Meghan N. Wilson

Updated systematic review of tonsillectomy and adenoidectomy for treatment of pediatric obstructive sleep apnea/hypopnea syndrome

Objective: Perform an updated systematic review and meta-analysis to determine the cure rate of tonsillectomy and adenoidectomy (T&A) for pediatric obstructive sleep apnea/hypopnea syndrome (OSAHS). Methods: A systematic review was performed to identify English-language studies that evaluate the treatment of pediatric (age < 20 years) OSAHS patients with T&A using polysomnography as a metric of cure. Twenty-three studies fit the inclusion criteria and a meta-analysis was performed to determine the overall success. Meta-analysis was also performed to determine the success in obese and comorbid populations vs cohorts of healthy children. Results: The meta-analysis included 1079 subjects (mean sample size of 42 patients) with a mean age of 6.5 years. The effect measure was the percentage of pediatric patients with OSAHS who were successfully treated (k = 22 studies) with T&A based on preoperative and postoperative PSG data. Random-effects model estimated the treatment success of T&A was 66.3 percent, when cure was defined per each individual study. When “cure” was defined as an apnea-hypopnea index (AHI) of <1 (k = 9 studies), random-effects model estimate for OSAHS treatment success with T&A was 59.8 percent. Postoperative mean AHI was significantly decreased from preoperative levels. Conclusions: Contrary to popular belief, meta-analysis of current literature demonstrates that pediatric sleep apnea is often not cured by T&A. Although complete resolution is not achieved in most cases, T&A still offers significant improvements in AHI, making it a valuable first-line treatment for pediatric OSAHS.

Clinical Practice Guideline Allergic Rhinitis

Objective Allergic rhinitis (AR) is one of the most common diseases affecting adults. It is the most common chronic disease in children in the United States today and the fifth most common chronic disease in the United States overall. AR is estimated to affect nearly 1 in every 6 Americans and generates

Normal tension glaucoma in patients with obstructive sleep apnea/hypopnea syndrome.

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Screening for obstructive sleep apnea/hypopnea syndrome: Subjective and objective factors

5 billion in direct health expenditures annually. It can impair quality of life and, through loss of work and school attendance, is responsible for as much as

Clinical practice guideline: allergic rhinitis executive summary.

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Measurements of adult lingual tonsil tissue in health and disease

