Hayriye Karabulut

Low-Temperature Bipolar Radiofrequency Ablation (Coblation) of the Tongue Base for Supine-Position-Associated Obstructive Sleep Apnea

Objective: To assess the effectiveness of low-temperature bipolar radiofrequency ablation for Coblation of the tongue base in the multilevel management of supine-position-associated obstructive sleep apnea syndrome (OSAS). Study Design and Setting: A retrospective analysis of the data of 16 subjects undergoing uvulopalatopharyngoplasty and tongue base Coblation. The efficacy of the procedure was investigated on the basis of polysomnographic results. Results: The success rate was 62.5% in 16 patients who underwent surgery for OSAS, with decreases in the mean Apnea Hypopnea Index of 20.1–8.9. The success rate was separately evaluated according to the subjects’ posture. A rate of 87.5% was found for the supine position, while the rate was 56.6% in non-supine positions. The minimum postoperative O2 saturation was significantly increased for REM and non-REM stage 3 sleep rates. Conclusion: It is important to evaluate the relation of the disease to the body position in sleep apnea subjects. Coblation of the tongue base is an applicable method of therapy for patients who have sleep apnea that is more marked in the supine position.

Sensorineural hearing loss in pediatric celiac patients

OBJECTIVEnCeliac disease (CD) is an immune-mediated chronic inflammatory gluten-dependent intestinal disease affecting 0.5-1% of the general population worldwide. CD is underdiagnosed even with sophisticated health care; approximately 10% of people affected by CD are now diagnosed. The recognition of the atypical extra-intestinal manifestations, including neurological disorders increased the diagnosis of CD. At present, no data are available on the presence of sensorineural hearing loss in pediatric CD patients. The aim of this study was to determine the incidence and severity of sensorineural hearing loss (SNHL) in different frequencies in pediatric CD patients.nnnMETHODSnA sample of 32 biopsies and serologically proven newly diagnosed pediatric CD patients (CD group) (64 ears) and 32 sex and age-matched healthy subjects (64 ears) as control group (C group) were included in this study. Anthropometric measurements, physical examinations including ear nose and throat and pure-tone audiometry at frequencies 250-8000 Hz were performed in all subjects in both groups. Slight/mild SNHL was defined as a loss of detection of sound within the 16-40 dB range. The mean age of patient and control group was 11.9 and 11.3, respectively (p>0.05).nnnRESULTSnIn CD group, sensorineural hearing loss was found in 13 (40.6%) patients (group A) as it was bilateral in six and unilateral in seven patients. In control group (group C), slight/mild SNHL was found in one (3.1%) subject. The frequency of hearing loss was significantly higher in CD group than in group C (p<0.001).nnnCONCLUSIONnThe present study showed a higher prevalence of sensory neural hearing loss in pediatric celiac patients than in healthy controls, suggesting an association between CD and SNHL. The findings of this study suggest that hearing impairment should be searched in newly diagnosed pediatric CD patients. Further longitudinal investigations on a larger sample size will be necessary to confirm the present data and to search the immunological processes which could be the basis of the association between CD and SNHL.

Audiological findings in celiac disease.

Objective: Celiac disease (CD) is a gluten-triggered immune enteropathy caused by a genetic predisposition. Recent papers suggest that CD is increasingly recognized by extraintestinal findings. The aim of this study was to investigate the effect of CD on hearing pathway including the olivocochlear efferent system in children. Methods: Forty-one pediatric CD patients and 31 controls were included in the study. Both groups were evaluated with audiometry, tympanometry, transiently evoked otoacoustic emission (TEOAE), distortion product otoacoustic emission (DPOAE), and contralateral suppression of the TEOAE. Results: The threshold at 250 Hz of the patients with CD was significantly higher (p < 0.05 in CD compared to control group, p < 0.0001). The signal to noise ratio (SNR) amplitudes in DPOAE testing and the SNR amplitudes with and without contralateral acoustic stimulus in TEOAE testing were significantly lower at 1,000 Hz in the CD compared to the control group. There was no significant difference between the CD and the control group regarding contralateral suppression amplitudes. Conclusion: CD seems to have an important impact on the auditory system, and results in an elevation of the thresholds at 250 Hz on audiometry and a decrease in the amplitudes of DPOAE and linear TEOAE at 1,000 Hz in children.

