Hasan Tanyeri

Clinical predictors of obstructive sleep apnea.

Objective: To identify physical findings that can be standardized to predict the presence and the severity of obstructive sleep apnea (OSA).

Effect of improved nasal breathing on obstructive sleep apnea

OBJECTIVES The goal was to compare the effect of an improved nasal airway on obstructive sleep apnea (OSA) by use of subjective and objective measures. METHODS A prospective study of 50 consecutive patients with nasal airway obstruction and OSA was carried out. RESULTS Subjectively, nasal breathing improved in 49 (98%) patients, whereas snoring decreased or disappeared in 17 (34%); the remaining 33 (66%) patients did not notice any significant change in their snoring. Daytime energy levels increased in 39 (78%) patients and remained unchanged or worsened in 11 (22%). In review of the polysomno-graphic data, the group overall did not have significant changes in respiratory disturbance index (RDI) or lowest oxygen saturation levels (LSaO2). Continuous positive airway pressure (CPAP) levels required to correct OSA decreased after nasal surgery (P < 0.01). Patients with mild OSA showed significant worsening in RDI (P < 0.05), whereas LSaO2 levels were improved in the group with moderate OSA (P < 0.05). In patients with severe OSA neither the RDI levels nor the LSaO2 changed, but CPAP levels required to alleviate the obstruction after surgery were reduced (P < 0.01). CONCLUSIONS Most patients report improvement in nasal and sleep symptoms after correction of nasal airway obstruction. However, nasal surgery alone does not consistently improve OSA when measured objectively. Depending on the severity of OSA, nasal airway reconstruction may contribute to a decrease in CPAP level and improvement in oxygen saturation. Correction of the obstructed nasal airway should certainly be included in the overall treatment plan for OSA. (Otolaryngol Head Neck Surg 2000;122:71–4.)

A Safe, Alternative Technique for Inferior Turbinate Reduction

Objective: Submucous resection of the inferior turbinates is a conventional technique for reducing their size to achieve patent nasal airways in situations where an enlarged turbinate contributes to airway obstruction. Many techniques and complications have been described in the past. We describe a new inferior turbinate reduction technique performed with powered instrumentation and assess its success and complication rates.

Histological evidence for hair cell regeneration after ototoxic cell destruction with local application of gentamicin in the chinchilla crista ampullaris.

Two experiments were conducted to study the ototoxic effects of local gentamicin (GM) administration and the subsequent hair cell (HC) regeneration process in the chinchilla cristae ampullares (CA). In the first experiment, 3 different doses of GM (0.1, 0.2 and 1.2 mg) were administered by surgical implantation of GM-soaked Gelfoam pledgets in the perilymphatic space in the otic capsule of the left superior semicircular canal. The CA was histologically processed for light-microscopic examination. In the second experiment, 6 groups of 2 chinchillas each were treated with 0.1 mg of GM. To document cell proliferation and HC regeneration, Alzet micro-osmotic pumps were implanted in each chinchilla to deliver bromodeoxyuridine (BrdU) at 125 micrograms/h for 1 week. Chinchillas were subsequently killed at 1 and 4 days and 1, 2, 4 and 8 weeks post-treatment (PT). The CA was processed for light microscopy and BrdU immunocytochemistry. In the first experiment the smallest dose produced damage restricted to HCs alone, while the medium and large doses produced severe damage in the sensory epithelium, including supporting cells and HCs. Results in the second experiment demonstrated that at 1 and 4 days PT the HCs showed extensive damage, including clumping of nuclear material. By 4 days PT the supporting cell nuclei lost their monolayer configuration. Calyceal terminals appeared empty, and vacuolized remnants of nerve calyces were evident in the basal portion. At 1 week PT complete disappearance of HCs from the sensory epithelium was evident, and there was cytoplasmic extrusion into the endolymphatic space. At 2 weeks PT there was complete HC loss, the supporting cell nuclei were scattered randomly in the crista, and the nerve fibers were retracted from the sensory epithelium. At 4 weeks PT there was evidence of sensory epithelium repair and HC regeneration. Short cells resembling type-II HCs were evident in the surface of the sensory epithelium. At 8 weeks PT the number of HCs increased in a uniform fashion on the surface of the sensory epithelium, and the supporting cell nuclei were realigned on the basal membrane. Nerve fibers with growth cones penetrated the basal membrane. Supporting cell proliferation was evident by the presence of mitotic figures and BrdU immunoreactivity in the chromatin material of dividing cells at 2 weeks PT. The labeling was more evident in newly formed cells at 4 and 8 weeks PT. These results demonstrate that in chinchillas the vestibular organs have the capacity of self-repair and the process includes HC regeneration after local administration of GM. The overall process involves changes in different cells in the sensory epithelium and neural elements, all of which show modifications with an orderly pattern.

