Carlos Torre

Epiglottis collapse in adult obstructive sleep apnea: A systematic review.

To systematically review the international literature evaluating the role of the epiglottis in snoring and obstructive sleep apnea and to explore possible treatment options available.

Supraglottoplasty for laryngomalacia with obstructive sleep apnea: A systematic review and meta-analysis

To determine if apnea‐hypopnea index (AHI) and lowest oxygen saturation (LSAT) improve following isolated supraglottoplasty for laryngomalacia with obstructive sleep apnea (OSA) in children.

Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement for Obstructive Sleep Apnea Is a Marker for Surgical Success: Observations From Drug-Induced Sleep Endoscopy

PURPOSE The efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) with anatomic airway changes has previously been studied using static imaging and endoscopy in awake subjects. The aim of the present study was to use drug-induced sleep endoscopy (DISE) to evaluate the dynamic upper airway changes in sleeping subjects before and after MMA and their association with the surgical outcome. PATIENTS AND METHODS This was a retrospective cohort study of subjects with OSA who had undergone MMA at the Stanford University Sleep Surgery Division from July 2013 to July 2014. The subjects were included if perioperative polysomnography and DISE had been performed. The predictor variable was the perioperative DISE velum-oropharynx-tongue-epiglottis score. The outcome variables were the apnea-hypopnea index (AHI), oxygen-desaturation index (ODI), and Epworth Sleepiness Scale (ESS). A subgroup analysis was performed for the subjects who had undergone primary and secondary MMA. The statistical analyses included Cronbachs α coefficient, the McNemar test, and the independent Student t test. The P value was set at <.01. RESULTS A total of 16 subjects (15 males, 1 female) were included in the present study, with an average age of 47 ± 10.9 years and body mass index of 29.4 ± 5.1 kg/m(2). Significant post-MMA decreases were found in the AHI (from 59.8 ± 25.6 to 9.3 ± 7.1 events/hr) and ODI (from 45 ± 29.7 to 5.7 ± 4.1 events/hr; P < .001). Greater improvement in the AHI occurred in the primary MMA group (P = .022). The post-MMA change in airway collapse was most significant at the lateral pharyngeal wall (P = .001). The subjects with the most improvement in lateral pharyngeal wall collapsibility demonstrated the largest changes in the AHI (from 60.0 ± 25.6 events/hr to 7.5 ± 3.4 events/hr) and ODI (from 46.7 ± 29.8 to 5.3 ± 2 events/hr; P = .002). CONCLUSIONS Using DISE, we observed that after MMA, the greatest reduction in upper airway collapsibility is seen at the lateral pharyngeal wall of the oropharynx, followed by the velum, and then the tongue base. The stability of the lateral pharyngeal wall is a marker of surgical success after MMA using the AHI, ODI, and ESS.

Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling.

Objectives To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters. Study Design Retrospective cohort study. Setting University medical center. Methods DISE was rated with the VOTE (velum, oropharynx, tongue, epiglottis) classification, and CFD was used to model airflow velocity and negative pressure exerted on pharyngeal wall. Changes in VOTE score by site and CFD measurements were correlated with perioperative polysomnography outcomes of apnea-hypopnea index (AHI), apnea index (AI), oxygenation desaturation index (ODI), and lowest oxygen saturation. Results After MMA, 20 subjects (17 males, 3 females) with a mean age of 44 ± 12 years and body mass index of 27.4 ± 4.6 kg/m2 showed mean decreases in AHI (53.6 ± 26.6 to 9.5 ± 7.4 events/h) and ODI (38.7 ± 30.3 to 8.1 ± 9.2 events/h; P < .001). Improvement in lateral pharyngeal wall collapse during DISE based on VOTE score correlated with the most decrease in AHI (60.0 ± 25.6 to 7.5 ± 3.4 events/h) and ODI (46.7 ± 29.8 to 5.3 ± 2 events/h; P = .002). CFD modeling showed significant positive Pearson correlations between reduction of retropalatal airflow velocity and AHI (r = 0.617, P = .04) and ODI (r = 0.773, P = .005). Conclusion AHI and ODI improvement after MMA is best correlated with (1) decreased retropalatal airflow velocity modeled by CFD and (2) increased lateral pharyngeal wall stability based on VOTE scoring from DISE.

Dexmedetomidine versus propofol during drug-induced sleep endoscopy and sedation: a systematic review

BackgroundThe purpose of the present study is to review the international literature, using a systematic review, for studies comparing propofol and dexmedetomidine for drug-induced sleep endoscopy (DISE) or sedation in which there is a description of the effect of the agents on the upper airway and associated variables (e.g., vital signs, sedation scores).MethodsThis is a systematic review through October 4, 2016. PubMed/MEDLINE and four additional databases were accessed for this study.ResultsTwo hundred twenty studies were screened, 79 were downloaded, and 10 met criteria. The majority of the studies identified dexmedetomidine as the preferred pharmacologic agent for DISE due to an overall safer and more stable profile based upon hemodynamic stability. However, propofol provided greater airway obstruction with oxygen desaturations. With either agent, the degree of obstruction in the upper airway lacks some degree of validity as to whether the obstructions accurately represent natural sleep or are simply a drug-induced effect.ConclusionDexmedetomidine and propofol have their advantages and disadvantages during DISE. Generally, dexmedetomidine was preferred and seemed to provide a more stable profile based upon cardiopulmonary status. However, propofol has a quicker onset, has a shorter half-life, and can demonstrate larger degrees of obstruction, which might more accurately reflect what happens during REM sleep. Additional research is recommended.

