Jason L. Acevedo

Nonsurgical therapies for lymphangiomas: a systematic review.

Objective Systematically review the published literature regarding the efficacy of nonsurgical therapies in the treatment of head and neck (H&N) lymphatic malformations (LM) in children. Data Source MEDLINE. Review Methods MEDLINE was searched for literature relating to nonsurgical treatments for H&N LM. Results The initial search returned 1876 articles, with 22 meeting criteria. The majority (20) were case series. All therapies were percutaneous, with OK-432 or bleomycin sclerotherapy being most common. Random-effects modeling revealed 43% (CI = 28.9%-57%) of patients undergoing OK-432 for LM achieved a complete/excellent response, 23.5% (CI = 5.8%-41.3%) achieved a good response, 16.9% (CI = 10.3%-23.4%) achieved a fair/poor response, and 15.4% (CI = 8.6%-22.2%) observed no response. In the bleomycin group, the results were: 35.2% (CI = 15.7%-54.6%) excellent, 37.1% (CI = 22%-52.3%) good, 18.4% (CI = 2.7%-34.2%) fair/poor, and 11.6% (CI = 3.5%-19.6%) no response. Seven major complications were noted out of the 289 patients in the series, including two mortalities. Conclusions The literature indicates that sclerotherapy for H&N LM achieves excellent/good clinical response in a majority of patients, with few complications, and anecdotally does not complicate future surgery.

Systematic Review of Complications of Tonsillotomy versus Tonsillectomy

Objective. Intracapsular tonsillotomy continues to gain acceptance as an alternative to traditional tonsillectomy. Despite large clinical studies, there is a lack of consensus as to which technique offers lower complication rates. This study seeks to analyze the available data and surmise the complication rates of partial tonsillectomy as compared with traditional tonsillectomy. Data Sources. MEDLINE was searched using multiple search terms. Review Methods. After the MEDLINE search, the following inclusion criteria were applied: English language, human subjects, and related to partial tonsillectomy. Multiple tonsillotomy techniques were included. The results of these studies were summated and the results analyzed. Subgroup analysis was then performed. Results. Thirty-three studies met inclusion criteria. Tonsillotomy had a lower postoperative bleeding rate, lower postoperative dehydration rate requiring medical care, reduced days of analgesic use, and reduced days to return to normal diet compared with tonsillectomy. When separated into higher versus lower quality studies, the differences in bleeding and dehydration were negligible, while differences in return to diet and days of analgesic use persisted. Mean intraoperative blood loss was similar for both techniques. Insufficient data were available to assess tonsil regrowth rates. Conclusions. Tonsillotomy appears to be a safe technique that may offer some advantages over tonsillectomy in terms of postoperative morbidity, but differences in hemorrhage and dehydration were not evident in high-quality studies. Data regarding tonsil regrowth rates and efficacy in treating sleep-disordered breathing are not yet sufficient for formal analysis, which may preclude widespread acceptance of this technique.

Inferior turbinate classification system, grades 1 to 4: development and validation study.

To develop a validated inferior turbinate grading scale.

Maxillomandibular Advancement and Tracheostomy for Morbidly Obese Obstructive Sleep Apnea A Systematic Review and Meta-analysis

Objective The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m2) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes. Data Sources MEDLINE, Scopus, Web of Science, and the Cochrane Library. Review Methods A search was performed from inception through April 8, 2014, in each database. Results Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m2) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m2) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h (P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% (P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h (P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h (P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% (P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy (P = .0034). Conclusion Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.

The Effect of Tonsillectomy Alone in Adult Obstructive Sleep Apnea

Objective The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). Study Design Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. Setting Tertiary care medical centers within the US Department of Defense. Subjects and Methods Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. Results A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate—with subjects achieving at least a 50% reduction of AHI to a value <15—was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. Conclusions Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

Complications in Tonsillotomy: A Systematic Review

Objective: Intracapsular tonsillectomy (or tonsillotomy) is a technique rapidly gaining acceptance. Multiple individual clinical trials have been performed, but there remains no clear consensus as to how tonsillotomy compares to traditional methods in regard to complication rates. The purpose of this study is to compile and critically analyze this data. Method: MEDLINE was searched using multiple search terms, with the following inclusion criteria: English language, human subjects, and related to complications of tonsillotomy. Multiple tonsillotomy techniques were included. The results of these studies were summated, and the results were analyzed. Random effects modeling was used to calculate summary effect measures. Results: Thirty-three studies met inclusion criteria. The bleeding rate for tonsillectomy was 3.4% (P < .01, 95% CI=0.027-0.041, k=23) with a dehydration re-visit rate of 3.4% (<0.01, 0.018-0.049, 13). For tonsillotomy, the rates were 1.5% (<0.01, 0.012-0.017, 31) and 1.4% (<0.01, 0.006-0.022, 17), respectively. When stratifying for tonsillotomy technique, the rates were 1.5% (<0.01, 0.014-0.017, 5) and 1.5% (<0.01, 0.014-0.017, 4) for coblation and 0.8% (<0.01, 0.006-0.01, 15) and 1.7% (<0.01, 0.007-0.026, 10) for microdebrider. Number of days receiving analgesia was 7.045 (<0.01, 6.31-7.76, 5) for tonsillectomy and 4.09 (3.19-4.99, 7) for tonsillotomy. There was no difference in blood loss between groups. Conclusion: Tonsillotomy appears to compare favorably with tonsillectomy and may offer a reduction in postoperative complications (bleeding and dehydration), as well as less use of analgesics. Subgroup analysis suggests that microdebrider tonsillotomy may have a lower bleeding rate than the coblation technique.

08:44: Nonsurgical Therapy of Lymphangioma: A Systematic Review

modality, success rates for endoscopic management included 3/3 (100%) for Grade 1 stenosis, 6/9 (67%) for Grade 2 stenosis, and 11/19 (58%) for Grade 3 stenosis. For the 35 children who had LTR with restenosis, 27/35 (77%) were successfully treated with endoscopic management without need for revision LTR. CONCLUSIONS: Endoscopic management of SGS in certain cases may avoid an open laryngotracheal reconstructive procedure, especially for less severe stenosis.