Middle turbinate medialization and preservation in endoscopic sinus surgery.

OBJECTIVE/HYPOTHESIS: Lateral synechia formation between the middle turbinate (MT) and the lateral nasal wall is the most common complication of endoscopic sinus surgery. In an attempt to prevent this complication, a simple technique to preserve and medialize the MT was studied. METHODS: Five hundred patients underwent endoscopic sinus surgery with MT medialization and preservation. The caudal end of the MT and the opposing septal mucosa were abraded with a microdebrider for controlled synechia formation in an attempt to avoid lateralization of the MT. Follow-up ranged from 6 to 18 months, with a mean follow-up of 10 months. RESULTS: Ninety-three percent of the patients had successful MT medialization with a well-defined synechia between the septum and the MT. CONCLUSIONS: MT medialization with a microde-brider is simple, is reliable, and should be considered an alternative to turbinate resection or to other turbinate medialization techniques.

Intraoperative and postoperative assessment of frontal sinus patency by transillumination.

INTRODUCTION Transillumination of the paranasal sinuses was once considered an adjunctive technique in the diagnosis of sinus disease, but it has been replaced by modern diagnostic techniques that are far more accurate. Even when used, however, transillumination was limited to the maxillary and ethmoid sinuses only.1 Even with perfectly healthy sinuses, frontal sinus transillumination does not occur if the frontal sinus has not been operated on. The use of frontal sinus transillumination as an aid to intraoperative or postoperative identification of the frontal sinus has never been popularized. Endoscopic sinus surgery has evolved to include the frontal sinuses. Often, the novice frontal sinus surgeon, and sometimes even the experienced frontal sinus surgeon, needs to differentiate an agger nasi cell,2 a frontal cell,3 a supraorbital cell, or a high superior attachment of the uncinate process (terminal recess)4 from the frontal sinus. In the early years of frontal sinus surgery, intraoperative cross table lateral radiographs or fluoroscopy was recommended to differentiate these cells from the frontal sinus and to confirm that the frontal sinus was opened. Currently, image-guided technology is often used to confirm the location of the frontal sinus. We have used frontal sinus transillumination in more than 200 cases of frontal sinus surgery and have found transillumination to be 100% accurate in differentiating the frontal sinus from its neighboring cells. Although the frontal sinus can be identified with 30° or 70° telescopes once it is opened and cleaned of polyps and secretions, early identification of the sinus before removal of obstructing cells is sometimes difficult. The access to the frontal sinus at this point is inadequate for visualization but is adequate for transillumination. Postoperative examination to assess the patency of the frontal sinus can also be difficult because an open cell may be one of the “neighboring cells” rather than the frontal sinus. We have used frontal sinus transillumination to confirm a patent frontal sinus (Fig. 1). Transillumination is either positive with an open sinus or completely negative if an obstruction has recurred. Only one study has been published that describes frontal sinus transillumination to verify patency.5 However, in that study transillumination was used to verify the patency of connected frontal sinuses after endoscopic Lothrop procedure. We suggest that an exposed natural frontal ostium is all that is needed to efficiently transfer transillumination.

