Kasey Li

Adenotonsillectomy and obstructive sleep apnea in children: A prospective survey

Objective Prospective survey of children up to 14 years of age with OSA submitted to adenotonsillectomy. Methods Clinical evaluation, with questionnaires and clinical scales evaluating facial structures including tonsils and Mallampati scales and otolaryngologic evaluation; nocturnal polysomnography and repeat evaluation three to five months postsurgery. Results Of 207 successively seen children, 199 had follow-up polysomnography, and 94 had still abnormal sleep recording. Multivariate analysis indicates that Mallampati scale score 3 and 4, retro-position of mandible, enlargement of nasal inferior turbinates at +3 (subjective scale 1 to 3), and deviated septum were significantly associated with persistence of abnormal polysomnography (with high 95% CI for Mallampati scale and deviated septum). Conclusion Mallampati scale scores are resultant of several facial factors involving maxilla, mandible, and oral versus oral breathing but add information on risk of partial response to adenotonsillectomy. Significance Adenotonsillectomy may not resolve obstructive sleep apnea in children.

Radiofrequency Treatment of Turbinate Hypertrophy in Subjects Using Continuous Positive Airway Pressure: A Randomized, Double‐Blind, Placebo‐Controlled Clinical Pilot Trial

Objectives To estimate the treatment effect of temperature‐controlled radiofrequency (TCRF) reduction of turbinate hypertrophy in patients with sleep‐disordered breathing (SDB) treated with nasal continuous positive airway pressure (CPAP), and to assess the impact of study design on this estimate.

The road to danger : The comparative risks of driving while sleepy

Objectives/Hypothesis A large sector of the population of the United States has sleep deprivation directly leading to excessive daytime sleepiness. The prevalence of excessive daytime sleepiness in this population ranges from 0.3% to 13.3%. The consequences of even 1 to 2 hours of sleep loss nightly may result in decrements in daytime functions resulting in human error, accidents, and catastrophic events. The magnitude of risks in the workplace or on the highways resulting from sleepiness is not fully understood or appreciated by the general population. Hence, to more clearly emphasize the magnitude of these risks, we question whether mild sleep deprivation may have the same effect as alcohol on reaction times and driving performance.

Sleepy Driving: Accidents and Injury

OBJECTIVE: The study goals were to evaluate the associated risks of driving and to assess predictors of accidents and injury due to sleepiness. STUDY DESIGN: A cross-sectional Internet-linked survey was designed to elicit data on driving habits, sleepiness, accidents, and injuries during the preceding 3 years. Statistical analysis included logistic models with covariate-adjusted P values of <0.01 (odds ratios and 95% confidence intervals or limits). Independent accident predictors were sought. RESULTS: Responses from 10,870 drivers were evaluated. The mean ± SD age was 36.9 ± 13 years; 61% were women and 85% were white. The Epworth Sleepiness Scale overall baseline score was 7.4 ± 4.2 (for drivers with no accidents) and ranged to 12.7 ± 7.2 (for drivers with ≥ 4 accidents) (P = < 0.0001). Twenty-three percent of all respondents experienced ≥ 1 accident. Among respondents who reported ≥ 4 accidents, a strong association existed for the most recent accident to include injury (P < 0.0001). Sleep disorders were reported by 22.5% of all respondents, with a significantly higher prevalence (35%, P = 0.002) for drivers who had been involved in ≥ 3 accidents. CONCLUSION: Factors of sleepiness were strongly associated with a greater risk of automobile accidents. Predictors were identified that may contribute to accidents and injury when associated with sleepiness and driving.

Adeno-tonsillectomy and rapid maxillary distraction in pre-pubertal children, a pilot study

IntroductionWhen both narrow maxilla and moderately enlarged tonsils are present in children with obstructive sleep apnea, the decision of which treatment to do first is unclear. A preliminary randomized study was done to perform a power analysis and determine the number of subjects necessary to have an appropriate response. Thirty-one children, 14 boys, diagnosed with OSA based on clinical symptoms and polysomnography (PSG) findings had presence of both narrow maxillary complex and enlarged tonsils. They were scheduled to have both adeno-tonsillectomy and RME for which the order of treatment was randomized: group 1 received surgery followed by orthodontics, while group 2 received orthodontics followed by surgery. Each child was seen by an ENT, an orthodontist, and a sleep medicine specialist. The validated pediatric sleep questionnaire and PSG were done at entry and after each treatment phase at time of PSG. Statistical analyses were ANOVA repeated measures and t tests.ResultsThe mean age of the children at entry was 6.5u2009±u20090.2xa0years (mean ± SEM). Overall, even if children presented improvement of both clinical symptoms and PSG findings, none of the children presented normal results after treatment 1, at the exception of one case. There was no significant difference in the amount of improvement noted independently of the first treatment approach. Thirty children underwent treatment 2, with an overall significant improvement shown for PSG findings compared to baseline and compared to treatment 1, without any group differences.ConclusionThis preliminary study emphasizes the need to have more than subjective clinical scales for determination of sequence of treatments.

