George P. Katsantonis

The predictive efficacy of the Müller maneuver in uvulopalatopharyngoplasty

Flexible pharyngoscopy with the Müller maneuver has been proposed as a method for selection of uvulopalatopharyngoplasty candidates. In this prospective study, its predictive efficacy has been evaluated in 24 consecutive obstructive sleep apnea patients undergoing uvulopalatopharyngoplasty. FPMM enabled us to accurately predict the uvulopalatopharyngoplasty outcome in 12 of the 24 patients (50%).

Management of obstructive sleep apnea: Comparison of various treatment modalities†

From July, 1982 through March, 1986, 253 patients with moderate to severe sleep apnea (OSA) were treated and had polysomnographic assessment of treatment. The treatment modalities were: 1. uvulopalatopharyngoplasty (UPP), 2. nasal continuous positive airway pressure (CPAP), 3. tracheostomy, 4. medication (tricyclic antidepressants), 5. tongue retaining device (TRD), and 6. orthodontic device.

Somnofluoroscopy: Its Role in the Selection of Candidates for Uvulopalatopharyngoplasty

The purpose of this study was to evaluate the efficacy of somnofluoroscopy in the selection of candidates for uvulopalatopharyngoplasty (UPPP). Somnofluoroscopy is a lateral fluoroscopic examination of the upper airway with synchronous polysomnography that provides information about the dynamic function of the airway and the level of stenosis or occlusion during sleep. Somnofluoroscopies were performed preoperatively in 26 consecutive patients undergoing UPPP. Preoperative and postoperative polysomnographic data were obtained on each patient. On review of the somnofluoroscopic recordings, two levels of the airway were considered: level 1, above the horizontal plane through the midportion of body of the second cervical disk, and level 2, below this plane. The examinations were then scored for the following: (A) most narrow level of airway during wakefulness, (B) first level(s) of airway to collapse during apnea, and (C) all levels of the airway to collapse during apnea. It was shown that patients whose narrowest part of the upper airway is at level 1 and whose first point of airway collapse during apnea episodes is at level 1 are good candidtates for the UPPP. Only three of 15 patients in this group did not respond to the operation. Patients with other patterns are uniformly poor candidates for this procedure. Results are encouraging but preliminary because of the small number of patients. It appears that somnofluoroscopy is a reliable selection criterion for UPPP in patients with obstructive sleep apnea.

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.

Determining the site of airway collapse in obstructive sleep apnea with airway pressure monitoring

Twenty patients with obstructive sleep apnea (OSA) underwent complete polysomnography and simultaneous upper airway pressure monitoring with a custom‐made, soft silicone‐covered catheter measuring 2.3 mm in diameter. The catheter had four solid‐state microtip pressure sensors positioned in the posterior nasopharynx, immediately caudal to the tip of the uvula, at the level of the hyoid bone, and in the midesophagus. The level(s) of airway collapse was determined by changes in the pressure patterns between transducers. In 14 of the 20 patients, airway collapse was confined or initiated at the oropharyngeal region. The obstruction extended to the base of tongue in 7 and to the entire collapsible upper airway in 2 patients. Four patients had collapse at the base of the tongue and 2 had collapse at the hypopharynx. The site of airway collapse remained fairly constant through various sleep stages and positions. Uvulo‐palatopharyngoplasty (UPPP) and postoperative polysomnography were performed in 4 patients (2 with hypopharyngeal, 1 with base of tongue, and 1 with oropharyngeal airway collapse). Two patients had a favorable response to UPPP.

Further evaluation of uvulopalatopharyngoplasty in the treatment of obstructive sleep apnea syndrome.