4 billion in lost productivity annually. Not surprisingly, myriad diagnostic tests and treatments are used in managing this disorder, yet there is considerable variation in their use. This clinical practice guideline was undertaken to optimize the care of patients with AR by addressing quality improvement opportunities through an evaluation of the available evidence and an assessment of the harm-benefit balance of various diagnostic and management options. Purpose The primary purpose of this guideline is to address quality improvement opportunities for all clinicians, in any setting, who are likely to manage patients with AR as well as to optimize patient care, promote effective diagnosis and therapy, and reduce harmful or unnecessary variations in care. The guideline is intended to be applicable for both pediatric and adult patients with AR. Children under the age of 2 years were excluded from the clinical practice guideline because rhinitis in this population may be different than in older patients and is not informed by the same evidence base. The guideline is intended to focus on a limited number of quality improvement opportunities deemed most important by the working group and is not intended to be a comprehensive reference for diagnosing and managing AR. The recommendations outlined in the guideline are not intended to represent the standard of care for patient management, nor are the recommendations intended to limit treatment or care provided to individual patients. Action Statements The development group made a strong recommendation that clinicians recommend intranasal steroids for patients with a clinical diagnosis of AR whose symptoms affect their quality of life. The development group also made a strong recommendation that clinicians recommend oral second-generation/less sedating antihistamines for patients with AR and primary complaints of sneezing and itching. The panel made the following recommendations: (1) Clinicians should make the clinical diagnosis of AR when patients present with a history and physical examination consistent with an allergic cause and 1 or more of the following symptoms: nasal congestion, runny nose, itchy nose, or sneezing. Findings of AR consistent with an allergic cause include, but are not limited to, clear rhinorrhea, nasal congestion, pale discoloration of the nasal mucosa, and red and watery eyes. (2) Clinicians should perform and interpret, or refer to a clinician who can perform and interpret, specific IgE (skin or blood) allergy testing for patients with a clinical diagnosis of AR who do not respond to empiric treatment, or when the diagnosis is uncertain, or when knowledge of the specific causative allergen is needed to target therapy. (3) Clinicians should assess patients with a clinical diagnosis of AR for, and document in the medical record, the presence of associated conditions such as asthma, atopic dermatitis, sleep-disordered breathing, conjunctivitis, rhinosinusitis, and otitis media. (4) Clinicians should offer, or refer to a clinician who can offer, immunotherapy (sublingual or subcutaneous) for patients with AR who have inadequate response to symptoms with pharmacologic therapy with or without environmental controls. The panel recommended against (1) clinicians routinely performing sinonasal imaging in patients presenting with symptoms consistent with a diagnosis of AR and (2) clinicians offering oral leukotriene receptor antagonists as primary therapy for patients with AR. The panel group made the following options: (1) Clinicians may advise avoidance of known allergens or may advise environmental controls (ie, removal of pets; the use of air filtration systems, bed covers, and acaricides [chemical agents formulated to kill dust mites]) in patients with AR who have identified allergens that correlate with clinical symptoms. (2) Clinicians may offer intranasal antihistamines for patients with seasonal, perennial, or episodic AR. (3) Clinicians may offer combination pharmacologic therapy in patients with AR who have inadequate response to pharmacologic monotherapy. (4) Clinicians may offer, or refer to a surgeon who can offer, inferior turbinate reduction in patients with AR with nasal airway obstruction and enlarged inferior turbinates who have failed medical management. (5) Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with AR who are interested in nonpharmacologic therapy. The development group provided no recommendation regarding the use of herbal therapy for patients with AR.

Difference of Helicobacter pylori colonization in recurrent inflammatory and simple hyperplastic tonsil tissues.

PurposeTo determine the prevalence of normal tension glaucoma (NTG) in patients with obstructive sleep apnea/hypopnea syndrome (OSAHS) and further investigate whether the severity of OSAHS would increase the risk of glaucoma. Patients and MethodsTwo hundred fifty-six participants were consecutively admitted for polysomnographic exam to diagnose OSAHS. All participants, then underwent a complete ophthalmologic evaluation, including best-corrected visual acuity, intraocular pressure, slit lamp biomicroscopy, gonioscopy, fundoscopy, automated visual field (VF), and retinal nerve fiber layer (RNFL) evaluation. ResultsA total of 247 participants were enrolled in the study. Two hundred nine patients were OSAHS and 38 participants were classified as the normal group. Among the OSAHS patients, NTG was found in 12 patients with a prevalence of 5.7%, which was higher than that in the normal group (P=0.003). In the NTG patients, 1 was in the mild, 3 were in the moderate, and 8 were in the severe OSAHS group. There was no glaucoma patient in the normal group. The prevalence of NTG in moderate/severe OSAHS patients was 7.1%, significantly higher (P=0.033) than that in normal/mild OSAHS patients. The mean saturation of oxygen and lowest saturation of oxygen correlated with the average thickness of RNFL in the OSAHS patients. ConclusionsPatients with OSAHS had a high prevalence of NTG, especially in patients with moderate and severe OSAHS. The severity of OSAHS inversely correlated with retinal nerve fiber layer thickness. Clinicians need to consider the possibility of glaucoma in patients with moderate and severe OSAHS.

