Eric A. Mair

Complications of Tracheobronchial Airway Stents

OBJECTIVE Our goal was to identify and analyze airway stent complications and to devise approaches to manage stent complications. STUDY DESIGN AND SETTING We conducted a retrospective review of patients from a tertiary medical center. METHODS Twenty-eight airway stents were placed in 23 patients for benign (n = 15) and malignant (n = 13) tracheobronchial diseases. All patients were followed clinically for signs of complications. RESULTS Nine complications (8 in those with benign disease and 1 in a patient with malignant disease) were identified and included stent migration (n = 3), excessive granulation tissue (n = 2), stent fracture (n = 1), poor patient tolerance (n = 2), and inability to place (n = 1). Avoidance and management strategies for stent complications are introduced. CONCLUSION Tracheobronchial stents provide minimally invasive therapy for significant airway obstruction. Stent complications are more frequently encountered in the long-term treatment of benign conditions. Stents can be successfully removed endoscopically if complications arise, but the longer a metallic stent is in place, the more difficult it is to remove. SIGNIFICANCE As airway stent use increases, proper management will be required to avoid and manage complications. This is the first report to focus on stent complications and their management.

Endoscopic Surgery of the Anterior Skull Base

Objectives/Hypothesis: Traditional surgical approaches to the anterior skull base often involve craniotomy, facial incisions, disruption of skeletal framework, tracheotomy, and an extended hospital stay. As experience with endoscopic sinus surgery has grown, the techniques and equipment have been found to be adaptable to treatment of lesions of the anterior and central skull base. A minimally invasive endoscopic approach theoretically offers the advantages of avoiding facial incisions, osteotomies, and tracheotomy; surgery should be less painful, recovery quicker, and hospital stays should be shorter. The study attempted to assess endoscopic approaches to the anterior and central skull base for its ability to achieve those goals.

Injection Snoreplasty: How to Treat Snoring without All the Pain and Expense

OBJECTIVE: We introduce Injection Snoreplasty: an innovative, safe, and effective palatal snoring procedure with minimal cost and discomfort to the patient. A well-described sclerotherapy agent, Sotradecol, is injected into the soft palate to reduce/eliminate palatal flutter snoring. STUDY DESIGN AND SETTING: Twenty-seven patients with a diagnosis of palatal flutter snoring (respiratory disturbance index less than 10) by sleep study were enrolled in the protocol. Office treatment sessions were performed 6 to 8 weeks apart. Success was judged by subjective improvement in snoring and objective evidence of palatal stiffening/scarring. RESULTS: Twenty-five (92%) of 27 patients reported significant decrease in snoring. There were no significant postinjection complications. Visual analog pain scale confirmed minimal discomfort. Most patients received more than 1 treatment (average, 1.8) in order to receive optimal palatal stiffening. CONCLUSION/SIGNIFICANCE: Injection Snoreplasty is a simple, safe, and effective office treatment for primary snoring. Advantages over current snoring procedures include simplicity, low cost, decreased posttreatment pain levels, and minimal/no convalescence.

Submucosal minimally invasive lingual excision: an effective, novel surgery for pediatric tongue base reduction.

Objectives: The aim of this study was to develop an effective single intraoral, minimally invasive technique to reduce the enlarged tongue base in children with obstructive macroglossia. Methods: We present the anatomic dissection of fresh cadavers and a representative case series of children who underwent submucosal minimally invasive lingual excision (SMILE) with a plasma-mediated radiofrequency device (coblation) under intraoral ultrasonic and endoscopic guidance. Multiple anatomic dissections determined the relative location of the hypoglossal nerve and lingual neurovascular bundle in relation to removable tongue base musculature. A pediatric case series demonstrates the straightforward SMILE technique. Results: Laboratory anatomic dissection and clinical lingual ultrasonography revealed the surgical safety borders for SMILE. The surgical safety and efficacy of SMILE is demonstrated by preoperative and postoperative clinical examinations and polysomnograms in children with obstructive macroglossia (such as Beckwith-Wiedemann and Down syndromes and tongue vascular malformation). Coblation submucosally removes excessive tongue base tissue through a small anterior tongue incision. SMILE was performed without excessive pain, bleeding, edema, infection, or tongue dysfunction. Conclusions: SMILE is an effective novel operation that incorporates coblation with ultrasonography and endoscopic guidance for children who need tongue base reduction. Anatomic dissection and clinical cases demonstrate the potential for aggressive yet relatively safe tissue removal by this minimally invasive technique. SMILE also has significant potential for adults with obstructive sleep apnea due to a large tongue base.

Tracheal bronchus: classification, endoscopic analysis, and airway management.