Since its introduction in 1981 uvulopalatopharyngoplasty (UPPP) has become an alternative surgical approach to permanent tracheostomy in treating obstructive sleep apnea (OSA). However, the criteria for selecting candidates for this procedure are unclear and the prediction of a positive response remains an enigma. This article presents the experience with UPPPs performed on 35 patients who had moderate to severe OSA. Criteria for patient selection included apnea severity, cardiopulmonary sequelae, and clinical symptomatology. All but two patients demonstrated clinical improvement, although there was considerable variability in the degree of response. Patients were classified as good or poor responders on the basis of the severity index (SI), which represents the number of apneas and hypopneas per hour of sleep resulting in oxygen saturation below 85%. A greater than 50% improvement in the SI was considered a good response. Twenty-three patients (65.7%) were good responders and the remaining 12 (34.3%) were poor responders. The need for permanent tracheostomy was obviated In 16 of 32 patients presenting with disabling daytime sleepiness or severe cardiopulmonary sequelae. Therefore it appears that UPPP is useful for treating most OSA patients.

The Degree to Which Accuracy of Preoperative Staging of Laryngeal Carcinoma has been Enhanced by Computed Tomography

In this retrospective study, the accuracy of preoperative staging by high-resolution CT and clinical evaluation (indirect-direct laryngoscopy) is compared to the postsurgical pathologic staging of laryngeal cancer. Forty-two patients who were admitted to St. Louis University Hospital between the years of 1978 to 1985 with diagnoses of laryngeal cancer were included. All patients received high-resolution CT scan of the larynx preoperatively and subsequently underwent total or partial laryngectomy. None of these patients received preoperative radiotherapy. The accuracy of the clinical vs. CT staging—as well as the accuracy of the staging by combination of the two modalities—was determined by comparison with the postsurgical pathologic staging. The accuracy was assessed separately for glottic, supraglottic, and transglottic carcinoma. The accuracy of CT staging for glottic carcinoma was 75%. However, clinical evaluation in this group of lesions was very reliable, offering 92.9% accuracy. The accuracy of CT staging increased in the supraglottic and transglottic lesions, to become superior to the clinical staging. With combined information gained by both examinations, the preoperative staging accuracy was 91.4% for supraglottic carcinoma and 87.5% for transglottic carcinoma. It is, therefore, recommended that high-resolution CT should be included in the preoperative staging of laryngeal cancer.

Nasopharyngeal Complications Following Uvulopalatopharyngoplasty

This report presents our experience with nasopharyngeal complications of UPPP in 85 patients undergoing the procedure from May, 1982 to January, 1985. Three patients developed nasopharyngeal stenosis and one patient developed permanent velopharyngeal insufficiency. Surgical management in two patients with nasopharyngeal stenosis resulted in adequate nasopharyngeal airway, while one patient still has a moderate stenosis following two surgical procedures. The patient with velopharyngeal insufficiency underwent Teflon® paste injection in the posterior pharyngeal wall. This resulted in complete alleviation of his nasal regurgitation.

The surgical treatment of snoring: A patient's perspective

An increasing number of loud snorers seek medical attention because of the social impact of snoring as well as its association with sleep apnea. Uvulopalatopharyngoplasty is reported to reduce or eliminate snoring in the majority of patients; however, little data are available to document the procedures success.

Sphenoethmoidectomy: the case for ethmoid marsupialization

The authors report 510 sphenoethmoidectomics performed on 255 patients between 1969 and 1985. An overall polyp recurrence rate of 19.2% and less than a 1% complication rate are reported during that time. In patients followed jointly by the otolaryngologists and allergist, including 374 consecutive sphenoethmoidectomies on 187 patients who had this operation performed by the senior author, there was an overall polyp recurrence rate of 15% and a complication rate which was again less than 1%. Recent improvements in recurrence rates and diminished complication rates are attributed to better visualization and adherence to the concept of complete exenteration or marsupialization of the ethmoid labyrinth including middle turbinate resection in every case. Cooperation between the otolaryngologist and allergist is stressed, along with the realization that pulmonary and sinus diseases are frequently interrelated and may both be benefited by the performance of sphenoethmoidectomy in the patient with hyperplastic rhinosinusitis.