Mark E. Boseley

The role of the Genial Bone Advancement Trephine system in conjunction with uvulopalatopharyngoplasty in the multilevel management of obstructive sleep apnea.

OBJECTIVES: The successful surgical management of obstructive sleep apnea (OSA) requires surgical procedures that address both retropalatal and retrolingual airway obstruction. The Genial Bone Advancement Trephine (GBAT) system is a new, 1-step system that allows for isolation and advancement of the genioglossus muscle via a guided trephine system. The purpose of this project was to describe our experience using the GBAT system to perform genioglossus advancement (GGA) in conjunction with uvulopalatopharyngoplasty (UPPP) in the surgical management of OSA. STUDY DESIGN: Retrospective analysis of 35 consecutive patients undergoing GGA using the GBAT system in conjunction with UPPP for the management of OSA during a 3-year period (1999 to 2002). RESULTS: Twenty-four patients had complete preoperative and postoperative polysomnographic data. A 70% reduction in the Respiratory Disturbance Index (RDI) and Apnea Index (AI) in the preoperative versus postoperative PSG (RDI, 52.9 ± 17.1 versus 15.9 ± 7.5; AI, 20.1 ± 6.7 versus 6.1 ± 4.5; P ≤ 0.0001). The lowest oxygen desaturation increased from 80% to 88% (P = 0.0002), and the posterior airway increased from 7.9 to 12.6 mm (P < 0.0001). With a surgical cure defined as a greater than 50% reduction in the RDI and a final postoperative RDI of less than 20 events per hour, the true surgical cure rate was 67% (16 of 24 patients). CONCLUSIONS: The GBAT system performed in conjunction with UPPP can produce significant reductions in RDI and AI while improving the oxygen desaturation and enlarging the posterior airway space. The effective cure rates using the GBAT system are in agreement with previous reports in the literature using various GGA techniques. The GBAT may have some advantages in terms of simplicity and safety.

Development of the Human True Vocal Fold: Depth of Cell Layers and Quantifying Cell Types within the Lamina Propria:

Objectives: We sought to further describe the development of the 3-layered human vocal fold in children and to quantify macrophage and myofibroblast concentrations in each layer. Methods: We used an optical analysis software package to examine 8 longitudinally sectioned human vocal folds that had been fixed in formalin (ages 2 days to 14 years). Results: The 2-day-old vocal fold contained only a monolayer of cells. This became a bilayer by 5 months, and a trilayer began to become evident by 7 years. The percent of total depth represented by the superficial layer of the lamina propria (SLP) gradually decreased with age. The SLP made up 22% of the total lamina propria by age 7 years; this percentage approximates that in the adult vocal fold. Macrophages and myofibroblasts were predominately found in the SLP, and began to be apparent by 11 months of age. Conclusions: These results help describe the development of human voice and may have implications as to when phonosurgical therapy can be considered for children.

Prospective comparison of handheld pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children

OBJECTIVES To compare pneumatic otoscopy, binocular microscopy, and tympanometry in identifying middle ear effusions in children and to determine if a significant difference exists in sensitivity and specificity based on patient age and/or experience of the examiner. METHODS A prospective study of 102 patients, or 201 ears, enrolled over a 1-year period in a tertiary medical center. Sensitivity, specificity, positive predictive value, and negative predictive value were determined for staff and resident-performed pneumatic otoscopy, staff and resident-performed binocular microscopy, and tympanometry. Tympanometry data were stratified for age. A kappa correlation was used to compare each tool to myringotomy result (gold standard) and to compare staff versus resident. RESULTS Binocular microscopy by staff pediatric otolaryngologist was the most sensitive, 88.0% (95% CI 81.4-94.7), and specific, 89% (95% CI 83.1-94.9). Resident binocular microscopy revealed a sensitivity of 81.5% (95% CI 73.6-89.5) and specificity 78.9% (95% CI 71.2-86.6). Staff was more sensitive and specific than resident at pneumatic otoscopy, sensitivity 67.9% (95% CI 57.6-78.3) and specificity 81.4% (95% CI 73.8-88.9) versus 57.7% (95% CI 46.7-68.7) and 78.4% (95% CI 70.4-86.4). Tympanometry had a much lower specificity for ages 5-12 months than for older children. CONCLUSIONS Binocular microscopy by staff pediatric otolaryngologist revealed the best sensitivity and specificity. Pneumatic otoscopy even performed by an inexperienced examiner is more sensitive and specific than tympanometry. The tympanometer is less specific in children under 1 year of age.

