Leh-Kiong Huon

Outcomes of intratympanic gentamicin injection to treat Ménière's disease.

Objective To investigate the outcomes of intratympanic (IT) gentamicin sulfate injection to treat intractable Ménière’s disease (MD) using evidence-based methods. Data Source Data were retrieved from a MEDLINE search (January 1995 through January 2011). Study Selection Selected were English-language articles presenting outcomes of IT gentamicin injection to treat MD that had a prospective study design and an evidence level of II or higher. Data Extraction The database was searched using Boolean combinations of the keywords intratympanic, gentamicin, and Ménière’s disease. Data Synthesis Dichotomous outcomes (success rate and total deafness) were expressed using a Mantel-Haenszel fixed-effects model. Pretreatment and posttreatment pure-tone audiometry results, and word discrimination scores were summarized using data synthesis techniques. Conclusion A critical literature appraisal and meta-analysis shows that IT gentamicin injection can control vertigo in patients with MD who have limited hearing injury. The quality of research in this field has improved remarkably over the years. However, a large-scale randomized controlled trial is warranted to confirm the predictive factors for the effectiveness of IT gentamicin injection in treating MD.

Epiglottis collapse in adult obstructive sleep apnea: A systematic review.

To systematically review the international literature evaluating the role of the epiglottis in snoring and obstructive sleep apnea and to explore possible treatment options available.

Lateral Pharyngeal Wall Tension After Maxillomandibular Advancement for Obstructive Sleep Apnea Is a Marker for Surgical Success: Observations From Drug-Induced Sleep Endoscopy

PURPOSE The efficacy of maxillomandibular advancement (MMA) for obstructive sleep apnea (OSA) with anatomic airway changes has previously been studied using static imaging and endoscopy in awake subjects. The aim of the present study was to use drug-induced sleep endoscopy (DISE) to evaluate the dynamic upper airway changes in sleeping subjects before and after MMA and their association with the surgical outcome. PATIENTS AND METHODS This was a retrospective cohort study of subjects with OSA who had undergone MMA at the Stanford University Sleep Surgery Division from July 2013 to July 2014. The subjects were included if perioperative polysomnography and DISE had been performed. The predictor variable was the perioperative DISE velum-oropharynx-tongue-epiglottis score. The outcome variables were the apnea-hypopnea index (AHI), oxygen-desaturation index (ODI), and Epworth Sleepiness Scale (ESS). A subgroup analysis was performed for the subjects who had undergone primary and secondary MMA. The statistical analyses included Cronbachs α coefficient, the McNemar test, and the independent Student t test. The P value was set at <.01. RESULTS A total of 16 subjects (15 males, 1 female) were included in the present study, with an average age of 47 ± 10.9 years and body mass index of 29.4 ± 5.1 kg/m(2). Significant post-MMA decreases were found in the AHI (from 59.8 ± 25.6 to 9.3 ± 7.1 events/hr) and ODI (from 45 ± 29.7 to 5.7 ± 4.1 events/hr; P < .001). Greater improvement in the AHI occurred in the primary MMA group (P = .022). The post-MMA change in airway collapse was most significant at the lateral pharyngeal wall (P = .001). The subjects with the most improvement in lateral pharyngeal wall collapsibility demonstrated the largest changes in the AHI (from 60.0 ± 25.6 events/hr to 7.5 ± 3.4 events/hr) and ODI (from 46.7 ± 29.8 to 5.3 ± 2 events/hr; P = .002). CONCLUSIONS Using DISE, we observed that after MMA, the greatest reduction in upper airway collapsibility is seen at the lateral pharyngeal wall of the oropharynx, followed by the velum, and then the tongue base. The stability of the lateral pharyngeal wall is a marker of surgical success after MMA using the AHI, ODI, and ESS.

Efficacy of Maxillomandibular Advancement Examined with Drug-Induced Sleep Endoscopy and Computational Fluid Dynamics Airflow Modeling.