Frontal Sinus Surgery : Endoscopic Technique and Preliminary Results

Endoscopic frontal sinus surgery, once the last frontier in the evolution of endoscopic sinus surgery. is considered difficult, risky to the patient. and likely to result in a high failure rate. We clarify the surgical anatomy for frontal sinus surgery that, based on a review of our data, provides safe and predictable access to the frontal sinus. We studied 200 consecutive patients with respect to indications, endoscopic and radiographic findings, results. and complications. The study will describe the technique in detail, including the following points: 1) computed tomography identification of the superior attachment of the uncinate process; 2) complete removal of the uncinate process, including its superior attachments, by using the microdebrider; 3) removal of the agger nasi cell, if present; and 4) verification of an open frontal sinus by a transillumination or image-guided system. Postoperative assessment of patients’ symptoms and the confirmation of a patent frontal sinus by office endoscopy and transillumination indicated a 90% patency for short-term follow-up (average 12.2 months). There were no major complications. Postoperative complications included frontal recess stenosis, polypoid mucosa occluding the frontal recess, and middle turbinate lateralization. All of these situations may lead to recurrence of infection and symptoms. In-depth understanding of anatomic variations of the uncinate process and precise surgical removal of its superior attachments provide surgical access to the frontal sinus that is based on the natural ostia and is, therefore, more likely to remain patent.

Effects of Middle Turbinate Medialization on Olfaction

Objective/Hypothesis: Turbinate medialization techniques have gained popularity in an attempt to prevent turbinate lateralization. Theoretically, adhesions between the septum and middle turbinate will prevent lateralization but may compromise airflow to the olfactory neuroepithelium and affect the sense of smell. No studies have addressed this issue. The objective of this study is to evaluate effects of middle turbinate medialization on olfaction.

Experience with percutaneous dilational tracheostomy.

Percutaneous dilational tracheostomy (PDT) has gained popularity among critical care specialists in the past 10 years. The initial studies in our specialty resulted in essentially banning the procedure as a dangerous substitute for standard operative tracheostomy. Despite this action, more than 1,100 cases of percutaneous tracheostomy have been reported with details on complications. We reviewed all published data and studied 311 patients of our own. A prospective study was performed in 3 groups of patients: 1) 50 patients scheduled for PDT performed in the operating room by a head and neck surgeon (group 1); 2) 50 patients who underwent standard operative tracheostomy performed by the same surgeon (group 2); and 3) 211 patients who underwent bedside PDT by critical care physicians (group 3). The intraoperative complication rates were 0% in group 1, 2% in group 2, and 4% in group 3; the postoperative complication rates were 13%, 4%, and 12%, respectively. There were 2 deaths in group 3, and none in groups 1 or 2. The statistically significant differences among the groups were the superiority of group 1 over group 3 in intraoperative complications, as well as the lower postoperative complication rate of the standard tracheostomy group. These results show that PDT can be performed with acceptable morbidity rates in relation to published complication rates of standard tracheostomy, but it has no advantage over standard tracheostomy with respect to postoperative morbidity. When they are performed by a head and neck surgeon, the morbidity associated with both standard and percutaneous tracheostomies can be reduced.

Juvenile xanthogranuloma of the tongue.

He reported a gradual increase in the size of the lesion, which was visible when he opened his mouth and protruded his tongue. He denied dysphagia, odynophagia, difficulty breathing, weight loss, and pain. His medical history was significant for pulmonary tuberculosis as a child. He had not had any surgeries in the past. He did not use any medications. He did not smoke or drink alcohol. Oropharyngeal examination revealed a 1 × 1.5 cm sessile mass covered with normal mucosa on the left posterolateral tongue (Fig 1). On palpation, the lesion was soft and nontender. Laryngeal examination showed erythema of the left aryepiglottic fold and left false vocal cord. Neck examination showed bilateral posterior hypopigmented scars. There was no mass or adenopathy. The rest of the examination was unremarkable. The patient underwent triple endoscopy and excisional biopsy of the mass. The wound healed well, and there was no evidence of recurrence at the 1-month follow up. The pathologic diagnosis was juvenile xanthogranuloma (JXG). A histopathologic section is shown (Fig 2).