OBJECTIVE: Tracheal bronchus (bronchus suis) is an unusual congenital anomaly in which the right upper lobe has its origin in the trachea rather than distal to the carina. We sought to analyze the anatomy, presentation, and airway management principles of tracheal bronchi, and we present the first endoscopically documented tracheal diverticulum. STUDY DESIGN/METHODS: Retrospective case series. RESULTS: The tracheal bronchus is located at the junction of the mid and distal thirds of the right lateral trachea, is more common in males and children with other congenital anomalies, and may be associated with right main bronchus stenosis. Bronchoscopy provides a clear definitive view of the anomaly, which we found in 5 children during a 12-year period (0.5% of pediatric bronchoscopy procedures). We illustrate 3 types of tracheal bronchi: (1) vestigial tracheal diverticulum (newly described), (2) high apical lobe, and (3) fully developed supranumerary aerated tracheal bronchus. Endoscopic documentation of each type is presented. Children with tracheal bronchi may present with stridor, cough, and/or recurrent right-sided pneumonia and/or to have foreign body aspiration ruled out. Treatment is based on the severity of symptoms and ranges from observation to right upper lobectomy. CONCLUSIONS: Otolaryngologists should be aware of the tracheal bronchus, to include classification, endoscopic analysis, and airway management of this uncommon anomaly. Bronchoscopy with selected radiographic imaging allows the otolaryngologist to fully evaluate the child with a tracheal bronchus and to present timely therapeutic options. Tracheal bronchus is a congenital anomaly in which a right upper lobe bronchus has its origin in the trachea rather than at the carina. Bronchus suis, or “pig bronchus,” is an alternate name that is used because a tracheal bronchus is normal in swine and other ruminant animals. In approximately 1000 pediatric bronchoscopy procedures performed by the senior author during a 12-year period, only 5 children (approximately 0.5%) were identified with a tracheal bronchus. We present 3 representative cases to highlight salient features of each variant of the tracheal bronchus. A newly described “tracheal diverticulum” variant is presented. Tracheal bronchus classification based on endoscopic analysis assists with airway management for this uncommon anomaly.

Complications of radiofrequency ablation in the treatment of sleep-disordered breathing.

OBJECTIVE: To evaluate complications of radiofrequency ablation (RFA) in the treatment of sleep-disordered breathing and to outline complication avoidance strategies. STUDY DESIGN AND SETTING: Retrospective review of 51 consecutive RFA treatment sessions for SDB to the soft palate and tongue base by a single surgeon at a tertiary medical center. RESULTS: Over 2 years, 51 treatments comprising 26 palatal and 25 tongue base RFA treatments were performed for sleep-disordered breathing on 30 patients. Complications included palatal mucosal breakdown (11 cases), temporary tongue base neuralgias (4 cases), uvular sloughing (2 cases), tongue base abscesses (2 cases), and floor of mouth edema with airway compromise (2 cases). CONCLUSIONS/SIGNIFICANCE: This is the first paper focusing on complications of RFA. While complications from soft palate RFA present rapidly and are self-limiting, complications from tongue base RFA may be delayed and life threatening. A detailed strategy is provided to avoid and treat these complications.

Cautery-assisted palatal stiffening operation for the treatment of obstructive sleep apnea syndrome

Cautery-assisted palatal stiffening operation (CAPSO) is a recently developed single office-based procedure performed with local anesthesia for the treatment of palatal snoring. A midline strip of soft palate mucosa is removed, and the wound is allowed to heal by secondary intention. The flaccid palate is stiffened, and palatal snoring ceases. This prospective study evaluated the ability of CAPSO to treat obstructive sleep apnea syndrome (OSAS). Twenty-five consecutive patients with OSAS underwent CAPSO. Responders were defined as patients who had a reduction in apnea-hypopnea index (AHI) of 50% or more and an AHI of 10 or less after surgery. By these strict criteria, 40% of patients were considered to have responded to CAPSO. Mean AHI improved from 25.1 ± 12.9 to 16.6 ± 15.0 (P = 0.010). The Epworth Sleepiness Scale, a subjective measure of daytime sleepiness, improved from 12.7 ± 5.6 to 8.8 ± 4.6 (P < 0.001). These results indicate that CAPSO is as effective as other palatal surgeries in the management of OSAS.

Injection snoreplasty: Extended follow-up and new objective data

OBJECTIVE Injection snoreplasty was recently introduced as a safe, effective, and minimally invasive treatment for primary snoring. Extended follow-up data (19 months) are presented from the initial pilot study cohort, and pretreatment/posttreatment objective data are presented on a new prospective patient cohort. STUDY DESIGN AND SETTING The successfully treated patients from the initial pilot study (n = 25) were surveyed regarding their current snoring level, overall discomfort, and overall satisfaction. A new patient cohort with primary snoring (Respiratory Disturbance Index <10) was prospectively treated with injection snoreplasty. Snoring was objectively measured pretreatment and posttreatment using a take-home acoustical analysis device. RESULTS Subjective success dropped from 92% to 75% at a mean of 19-month follow-up with a snoring relapse rate of 18%. Objective analysis of a new patient cohort (n = 17) confirmed statistically significant decreases in palatal flutter snoring and palatal loudness after injection. Preprocedure measurements were highly correlated to eventual treatment success. CONCLUSIONS AND SIGNIFICANCE Success and snoring relapse rates of injection snoreplasty are similar to those of other current treatments. Objective analysis confirms the procedure is effective in reducing palatal flutter snoring. Preprocedure snoring analysis may predict patient response to palatal stiffening treatments.