Objectives To use drug-induced sedation endoscopy (DISE) and computational fluid dynamics (CFD) modeling to study dynamic airway and airflow changes after maxillomandibular advancement (MMA), and how the changes correlate with surgical success based on polysomnography parameters. Study Design Retrospective cohort study. Setting University medical center. Methods DISE was rated with the VOTE (velum, oropharynx, tongue, epiglottis) classification, and CFD was used to model airflow velocity and negative pressure exerted on pharyngeal wall. Changes in VOTE score by site and CFD measurements were correlated with perioperative polysomnography outcomes of apnea-hypopnea index (AHI), apnea index (AI), oxygenation desaturation index (ODI), and lowest oxygen saturation. Results After MMA, 20 subjects (17 males, 3 females) with a mean age of 44 ± 12 years and body mass index of 27.4 ± 4.6 kg/m2 showed mean decreases in AHI (53.6 ± 26.6 to 9.5 ± 7.4 events/h) and ODI (38.7 ± 30.3 to 8.1 ± 9.2 events/h; P < .001). Improvement in lateral pharyngeal wall collapse during DISE based on VOTE score correlated with the most decrease in AHI (60.0 ± 25.6 to 7.5 ± 3.4 events/h) and ODI (46.7 ± 29.8 to 5.3 ± 2 events/h; P = .002). CFD modeling showed significant positive Pearson correlations between reduction of retropalatal airflow velocity and AHI (r = 0.617, P = .04) and ODI (r = 0.773, P = .005). Conclusion AHI and ODI improvement after MMA is best correlated with (1) decreased retropalatal airflow velocity modeled by CFD and (2) increased lateral pharyngeal wall stability based on VOTE scoring from DISE.

Static craniofacial measurements and dynamic airway collapse patterns associated with severe obstructive sleep apnoea: a sleep MRI study.

Using sleep MRI, we aimed to identify static craniofacial measurements and dynamic upper airway collapse patterns associated with severe obstructive sleep apnoea (OSA) during natural sleep in age and BMI‐matched patients.

Vertigo and stroke: a national database survey.

Objective To investigate the association between vertigo and stroke in Taiwan using the Bureau of National Health Insurance research database. Methods Information on adult patients with an index vertigo attack in 2006 was retrieved from Bureau of National Health Insurance research database. All patients with specific diagnostic codes for vertigo were included. Occurrence of stroke during a 1-year follow-up period was identified. Risk factors for stroke were examined. Using &khgr;2 test, t test, and a multilevel logistic regression model, patients with vertigo were categorized into stroke and nonstroke groups for comparative analyses. An age- and sex- matched control cohort was prepared for comparison. Results Patients with vertigo (n = 527,807) (mean age, 55.1 yr) accounted for 3.1% of the general Taiwanese adult population. The prevalence of stroke among vertigo patients of 0.5% (mean age, 67.8 yr) was slightly higher than that of the control group (0.3%; mean age, 72.3 yr; p < 0.0001). The types of stroke were ischemic (66.7%), nontypical (29.0%), and hemorrhage (4.3%). The prevalence of stroke increased with age (p < 0.001). Patients with vertigo had higher prevalence of comorbid conditions (p < 0.0001); those with diabetes mellitus, hypertension, dyslipidemia, coronary artery disease, or atrial fibrillation had a higher prevalence of stroke (p < 0.001). Hypertension was the most significant predictor of stroke (odds ratio, 3.77; 95% confidence interval, 3.36–4.23; p < 0.001). Conclusion Patients with vertigo had higher chance to develop stroke than the control group. Some strokes may initially manifest as peripheral vertigo, and some central vertigo may eventually evolve into a stroke. Middle aged male, diabetes, hypertension, dyslipidemia, coronary artery disease, and atrial fibrillation are risk factors for subsequent stroke in vertigo patients.

Head and neck manifestations of spontaneous pneumomediastinum.

Objective. Spontaneous pneumomediastinum (SPM) is a rare disease entity that often manifests localized signs in the head and neck region. The thoracic features of SPM have been well described; however, there is a paucity of information on its otolaryngological characteristics. The authors describe the clinical management among SPM patients having primarily head and neck symptoms. Study Design. Case series with chart review. Setting. Cathay General Hospital, Taiwan. Results. The study included 13 men and 1 woman, with a mean age of 18.8 years (range, 14-29 years). The primary initial symptoms were neck swelling (11), neck pain (10), and odynophagia (9). Neck soft tissue and chest radiography was diagnostic of SPM in all patients. Conservative treatment consisted of bed rest and analgesics, which led to rapid resolution of SPM. Conclusions. SPM is a benign entity that responds well to conservative treatment. The results of our investigation highlight the importance of an ear, nose, and throat (ENT) clinical examination as a guide for diagnosing SPM because of the high percentage of ENT manifestations in the initial clinical profiles. Secondary causes of SPM must be ruled out to avoid an unfavorable outcome.

