature of middle ear myoclonus and discuss the symptoms, evaluation, and management of this rare condition.