David S. Utley

Radiofrequency energy tissue ablation for the treatment of nasal obstruction secondary to turbinate hypertrophy

Objective/Hypothesis: We hypothesized that the success rate of radiofrequency energy (RFe) tissue ablation of the inferior turbinate for nasal obstruction achieved by previous investigators would be improved by using a longer needle electrode and creating two lesions per turbinate. Methods: Ten patients with nasal obstruction secondary to inferior turbinate hypertrophy were prospectively enrolled. A 40‐mm needle delivered RFe to two sites in each inferior turbinate. Patients used a visual analog scale (VAS) to grade nasal obstruction preoperatively and at 1 week and 8 weeks after surgery. Preoperative and postoperative digital images of the nasal cavity were graded for obstruction (0% to 100%) in a blinded manner. Results: All patients (100%) were subjectively improved at 8 weeks. Mean obstruction (VAS) improved from 50% ± 21% to 16% ± 15% (right side) and from 53% ± 29% to 13% ± 13% (left side). Mean improvements were 68% (right side) (P = .004) and 75% (left side) (P = .001). Mean obstruction graded during blinded review of nasal cavity images improved from 73.5% ± 8% to 51% ± 8% (right side) and from 76% ± 6% to 64% ± 7% (left side). Of nine patients using medications for nasal obstruction before treatment, eight (89%) noted no further need for medications at 8 weeks. Conclusion: The use of RFe for submucosal tissue ablation in the hypertrophied inferior turbinate is an effective modality for reducing symptoms of nasal obstruction. Improved results may occur by using a longer needle and creating two lesions per turbinate. Of patients in this study, 100% reported improvement of nasal obstruction.

Simultaneous treatment with BDNF and CNTF after peripheral nerve transection and repair enhances rate of functional recovery compared with BDNF treatment alone

The objective was to investigate the effects of brain‐derived neurotropic factor (BDNF) and ciliary neurotropic factor (CNTF) on peripheral nerve regeneration. Thirty Sprague‐Dawley rats underwent left sciatic nerve transection and repair according to three experimental groups: epineurial coaptation (EC), EC with BDNF delivered by an osmotic pump (EC‐BDNF), and EC with BDNF and CNTF delivered similarly (EC‐BDNF/CNTF). Nerve regeneration was assessed using sciatic functional indices, quantitative histomorphology, and molecular analysis for proteins associated with nerve regeneration. Analysis of variance (ANOVA) comparing all groups at each time point demonstrated significant differences between groups on days 20, 30, 40, 50, 60, and 80. A paired, two‐tailed Students t‐test with the Bonferroni correction for multiple comparisons demonstrated that at 40 days postoperatively, animals in the EC‐BDNF/CNTF group (n = 7) manifested superior functional recovery compared with those in the EC group (n = 9) and those in the EC‐BDNF group (n = 9) (P < 0.001 and P < 0.05, respectively). At 80 days, the animals in both the EC‐BDNF (P < 0.01) and EC‐BDNF/CNTF (P < 0.05) groups demonstrated greater functional recovery compared with those in the EC group, with no significant difference between the two factor groups at the endpoint. Morphometric analysis demonstrated that nerves from animals in the EC‐BDNF/CNTF group had the largest mean axon diameters as compared with those from the EC (proximal: P < 0.001, distal: P < 0.05) and EC‐BDNF(proximal: P < 0.01) groups. No significant differences were seen in nerve cross‐sectional area. In distal nerve segments, Western blot analysis revealed that expression of myelin‐associated glycoprotein was higher than control for the EC group and lower than control for both the EC‐BDNF and EC‐BDNF/CNTF groups. We conclude that BDNF/CNTF combined treatment increases the early rate of functional sciatic nerve regeneration over treatment with BDNF alone, although the degree of maximal recovery was similar at the conclusion of the experiment.

