Hani Ibrahim

Clinical staging for sleep-disordered breathing

OBJECTIVE: The purpose of this study was to identify prognostic indicators that would lead to stratification of patients likely to have successful surgery for sleep-disordered breathing (SDB) versus those destined to fail. STUDY DESIGN: We retrospectively reviewed 134 patients to correlate palate position and tonsil size to the success of the UPPP as based on postoperative polysomnography results. Similar to our previously published data on the Friedman Score as a predictor of the presence and severity of SDB, the palate position was determined on physical examination of the oral cavity and was graded for each patient. This grade combined with tonsil size was used to stage the patients. Stage I was defined as having palate position 1 or 2 combined with tonsil size 3 or 4. Stage II was defined as having palate position 3 or 4 and tonsil size 3 or 4. Stage III patients had palate position 3 or 4 and tonsil size 0, 1, or 2. Any patient with body mass index of greater than 40 was placed in the stage III group. The results of uvulopalatopharyngoplasty (UPPP) were then graded as success or failure and success rates were compared by stage. SETTING: Academically affiliated tertiary care referral center. RESULTS: Stage I patients who underwent UPPP had a success rate of 80.6%, stage II patients had a success rate of 37.9%, and stage III patients had a success rate of 8.1%. CONCLUSION: A clinical staging system for SDB based on palate position, tonsil size, and body mass index is presented. It appears to be a valuable predictor of the success of UPPP. Additional studies and wider use of the staging system will ultimately define its role in the treatment of SDB.

Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment†

Objective Early studies by Friedman et al. have demonstrated the value of staging obstructive sleep apnea/hypopnea syndrome (OSAHS) patients for the prediction of success for uvulopalatopharyngoplasty (UPPP) on the basis of short‐term follow up. The goal of this study is to test the value of this staging system in a prospective study.

Percutaneous Endoscopic Gastrostomy: Strategies for Prevention and Management of Complications

Objective The placement of percutaneous endoscopic gastrostomy (PEG) tubes is within the realm of the head and neck surgeon because most are proficient in the use of rigid and flexible esophagoscopes. The ability to provide comprehensive care for the patient with head and neck cancer provides further incentive for the head and neck surgeon to adopt this technique. Although it is a technically simple procedure, the surgeon must be aware of the range of complications that can occur with PEG. We review our experience with PEG focusing on the complications as well as strategies for the prevention and management of these complications.

Combined Uvulopalatopharyngoplasty and Radiofrequency Tongue Base Reduction for Treatment of Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE: In this study, we compare the objective results of uvulopalatopharyngoplasty (UPPP) combined with tongue base radiofrequency reduction (TBRF) with standard UPPP treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS). STUDYDESIGN: We conducted a retrospective study of 277 patients who had stage I, II, or III OSAHS based on the Friedman staging system previously presented. METHODS: One hundred thirty-four patients who had treatment with UPPP only were used as a control group. This included 31 patients with stage I, 29 patients with stage II, and 74 patients with stage III OSAHS. An additional 143 patients with Stage II (n = 52) and III (n = 91) OSAHS were treated with combined UPPP and TBRF, initially and followed by additional TBRF treatments (up to 9000 J) as necessary. Subjective results were collected based on questionnaires and the Epworth Sleepiness Scale score for the experimental group, but these subjective measures were not available for the control group. Objective results were compared based on the polysomnographic findings before and after surgery. RESULTS: Subjectively, the study group did extremely well. Based on objective measures of successful treatment, UPPP plus TBRF resulted in a significantly higher percentage of patients who were “cured” of OSAHS compared with the control group. CONCLUSIONS: Stage I patients were usually successfully treated with UPPP only. However, patients allocated to stage II or III will benefit from the addition of TBRF to standard UPPP. Many UPPP-plus-TBRF patients in this study aborted further recommended TBRF treatments after subjective improvement and therefore objective results for this group, although improved in comparison to stage II and III patients treated with UPPP only, may not represent maximal potential improvement.