Management of tracheal stenosis.

Purpose of reviewThe treatment for pediatric tracheal stenosis has evolved over the past 50 years. Open airway reconstruction has traditionally been the treatment of choice for this condition. Numerous recent publications now support the use of endoscopic techniques to both augment and sometimes replace open procedures. Recent findingsDuring the past 12 months, a significant interest in expanding the role of airway dilation with balloons to manage airway stenoses has emerged. Development of novel airway stents, to include bioabsorbable products, holds promise to decrease the morbidity of stenting procedures. Continued improvement in preoperative imaging, in the form of virtual bronchoscopy, may someday replace airway endoscopy for planning purposes. Additionally, perioperative management strategies and the use of novel adjuvants have been introduced with a goal of improving outcomes in both endoscopic and open techniques through better control of granulation. Ultimately, advances in tissue engineering may provide yet another reconstructive option in the future. SummaryEndoscopic techniques have an increasing role in the management of pediatric subglottic and tracheal stenosis. However, open airway reconstructive procedures are still required in cases of mature scar, high-grade stenosis, and long-segment stenosis.

Laryngotracheoplasty for subglottic stenosis in Down Syndrome children: the Cincinnati experience

Previous studies from our institution have noted difficulties in the surgical repair of subglottic stenosis (SGS) in children with Down Syndrome. The objectives of this paper were to update our 15 year experience in the Down Syndrome patient population, compare our results with our overall series of laryngotracheoplasty for SGS, and to report on the increased incidence of posterior glottic stenosis (PGS) within this group of patients. Medical records of all children with SGS and Down Syndrome evaluated between 1982 and 1997 were reviewed for history of prior intubation, tracheotomy, gastroesophageal reflux disease (GERD), pre-operative SGS grade, and decannulation. From this review several conclusions have been drawn. First, the risk factors for SGS appear to be the same in the Down Syndrome group as the general population. Second, SGS continues to be more prevalent among children with Down Syndrome than among children in the general population. Third, we have now found a higher rate of PGS within these patients when compared to our overall series. Finally, it now seems that our decannulation rates in Down Syndrome children are approaching our overall series results.

Pacific Northwest Survey: Posttympanostomy Tube Water Precautions

OBJECTIVES To determine what recommendations are given to patients or parents of patients with tympanostomy tubes regarding water exposure and to elucidate any recommendation differences between primary care and specialty care physicians. DESIGN Clinical survey. SETTING General community in the Pacific Northwest, including Washington, Oregon, and Idaho. PARTICIPANTS Physician surveys (N = 1116) were mailed to otolaryngologists, pediatricians, and family practitioners in the Pacific Northwest. Questions included what, if any, water precautions are given to patients or parents of patients who underwent tympanostomy tube insertion. Data were tabulated and compared among the 3 physician groups. MAIN OUTCOME MEASURES Recommendations regarding water exposure. RESULTS A response rate of 23.5% (n = 263) was obtained. Most respondents were self-described otolaryngologists (n = 150) followed by family practitioners (n = 77) and pediatricians (n = 36). chi(2) Analysis of the responses from each specialty group showed an overall significant difference about swimming precautions (P < .001). Further analysis of these data shows that many otolaryngologists (47% [n = 71]) and most primary care physicians (73% [n = 83]) recommend the use of barrier devices for swimming. Another 47% of otolaryngologist respondents allow swimming without any water precautions. With regard to depth of dive, there was no statistical significance found between the physician groups. CONCLUSIONS Recommendations for swimming precautions are not universal among the physician groups that routinely see patients with tympanostomy tubes. Most primary care physicians and many otolaryngologists continue to prescribe water precautions to patients or parents of patients with tympanostomy tubes, despite published articles that have shown no reduction in the incidence of otorrhea from the use of barrier devices or from the avoidance of swimming.