Acoustic-integrated dynamic MR imaging for a patient with obstructive sleep apnea

Obstructive sleep apnea syndrome (OSAS) is caused by multi-level upper airway obstruction. Anatomic changes at the sites of obstruction may modify the physical or acoustic properties of snores. The surgical success of OSA depends upon precise localization of obstructed levels. We present a case of OSAS who received simultaneous dynamic MRI and snore acoustic recordings. The synchronized image and acoustic information successfully characterize the sites of temporal obstruction during sleep-disordered breathing events.

Synchronized imaging and acoustic analysis of the upper airway in patients with sleep-disordered breathing.

Progressive narrowing of the upper airway increases airflow resistance and can produce snoring sounds and apnea/hypopnea events associated with sleep-disordered breathing due to airway collapse. Recent studies have shown that acoustic properties during snoring can be altered with anatomic changes at the site of obstruction. To evaluate the instantaneous association between acoustic features of snoring and the anatomic sites of obstruction, a novel method was developed and applied in nine patients to extract the snoring sounds during sleep while performing dynamic magnetic resonance imaging (MRI). The degree of airway narrowing during the snoring events was then quantified by the collapse index (ratio of airway diameter preceding and during the events) and correlated with the synchronized acoustic features. A total of 201 snoring events (102 pure retropalatal and 99 combined retropalatal and retroglossal events) were recorded, and the collapse index as well as the soft tissue vibration time were significantly different between pure retropalatal (collapse index, 2 ± 11%; vibration time, 0.2 ± 0.3 s) and combined (retropalatal and retroglossal) snores (collapse index, 13 ± 7% [P ≤ 0.0001]; vibration time, 1.2 ± 0.7 s [P ≤ 0.0001]). The synchronized dynamic MRI and acoustic recordings successfully characterized the sites of obstruction and established the dynamic relationship between the anatomic site of obstruction and snoring acoustics.

Epstein Barr virus-associated lymphoepithelial carcinoma in the middle ear.

Histopathologically, lymphoepithelial carcinoma (LEC) is characterized by individual, sheets, or nests of poorly to undifferentiated epithelial cells. The malignant epithelial cells are surrounded and infiltrated by prominent components of small mature lymphocytes and plasma cells. The most frequent site of LEC occurrence is the nasophayrnx (nasopharyngeal carcinoma [NPC]), where it is almost invariably associated with Epstein-Barr virus (EBV) infection. NPC is an endemic disease prevalent in southeastern coastal provinces of China. Isolated nonnasopharyngeal LEC occurrence is rare, and its association with EBV remains controversial. Primary temporal bone LEC is a rare disease entity. To the best of our knowledge, only 4 patients have been reported in the literature to date, all with confirmed EBV infection. In this report, we present the diagnosis and management of a rare LEC case that originated from the middle ear. Its association with EBV is also addressed. A 56-year-old otherwise healthy woman (a native of Guangdong Province, China) presented to our clinic with aural fullness and hearing loss on her right ear for 1 year. Otoscopic examination revealed a lobulated mass extending from the middle ear space (Figure 1). There was no history of otorrhea. Her brother had had cured NPC for several years. The pure-tone audiometry (PTA; 45 dB) revealed a mixed-type hearing loss with a 30-dB air-bone gap on the right side. The left-side PTA was 18 dB, showing a high-tone sensorineural loss with no conductive component. High-resolution temporal bone computed tomography showed a middle ear mass with no bone or ossicle erosion. Exploratory tympanotomy revealed that the multilobulated lesion originated from the promontory wall, filling the whole mesotympanum and partially extending into the Eustachian tube. The tumor was removed piece by piece without disrupting the ossicular chain. The patient received adjuvant radiotherapy (62 Gy, 31 fractions) over a period of 7 weeks. Histopathological examination demonstrated irregular sheets of undifferentiated carcinoma intermingled with abundant lymphoid infiltrate (Figure 2). Immunohistochemical staining was positive for keratin and negative for leukocyte common antigen. The diagnosis of LEC was confirmed. In situ hybridization for EBV-encoded RNA was strongly positive. However, serum Case Report