A Cost-Effective and Rational Surgical Approach to Patients With Snoring, Upper Airway Resistance Syndrome, or Obstructive Sleep Apnea Syndrome†

The past decade has seen several innovations in the surgical techniques available for treatment of patients with sleep‐disordered breathing. Outpatient techniques such as laser‐assisted uvulopalatoplasty (LAUP) and more aggressive procedures designed to address hypopharyngeal and base of tongue obstruction (genioglossus advancement and hyoid myotomy) have been developed and proven successful. We describe the efficacy of LAUP for snoring (72.7%), upper airway resistance syndrome (81.8%), and mild (mean[±SD] respiratory disturbance index [RDI] = 12 ± 8.1) obstructive sleep apnea (41.7%) in 56 patients who underwent 132 LAUP procedures in a 26‐month period. Thirty‐two patients with more significant obstructive sleep apnea (mean RDI = 41.8 ± 23.1) underwent multilevel pharyngeal surgery consisting of genioglossus advancement and hyoid myotomy combined with uvulopalatopharyngoplasty. The surgical success rate in this group of patients was 85.7% when commonly accepted criteria were applied. We recommend a stratified surgical approach to patients with sleep‐disordered breathing. Progressively worse airway obstruction marked by multilevel pharyngeal collapse and more severe sleep‐disordered breathing is treated with incrementally more aggressive surgery addressing multiple areas of the upper airway.

The temporalis muscle flap for reconstruction after head and neck oncologic surgery

Objective To explain the applications, technique, and potential complications of the temporalis muscle flap used for immediate or delayed reconstruction of head and neck oncologic defects.

Cephalometric Parameters After Multilevel Pharyngeal Surgery for Patients With Obstructive Sleep Apnea

Cephalometric studies have shown narrowing in the upper airway at multiple levels in patients with obstructive sleep apnea. Uvulopalatopharyngoplasty (UPPP), mandibular osteotomy with genioglossus advancement, and hyoid myotomy with advancement address narrowing in the retropalatal and retrolingual regions. In an effort to relate postoperative clinical changes to anatomic changes, cephalometric studies were performed on 44 patients who underwent multilevel pharyngeal surgery (UPPP, genioglossus advancement, hyoid myotomy with advancement). Both preand postoperative radiographs were available for 23 of these patients. The posterior airway space (P = .09), minimal posterior airway space (P = .04), posterior uvular space (P = .06), mandibular plane‐to‐hyoid distance (MP‐H) (P = .06) and central incisor‐to‐tongue base distance (P = .02) all improved after surgery. None of the measurements of the posterior airway were significantly different between responders and nonresponders. The degree of collapse of the palate on modified Müller maneuver was highly correlated with the severity of sleep apnea as measured by the respiratory disturbance index; the collapse of the lateral pharyngeal walls was moderately correlated; and collapse of the base of tongue was not correlated. Cephalometric radiographs may reflect the anatomic changes that result from upper airway surgery for sleep apnea, but these changes are not useful for assessing surgical efficacy. The modified Müller maneuver, however, may represent a more predictive evaluation.

Histologic analysis of the thermal effect on epidermal and dermal structures following treatment with the superpulsed CO2 laser and the Erbium:YAG laser: An in vivo study†

To compare the in vivo histologic effects of the carbon dioxide (CO2) and erbium:yttrium aluminum garnet (Er:YAG) lasers. To ascertain the effects of combining CO2 and Er:YAG laser modalities during a single treatment session.

Temperature-Controlled Radiofrequency Energy Delivery for Gastroesophageal Reflux Disease: The Stretta Procedure