Multimedia Approach to Preoperative Adenotonsillectomy Counseling

Objective. The primary objective was to compare retention of knowledge of surgical risks in parents of children having an adenotonsillectomy who received a preoperative handout or watched a video, in addition to standard counseling. A secondary objective was to determine whether time from counseling to day of surgery affects risk retention. Study Design. Prospective randomized control study. Setting. Tertiary referral center. Subjects and Methods. The study, conducted March 2010 through April 2011, included participants who had children undergoing adenotonsillectomy. The preoperative and postoperative test scores of those undergoing verbal counseling, counseling with handout, or counseling with video were compared. Results. Forty-five participants were tasked to identify 9 risks of adenotonsillectomy. Preoperatively, participants identified an average of 6.8 (95% confidence interval [CI], 6.2-7.3) in the counseling group, 7.3 (95% CI, 6.4-8.3) in the counseling and handout group, and 6.6 (95% CI, 5.9-7.3) in the counseling and video group (P = .32). Postoperatively, participants identified an average of 5.8 (95% CI, 4.9-6.7) in the counseling group, 6.5 (95% CI, 5.3-7.6) in the counseling and handout group, and 5.2 (95% CI, 4.1-6.3) in the counseling and video group (P = .19). Time between preoperative counseling and day of surgery was inversely correlated with postoperative score (β −.34, P = .02). Conclusion. Participants were not able to identify all of the risks associated with adenotonsillectomy. There was no difference in identification of risks associated with adenotonsillectomy among different modalities of counseling. Participants retained more information when there was less time between the preoperative counseling and day of surgery.

A Case of Paranasal Sinus Angiolipoma

Objective To present the first documented case of an angiolipoma of the maxillary sinus, our treatment of the patient, and the 1‐year follow‐up results. At the conclusion of the report, the reader should be able to discuss the incidence, treatment options, and long‐term prognosis of angiolipomas of the paranasal sinuses.

Laryngeal sporotrichosis mimicking merkel cell carcinoma recurrence.

A 60-year-old male with steroid-dependent asthma and a history of merkel cell carcinoma of the left neck presented to our office with a 2-month history of progressive dysphagia and odynophagia. His pertinent surgical history was a total parotidectomy and neck dissection with postoperative chemotherapy approximately 3 years prior to this presentation. He reported that a biopsy of a left true vocal fold polyp performed at an outside institution 6 months prior to admission revealed evidence of a fungal infection, for which itraconazole had been started. Of note, he lived in rural Kansas and was an avid gardener. He had no history of tobacco or alcohol use. Physical examination was significant for adherent white plaques on the patient’s tongue and left vallecula. Supraglottic erythema and edema of the left false vocal cord and aryepiglottic fold and decreased left true vocal cord mobility were seen on flexible endoscopic examination. Neck CT with contrast revealed nonspecific soft-tissue edema of the postcricoid and left pyriform areas (Fig 1). With high suspicion for recurrent merkel cell carcinoma, the patient was hospitalized for panendoscopy with directed biopsies. Direct laryngoscopy was remarkable for findings similar to those on nasopharyngoscopy. Tongue scrapings grew Candida albicans and Sporothrix schenckii. Histopathological examination of biopsy specimens of the left false vocal fold and left pyriform sinus revealed chronic granulomatous inflammation and intracellular budding yeast of varying size and shape (Fig 2). Culture of these biopsy specimens yielded S. schenckii. Infectious diseases consultation was obtained and the patient was initially started on itraconazole 200 mg intravenously twice daily. Chest radiographs and CT scans did not reveal evidence of pulmonary infection. After several days he was converted to itraconazole 200 mg oral solution twice daily. His symptoms significantly improved and he was discharged home with his serum itraconazole level in the therapeutic range. Within 72 hours of discharge, he was hospitalized at an outside facility for respiratory distress requiring intubation and mechanical ventilation. He was found to have evidence of pulmonary and cutaneous sporotrichosis. Central nervous system involvement was also suspected. He had a protracted hospital course and ultimately died of disseminated sporotrichosis about 4 months after initial presentation despite several weeks of intravenous amphotericin B therapy.

Double-Reversing Z-Plasty (Furlow Palatoplasty)

Dr. Leonard Furlow first described the double-reversing z-plasty technique for cleft soft palate repair in 1978. This approach allows for repair of an overt or submucous cleft palate, but just as an importantly, provides additional length to the palate and also realigns the palatal musculature. The Furlow palatoplasty (the name by which the procedure is commonly referred) has therefore been instrumental in the treatment of velopharyngeal insufficiency. The primary aims of this chapter are to provide the clinician with the indications for when to consider utilizing the Furlow palatoplasty and to give a stepwise description of how to perform the procedure.