In Reference to Effectiveness of Adenotonsillectomy in the Resolution of Nocturnal Enuresis Secondary to Obstructive Sleep Apnea

We with great interest the article by Suzanne Basha et al.1 In this article, the authors reports the role and efficacy of adenotonsillectomy in the treatment of nocturnal enuresis secondary to obstructive sleep apnea on 107 patients. As noted by the authors, patients with obstructive sleep apnea are common in the practice of otolaryngologists. Obstructive sleep apnea may result in significant hypercapnia and hypoxemia, as well as daytime sleepiness, irritability, hyperactivity, behavioral problems, personality changes, poor school performance, morning headaches, failure to thrive, and enuresis.2 Nocturnal enuresis is defined as involuntary voiding more than twice a month after the age of 4 to 6 years without the presence of urogenital defects,3 and is typically divided into the categories of primary and secondary. Primary enuresis occurs when a child has never developed bladder control; this occurs in 80% of cases. Secondary enuresis is the loss of bladder control after a 6-month dry period.3 Both forms of nocturnal enuresis have occurred in relation to upper airway obstruction in children.4,5 Bedwetting occurs in up to 20% of school-aged children, with 2.4% wetting at least nightly.6 Children tend to outgrow bedwetting, with a spontaneous remission rate of about 14% annually among bedwetters (with 3% remaining enuretic as adults).7 The authors reported that they included all children ages 2 to 18 in the study. Patients age 2 to 5 years old composed about 40% of all patients in their study, as shown in Figure 1, which depicts the age distribution of the patients. However, the patients who were ages 2 to 5 years may have been evaluated as physiological enuresis and should not have been included in the study. Also, the authors should have included a control group for excluding the spontaneous remission rate of about 14% annually among bedwetters.

Multilevel surgery in patients with rapid eye movement-related obstructive sleep apnea

Dr Shemen and colleagues report their experience with Ethicon Endo-Surgery Harmonic ACE (ACE23E model) in thyroid surgery. They also state that our paper, “Modified lateral neck lymphadenectomy: Prospective randomized study comparing harmonic scalpel with clamp-and-tie technique,” failed to mention the potential pitfalls of this device. We would like to point out that the ACE23E model was never mentioned in our paper. All the patients were operated on by a different device, the Harmonic Scalpel CS14C. These shears were designed for videoscopic surgery of the neck, with a 5-mm tip. Their application to lateral neck lymphadenectomy seemed therefore to be a natural evolution in the field of neck surgery. There is an important difference, in fact, between ACE23E and CS14C in terms of coagulation power, the first one being more powerful than the latter. As an obvious consequence, residual heat generated by ACE23E will be higher and more hazardous than that generated by CS14C. For this reason we agree with Dr Shemen’s concern about the use of ACE23E model during thyroid surgery, especially for new users switching from conventional to “energy” techniques. As Dr Shemen found in his previous study, and as we confirmed later, Harmonic Scalpel CS14C can be considered safe, effective, and advantageous in thyroid surgery, significantly reducing operative time, allowing a shorter incision, and minimizing intraoperative and postoperative blood loss. In our study, we found similar results when dealing with neck lymphadenectomy, thus confirming the safety and effectiveness of this device (CS14C) in head and neck surgery. On the other hand, in using ACE23E (probably more useful and effective in abdominal than in head and neck surgery) instead of CS14C during our routine activity, we also encountered the same problems evidenced by Dr. Shemen: burning of adjacent tissues and fracture of the instrument in two cases. The potential hazard of the shears temperature was so evident to the surgical community that a new instrument with different characteristics was recently developed for a specific use in thyroid surgery: Harmonic FOCUS Shear (Ethicon Endo-Surgery Inc, Cincinnati, OH). One of the main differences is that the shears are aluminum, a material that allows much speedier heat dispersion. This makes it possible to dissect, coagulate, and divide vessels with a single instrument, because the hazard of high residual heat is dramatically reduced. Paolo Miccoli, MD Gabriele Materazzi, MD Piero Berti, MD Department of Surgery, University of Pisa Pisa, Italy E-mail, gmaterazzi@yahoo.com

In reference to tacrolimus: a new option in therapy-resistant chronic external otitis.

We read with great interest the paper by Phillip P. Caffier, et al. entitled “Tacrolimus: a new option in therapy-resistant chronic external otitis.”1 In this paper, the authors report the role and efficacy of tacrolimus in the treatment of therapy-resistant chronic external otitis in 53 patients. Literature on this treatment is scarce. As noted by the authors, external otitis (EO) is one of the most frequent and painful diseases in otorhinolaryngologic practice worldwide.2 In the majority of cases, EO is a nonspecific diffuse inflammation of bacterial, viral, mycotic, or allergic origin. Eczematous integument changes of the acoustic meatus have an important role to play in an individual’s predisposition.3 The standard therapy consists of a local application of corticosteroids, antibiotics, or antimycotics,4 but some patients continue to have symptoms despite treatment. Various medications are used for the treatment of therapy-resistant chronic external otitis without consensus in the literature. For this reason, this study is important as it shows the efficacy of tacrolimus in treatment. Assessing the severity of pruritus is difficult because of its subjective nature. A questionnaire that takes into account how the symptom is perceived by the patient may provide a more accurate representation of the pruritus. It is difficult to evaluate the severity of symptoms because there is no known scale to measure the severity. In this study, the authors reported that they have measured the severity of symptoms on a score of 1 to 6, and the analysis of the efficacy of the treatment is according to this score. But there is no detailed information or any reference about the score. We think that in such a study, one should use more objective criteria to measure the severity. There are various new itch severity questionnaires in the literature. For example, a modified itch severity scale could be used that consists of more objective criteria such as health-related quality of life scores.5,6