Radiofrequency Ablation of Lymphangiomatous Macroglossia

INTRODUCTION Diagnosing a child with cystic hygroma carries with it the often devastating implication of a long-term disease requiring multiple medical and surgical interventions over many years. Cystic hygromas within the oral cavity are the most common cause of pediatric macroglossia and present a unique set of challenges for the otolaryngologist. These lesions are often noted at birth, almost exclusively microcystic, and the cause of severe swallowing and articulation difficulties. Children with this condition often have rapid enlargement of their tongue during periods of upper respiratory tract infections. This may lead to significant airway compromise and a tracheotomy. Macroglossia can eventually become strikingly severe and cause protrusion of the tongue from the mouth at rest. Exposed tongue tissue rapidly becomes dried and discolored and easily bleeds. Further secondary malformations of the dentition and mandible follow. Spontaneous regression, as is seen with other vascular malformations, rarely occurs with cystic hygromas. Historically, treatment of cystic hygromas has ranged from a variety of medical therapies to aggressive surgical techniques. Medically, a number of approaches have been investigated. Radiation therapy has been shown to be largely ineffective and has been abandoned altogether. Sclerosing agents injected directly into the cystic lesions have received more recent attention. Boiling water, hypertonic saline, and bleomycin have each been studied and judged ineffective. Currently OK-432, the product of lyophilized streptococcal bacteria treated with penicillin, has shown significant promise when used in macrocystic lesions but has shown no effect when used to treat microcystic lesions. These medical limitations have led most authors to conclude that surgical therapy should be the treatment of choice for cystic hygromas. Despite this recommendation, total surgical excision of involved tissue is possible only in 18% to 50% of patients. This is particularly true for the oral cavity and tongue, where partial glossectomy is required. In this instance, virtually no case reports are available demonstrating total removal of disease. On the contrary, in three separate series, multiple excisions were often the rule. Recurrence rates were highly variable, and treatment episodes were required over many years. In the present study we describe a new and more conservative surgical approach to this lesion using radiofrequency tissue ablation techniques.

Endoscopic image-guided transethmoid pituitary surgery

OBJECTIVE: We describe a new endoscopic transethmoid approach for pituitary surgery and to compare it with other surgical techniques. STUDY DESIGN AND SETTING: Eleven patients undergoing pituitary surgery from September 2000 through January 2002 underwent an image-guided endoscopic transethmoid procedure to remove pituitary tumors. Ease of approach, resection, exposure of the surgical field, and operative complications were documented. RESULTS: Endoscopic ethmoidectomy permits enhanced exposure and simplified tumor resection. The use of one nostril to stabilize the endoscope and the other to pass instruments affords a bimanual procedure that avoids the difficulty of small nares and keeping the scope fixed while exchanging instruments. Operative morbidity was low with no significant complications in this pilot study. CONCLUSIONS: This approach opens a generous operative exposure while safely allowing room to endoscopically maneuver and affords direct access should revision surgery be needed. SIGNIFICANCE: This procedure uses a technique familiar to otolaryngologists and may be used for pituitary and other skull base tumors. The transseptal approach to the sella turcica is the most commonly performed procedure to reach the pituitary gland. Three major variations of the transseptal approach are used: sublabial approach, external rhinoplasty approach, and transnasal approach. Each has unique advantages and disadvantages relative to each other and the endoscopic procedure, apart from the shared transseptal route (Table 1). The techniques have been described elsewhere previously. 1–3 More recently, endoscopy has been used to aid the approach to the pituitary. The first endoscopic procedures used the transseptal dissection route through a standard sublabial incision, with the endoscope passed through a self-retaining speculum. 4–6 In other cases the endoscope was used for the approach only, with the binocular operating microscope subsequently used for the tumor resection. 7 Except for the wide field of vision afforded by the endoscopic approach, the morbidity of a transseptal dissection remained. More recent advances have used an endonasal approach, which allows the surgeon to bypass the transseptal dissection. 8–11 The majority of procedures performed use one nostril to pass the endoscope and other instruments, with limited endoscopic operative maneuverability. We introduce an endonasal transethmoid approach bypassing the need for a nasal retractor, headrest, and postoperative nasal packing, while providing enhanced endoscopic operative maneuverability through bimanual instrumentation using both nares and an endoscope stabilizer.