SURGICAL MANAGEMENT OF THE HYPOPHARYNGEAL AIRWAY IN SLEEP DISORDERED BREATHING

The etiology of sleep disordered breathing is collapse or obstruction of the upper airway during sleep. This obstruction may be localized to one or two areas or may encompass the entire upper airway passages to include the nasal cavity, nasopharynx, oropharynx, hypopharynx, and larynx. The presurgical evaluation, which includes polysomnography, a comprehensive head and neck physical examination, fiberoptic nasopharyngoscopy, and lateral cephalometric analysis is essential in directing surgical therapy in a site specific approach. The surgical procedures available to address hypopharyngeal and base of the tongue collapse include inferior sagittal mandibular osteotomy and gengioglossus advancement, hyoid myotomy and suspension, laser midline glossectomy, lingualplasty, partial glossectomy, and maxillomandibular advancement surgery. The Riley-Powell-Stanford Surgical Protocol has proven to be an effective and safe method for controlling upper airway collapse in sleep disordered breathing.

Long-term results of surgical management of sleep disordered breathing: are our patients really benefiting?

The etiology of sleep disordered breathing (SDB), which includes upper airway resistance syndrome (UARS) and obstructive sleep apnea syndrome (OSAS), is collapse or obstruction of the upper airway during sleep. Surgical management was the first treatment modality available for SDB. Since the introduction of the tracheotomy to treat OSAS, there have been numerous procedures discovered to address the various sites of obstruction of the upper airway. This article reviews the long-term surgical results and may improve ones insight into the successes of surgical therapy for SDB.

Endoscopically-Assisted Surgical Expansion (EASE) for the Treatment of Obstructive Sleep Apnea

OBJECTIVEnThe aim of this retrospective study was to evaluate the results of an outpatient surgical procedure known as endoscopically-assisted surgical expansion (EASE) in expanding the maxilla to treat obstructive sleep apnea (OSA) in adolescent and adults.nnnMETHODSnThirty-three patients (18 males), aged 15-61 years, underwent EASE of the maxilla. All patients completed pre- and post-operative clinical evaluations, polysomnography, questionnaires (Epworth Sleepiness Scale [ESS] and Nasal Obstruction Septoplasty Questionnaire [NOSE]) as well as cone beam computed tomography (CBCT).nnnRESULTSnWith EASE, the overall apnea hypopnea index (AHI) improved from 31.6xa0±xa011.3 to 10.1xa0±xa06.3. The oxygen desaturation index (ODI) improved from 11.8xa0±xa09.6 to 1.8xa0±xa03.7, with reduction of ESS scores from 13.4xa0±xa04.0 to 6.7xa0±xa03.1. Nasal breathing improved as demonstrated by reduction of the NOSE scores from 57.8xa0±xa012.9 to 15.6xa0±xa05.7. Expansion of the airway from widening of the nasal floor was consistently evident on all postoperative CBCT; the anterior nasal floor expanded 4.9xa0±xa01.2xa0mm, posterior nasal floor expanded 5.6xa0±xa01.2xa0mm, and the dental diastema created was 2.3xa0±xa00.8xa0mm. Mean operative time was 54.0xa0±xa06.0xa0min. All patients with mild to moderate OSA were discharged the same day; patients with severe OSA were observed overnight. All patients returned to school or work and regular activities within three days.nnnCONCLUSIONSnEASE is an outpatient procedure that improves nasal breathing and OSA by widening the nasal floor in adolescents and adults. Compared to current surgical approaches for maxillary expansion, EASE is considerably less invasive and consistently achieves enlargement of the airway with minimal complications.

Response to Michael Friedman re: “Adenotonsillectomy and obstructive sleep apnea in children: a prospective survey”

1. Khalid AN, Quraishi SA, Kennedy DW. Long-term quality of life measures after functional endoscopic sinus surgery. Am J Rhinol 2004; 18:131–6. 2. Metson R, Glicklich RE. Clinical outcome of endoscopic surgery for frontal sinusitis. Arch Otolaryngol Head Neck Surg 1998;124:1090–6. 3. Videler WJ, van Drunen CM, van der Meulen FW, Fokkens WJ. Radical surgery: Effect on quality of life and pain in chronic rhinosinusitis. Otolaryngol Head Neck Surg 2007;136:261–7.