BACKGROUND The delivery of temperature-controlled radiofrequency (RF) energy has been utilized effectively for the treatment of benign prostatic hyperplasia, sleep-disordered breathing, joint laxity, tumors, and cardiac dysrhythmias. The mechanism of action of RF delivery, depending on the specific disease pathophysiology, is related to wound contraction/remodeling or nerve pathway ablation. More recently, temperature-controlled RF energy delivery has been applied for the treatment of gastroesophageal reflux disease (GERD). PURPOSE To review the use of temperature-controlled RF energy in clinical applications, specifically the safety and efficacy data regarding endoluminal delivery of RF energy for the treatment of GERD (Stretta procedure). RESULTS Endoluminal RF energy delivery to the gastroesophageal junction for the treatment of GERD is performed using conscious sedation on an outpatient basis. After treatment, medication use is significantly reduced or eliminated at 6 and 12 months, and there is a significant reduction in both the distal and proximal esophageal acid exposure on 24-hour ambulatory pH testing. All studies reviewed demonstrate improvement in GERD symptom scores, heartburn, satisfaction, and quality of life after treatment. There have been no cases of achalasia or stricture resulting from this procedure. Data support both an augmentation of the physical barrier function of the gastroesophageal junction and a reduction in triggering of transient LES relaxations as plausible mechanisms of action for this procedure. CONCLUSION Endoluminal RF energy delivery has been shown in several studies to be safe and effective for the treatment of GERD and is a promising new technology for this chronic disorder.

In vivo model of histologic changes after treatment with the superpulsed CO2 laser, Erbium:YAG laser, and blended lasers: A 4- to 6-month prospective histologic and clinical study†

To compare the in vivo histologic effects of the pulsed carbon dioxide (CO2) and erbium:ytrium aluminum garnet (Er:YAG) lasers and to assess the effects of combining CO2 and Er:YAG laser modalities during a single treatment session. We previously reported 10 patients treated with four laser regimens: CO2 alone, CO2/Er:YAG, Er:YAG alone, Er:YAG/CO2 with time points at 1 hour and 7 days between laser treatment and histologic analysis. This study found that the optimal treatment consisted of limited CO2 laser passes followed by Er:YAG. This treatment produced less collagen injury, less thermal necrosis, and more robust epithelial and dermal fibrous tissue regeneration in the acute phase of healing. The present study examines the histologic changes resulting from the host healing response to laser treatment on long‐term follow‐up of 4–6 months.

Recognition and Surgical Management of the Upper Airway Resistance Syndrome

Patients with upper airway resistance syndrome (UARS) have clinical signs and symptoms of excessive daytime somnolence (EDS) in the absence of obstructive sleep apnea. These patients have increased upper airway resistance, reflected by an elevated intrathoracic pressure measurement, despite a normal respiratory disturbance index (RDI). Physical findings often include excessive palatal tissue and narrowing of the oropharynx and hypopharynx.

Functional recovery following nerve injury and repair by silicon tubulization: Comparison of laminin-fibronectin, dialyzed plasma, collagen gel, and phosphate buffered solution

PURPOSE This study was designed to investigate the potential for enhancement of peripheral nerve regeneration by the manipulation of the neural microenvironment with laminin-fibronectin solution (LF), dialyzed plasma (DP), collagen gel (CG), or phosphate buffered saline (PBS) in a silicon tubulization repair model. METHOD A rat sciatic nerve model of injury and repair was used to study the effects of exogenous matrix precursors (contained in LF or DP), CG or PBS on nerve regeneration. A total of 50 Sprague-Dawley rats underwent left sciatic nerve transection and repair by silicon tubulization. The silicon tubules were either left empty (E), or filled with solutions of LF, DP, CG, or PBS. Nerve function was assessed preoperatively and then postoperatively, every 10 days for 90 days using sciatic functional indexes (SFI). On postoperative day 90, the sciatic nerves were harvested for histologic analysis and the posterior compartment muscles of each animal were harvested and weighed. Molecular analysis for two proteins associated with neural regeneration was performed on the nerve segments. RESULTS All five animal groups demonstrated equivalent functional recovery. Comparison of the rate of recovery and mean maximal recovery between each group revealed no statistically significant differences, with P-values ranging from 0.30 to 0.95. Posterior compartment muscle masses were similar in all groups except for LF, whose animals had muscle masses 8-9% lower than CG, PBS, or E (P < 0.05). CONCLUSION Alteration of the regenerating neural microenvironment with exogenous matrix precursors (LF, DP), CG or PBS failed to improve sciatic functional recovery after nerve transection and silicon tubulization in this model. From this study, we conclude that LF, DP, CG, and PBS do not enhance the rate or degree of recovery of peripheral nerve function across a narrow gap when nerves are repaired by silicon tubulization.