Radiofrequency Tonsil Reduction: Safety, Morbidity, and Efficacy

Objectives To evaluate the safety, morbidity, and efficacy of radiofrequency tissue volume reduction of tonsils using two different surgical techniques and to compare these two techniques with each other and with classic tonsillectomy.

Z-palatoplasty (ZPP): A technique for patients without tonsils

OBJECTIVE: Patients without tonsils and with Friedman tongue position (FTP) III and IV are poor candidates for uvulopalatopharyngoplasty (UP3). Even when combined with adjunctive hyopharyngeal techniques, results are poor. We assessed a modified uvulopalatoplasty based on a bilateral Z-plasty in treating patients without tonsils who have obstructive sleep apnea/hypopnea syndrome (OS-AHS). METHODS: 25 patients treated with a modified technique were matched with 25 patients previously treated with classic UP3. All patients in both groups also had radiofrequency tongue base reduction. Preoperative vs. postoperative measures of objective treatment success and subjective symptoms were compared for the 2 groups. Morbidity, including pain levels, narcotic use, and return to solid diet and normal activity, as well as complications were studied. RESULTS: Subjective improvement was good for both groups, but objective clinical improvement was significantly better for the experimental group. Morbidity and complications for the experimental group were comparable to the control group and to other published series on UP3. CONCLUSIONS: A modified technique for patients without tonsils who have OSAHS is presented. The new technique is more successful with acceptable morbidity for patients with OSAHS than classical techniques.

Inferior Turbinate Flap for Repair of Nasal Septal Perforation

INTRODUCTION Many surgical techniques are available for surgical repair of nasal septal perforations. The variety of techniques is evidence that no single technique is recognized as being uniformly reliable in closing all perforations. In fact, most perforations remain unclosed because available closure techniques are technically difficult and require training and experience to master. Many authors have described high success rates with their techniques, but these results are not reproducible by all surgeons. We have found success using the inferior turbinate as a composite flap as an option that may be helpful in selected cases. It is not to be presented as a replacement to currently accepted standard techniques using advancement flaps, but certainly may be an option in caudal septal perforations when advancement techniques are more difficult.

Allograft dermal implant (AlloDerm) in a previously irradiated field.

Objective To evaluate the integration of AlloDerm (LifeCell Corp., The Woodlands, TX) in a field exposed to external‐beam radiation (EBR) by analyzing graft thickness, fibroblast recellularization, and neovascularization.

Nasal valve suspension: an improved, simplified technique for nasal valve collapse.

INTRODUCTION Nasal valve collapse is a common cause of nasal airway obstruction. The valve area is commonly weakened secondary to rhinoplasty, aging, trauma, and other causes. The complexity of nasal valve repair techniques and its variable results combined with the fact that patients with valve collapse have often had previous surgery or are of advanced age are some of the reasons that this problem often goes untreated. Often, the problem is not even diagnosed until surgical treatment, such as septoplasty or turbinate reduction, has failed to correct the patient’s symptoms of nasal airway obstruction. Paniello published a preliminary report on 12 patients in which a simplified technique for nasal valve repair was used that involved suspension of the valve to the orbital rim. His technique was shown to be effective in improving the nasal airway. Since 1997, we have used this technique in more than 100 patients with significant modifications that will be described. The modified technique is simpler, safer, and equally effective. It is based on the use of a soft-tissue bone-anchor system that provides a simplified support of the valve area to the orbital rim.

The Occurrence of Sleep-Disordered Breathing Among Patients With Head and Neck Cancer†

Objective To identify the incidence of obstructive sleep apnea (OSA) in patients treated for head and neck cancer. Obstructive sleep apnea is a relatively common and highly morbid condition that affects 9.1% of male and 4% of female middle‐aged adults. 1 Patients who have been successfully treated for head and neck cancer may often have a partially obstructed upper airway which is functional during the day, but collapses during sleep.