Dead Sea salt irrigations vs saline irrigations with nasal steroids for symptomatic treatment of chronic rhinosinusitis: a randomized, prospective double‐blind study

Objectives: To determine the sensitivity and specificity of the Berlin Questionnaire and the Obstructive Sleep Apnea/Hypopnea Syndrome (OSAHS) score for individually predicting a diagnosis of OSAHS, and to propose a method for OSAHS screening incorporating objective and subjective factors. Study Design: Cross-sectional survey. Setting: Tertiary care center. Methods: Charts were reviewed from 223 consecutive patients for whom complete data regarding the Berlin questionnaire, OSAHS score (Friedman tongue position + tonsil size + body mass index grade), Epworth Sleepiness Scale, and visual analog scale for snoring were obtained prior to polysomnography (PSG). Sensitivity and specificity were determined for the Berlin questionnaire and OSAHS score for predicting an apnea hypopnea index (AHI) ≥ 5. Patient data were subjected to multivariate stepwise discriminant analysis and used to construct a screening system based on the Fishers linear classification equation. Results were cross-validated by PSG findings. Results: In predicting an AHI ≥ 5, the sensitivity and specificity, respectively, were 0.615 and 0.226 for the Berlin questionnaire, 0.863 and 0.468 for OSAHS score, and 0.82 and 0.834 for our predictive equation. When applied case-wise to the study population, this equation correctly predicted 82.5 percent of diagnoses. Accuracy was highest for severe OSAHS (87.4%) and lowest for mild disease (77.0%). Sensitivity was lowest for mild OSAHS (0.50). Conclusions: Neither the Berlin questionnaire nor the OSAHS score alone was both highly sensitive and specific for diagnosing OSAHS. By incorporating subjective and objective metrics into a single predictive equation, sensitivity and specificity were maximized, and 82.5 percent of diagnoses were accurately predicted.

Illumination guided balloon sinuplasty

The American Academy of Otolaryngology—Head and Neck Surgery Foundation (AAO-HNSF) has published a supplement to this issue featuring the new Clinical Practice Guideline: Allergic Rhinitis. To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed address the evaluation of patients with allergic rhinitis, including performing and interpretation of diagnostic testing and assessment and documentation of chronic conditions and comorbidities. It will then focus on the recommendations to guide the evaluation and treatment of patients with allergic rhinitis, to determine the most appropriate interventions to improve symptoms and quality of life for patients with allergic rhinitis.

Z-palatopharyngoplasty plus radiofrequency tongue base reduction for moderate/severe obstructive sleep apnea/hypopnea syndrome.

Objectives: To report computed tomography (CT) measurements of lingual tonsil tissue (LTT) in patients with laryngopharyngeal reflux (LPR), obstructive sleep apnea-hypopnea syndrome (OSAHS), both LPR and OSAHS, or neither disease. Study Design: Retrospective chart review. Setting: Tertiary care center. Subjects and Methods: Ninety-eight patients with CT scans including the tongue base and complete historical data regarding the presence or absence of symptoms, signs, and laboratory confirmation of LPR and/or OSAHS were included. LTT was measured on CT. Charts of patients meeting inclusion criteria were subsequently reviewed and patients were divided into four groups: 1) those without LPR or OSAHS, 2) those with LPR only, 3) those with OSAHS only, and 4) those with both LPR and OSAHS. Statistical analysis focused on correlating LTT thickness with the presence or absence of LPR and/or OSAHS. Results: The mean LTT thickness for group 1 (21 patients without reflux or OSAHS) was 0.937 mm (range 0-2.67 mm). The mean for group 2 (29 patients with LPR only) was 3.35 mm (range 0-7.4 mm). The mean for group 3 (16 patients with OSAHS only) was 4.29 mm (range 0-9 mm). The mean for group 4 (32 patients with LPR and OSAHS) was 4.00 mm (range 0-19.2 mm). The mean for group 1 was lower than the other 3 groups (P < 0.001). Conclusion: CT images including the tongue base allow precise measurement of LTT thickness. LTT > 2.7 mm was not identified in patients without OSAHS or LPR. The mean LTT for patients with LPR and/or OSAHS was significantly greater than for patients without either disease.