Ethmoidal desmoid tumor in a pediatric patient.

Desmoid tumors (DTs) are histologically benign, intermediate-grade fibrous neoplasms, originating from the muscleaponeurotic structures throughout the body. They most commonly develop in the torso and anterior abdominal wall. There have been isolated reports of DTs in the head and neck region but none of them in pediatric patients. This tumor has an infiltrative growing pattern and a high tendency for recurrence. We present a case of a DT in the ethmoidal region in a 3-year-old patient. A male patient, three years and three months old, was brought to our clinic with a nasal tumor. Evolution showed 18 months of growth with epiphora, left-eye proptosis, headache, and gradual weight loss. A nasal endoscopy was performed, finding a white, smooth, occupied mass at the left middle turbinate that extended to the roof of the nose. A CT scan and MRI were performed, finding a growth in process in the left ethmoidal region that pushed de papiracea lamina, the rectos internus muscle, and the roof of the maxillary sinus (hypointense T1 and hyperintense T2). The growth pushed the ocular globe contralaterally, extending toward the sphenoid sinus of the same side (Figs 1 and 2). An intranasal endoscopically assisted biopsy was performed. Grossly, the specimen was composed of several fragments that measured 3.5 2.5 2 cm; they were white or yellowish in color, with hard zones and a finely granular surface. Histologically, a benign-looking lesion was observed located immediately under the sinus epithelia and extending into the surrounding soft tissues. Some mineralised bone trabeculae were found within the tumor. The tumor was composed of fascicles with wide fibrous bands, some of them hyalinized, intermingled with spindle cells, relatively uniform in size and shape, which depicted

Obstructive sleep apnea phenotypes and markers of vascular disease: A review

Obstructive sleep apnea (OSA) is a chronic and heterogeneous disorder that leads to early mortality, stroke, and cardiovascular disease (CVD). OSA is defined by the apnea–hypopnea index, which is an index of OSA severity that combines apneas (pauses in breathing) and hypopneas (partial obstructions in breathing) associated with hypoxemia. Yet, other sleep metrics (i.e., oxygen nadir, arousal frequency), along with clinical symptoms and molecular markers could be better predictors of stroke and CVD outcomes in OSA. The recent focus on personalized medical care introduces the possibility of a unique approach to the treatment of OSA based on its phenotypes, defined by pathophysiological mechanisms and/or clinical presentation. We summarized what is known about OSA and its phenotypes, and review the literature on factors or intermediate markers that could increase stroke risk and CVD in patients with OSA. The OSA phenotypes where divided across three different domains (1) clinical symptoms (i.e., daytime sleepiness), (2) genetic/molecular markers, and (3) experimental data-driven approach (e.g., cluster analysis). Finally, we further highlight gaps in the literature framing a research agenda.

Impact of continuous positive airway pressure in patients with obstructive sleep apnea during drug-induced sleep endoscopy

The primary objective of the study was to understand the differential impact of continuous positive airway pressure (CPAP) on the location, degree and pattern of airway collapse in obstructive sleep apnea (OSA) patients utilizing drug‐induced sleep endoscopy (DISE).

Clinical and sociodemographic characteristics associated with disease severity in juvenile recurrent respiratory papillomatosis: A study of 104 patients in a tertiary care pediatric hospital

BACKGROUND Juvenile recurrent respiratory papillomatosis (JRRP) is generally aggressive and with a high recurrence rate. Currently, there is no definite curative treatment for JRRP. Therefore, a greater understanding of the aspects that influence the severity and prognosis of the disease is required. OBJECTIVE The aim of this study was to establish the clinical and socioeconomic characteristics of pediatric patients with JRRP and its relationship with the severity of the disease in a tertiary care pediatric hospital. RESULTS A strong relationship was observed between the severity of the disease and the age at the time of diagnosis, and having a tracheostomy. A moderate association was found between the severity of the disease and the age at the time of the study, the area of origin and the recurrence rate. None of the socioeconomic statuses had a correlation with the severity of the JRRP. CONCLUSIONS JRRP is associated with multiple surgeries due to the recurrence and aggressiveness of the disease. The socioeconomic status does not seem to influence the severity of the disease, whereas younger patients and users of tracheostomy should receive a more strict follow-up given the increased risk of severe disease.

Hypopharyngeal evaluation in obstructive sleep apnea with awake flexible laryngoscopy: Validation and updates to Cormack-Lehane and Modified Cormack-Lehane scoring systems

To validate the use of Cormack‐Lehane and Modified Cormack‐Lehane scoring systems to classify patterns of hypopharyngeal airway visualization seen during awake flexible laryngoscopy among patients with obstructive sleep apnoea.