Ninos J. Joseph

Staging of Obstructive Sleep Apnea/Hypopnea Syndrome: A Guide to Appropriate Treatment†

Objective Early studies by Friedman et al. have demonstrated the value of staging obstructive sleep apnea/hypopnea syndrome (OSAHS) patients for the prediction of success for uvulopalatopharyngoplasty (UPPP) on the basis of short‐term follow up. The goal of this study is to test the value of this staging system in a prospective study.

Z-palatoplasty (ZPP): A technique for patients without tonsils

OBJECTIVE: Patients without tonsils and with Friedman tongue position (FTP) III and IV are poor candidates for uvulopalatopharyngoplasty (UP3). Even when combined with adjunctive hyopharyngeal techniques, results are poor. We assessed a modified uvulopalatoplasty based on a bilateral Z-plasty in treating patients without tonsils who have obstructive sleep apnea/hypopnea syndrome (OS-AHS). METHODS: 25 patients treated with a modified technique were matched with 25 patients previously treated with classic UP3. All patients in both groups also had radiofrequency tongue base reduction. Preoperative vs. postoperative measures of objective treatment success and subjective symptoms were compared for the 2 groups. Morbidity, including pain levels, narcotic use, and return to solid diet and normal activity, as well as complications were studied. RESULTS: Subjective improvement was good for both groups, but objective clinical improvement was significantly better for the experimental group. Morbidity and complications for the experimental group were comparable to the control group and to other published series on UP3. CONCLUSIONS: A modified technique for patients without tonsils who have OSAHS is presented. The new technique is more successful with acceptable morbidity for patients with OSAHS than classical techniques.

Does severity of obstructive sleep apnea/hypopnea syndrome predict uvulopalatopharyngoplasty outcome?

Objectives: Uvulopalatopharyngoplasty (UP3) is the single most commonly performed surgical procedure for the treatment of obstructive sleep apnea/hypopnea syndrome (OSAHS), but its success is limited. Our objective was to determine whether severity of disease of OSAHS based on polysomnography (PSG) data (apnea/hypopnea index [AHI]) is a significant factor in predicting successful treatment by UP3. In addition, we compared anatomic staging with severity of disease to determine which is the better predictor of success.

Functional endoscopic dilatation of the sinuses : Patient satisfaction, postoperative pain, and cost

Background The purpose of this study was to determine how functional endoscopic dilatation of the sinuses (FEDS) compares with functional endoscopic sinus surgery (FESS) in a select group of patients with respect to (1) elimination of symptoms, (2) patient satisfaction, (3) postoperative narcotic use, and (4) cost. A retrospective study was performed of 70 patients with chronic rhinosinusitis who underwent FEDS or FESS as primary or revision treatment. Methods Symptoms and satisfaction based on the Sino-Nasal Outcome Test (SNOT-20) questionnaires and global patient assessment, postoperative narcotic use, and costs were compared after 3-month follow-up. Results SNOT-20 change scores indicated that both FEDS and FESS had clinically meaningful treatment responses. Patient satisfaction was higher and postoperative narcotics usage was less with FEDS. The cost for primary procedures was similar, whereas the cost for revision surgery using FEDS was considerably less. Turbinate lateralization and scarring was more common in the FEDS group, particularly early in the study. The incidence of recurrent sinus infections during the follow-up period was similar for both groups. Only one patient in the FEDS group required a repeat intervention within the short-term follow-up period. Conclusion Both FEDS and FESS resulted in significant improvement in SNOT-20 scores for selected patients with mild disease. Patient satisfaction and postoperative narcotic use of FEDS compare favorably with FESS. Cost of FEDS was comparable with FESS for primary procedures but was less than FESS for revision procedures. Long-term efficacy and final cost of FEDS remain to be addressed, taking into account the need for revision procedures after initial FEDS, by means of long-term studies and objective outcome measures.

Patient Selection and Efficacy of Pillar Implant Technique for Treatment of Snoring and Obstructive Sleep Apnea/Hypopnea Syndrome

OBJECTIVE: Pillar implant (PIT) is a simple, office-based procedure with minimal morbidity that was introduced in 2003 to treat snoring and mild/moderate obstructive sleep apnea/hypopnea syndrome (OSAHS). We studied the: (1) success rate using subjective symptoms and objective polysomnographic improvement; (2) success rate based on BMI, OSAHS severity and Friedman tongue position (FTP); and (3) its value as an adjunctive or revision procedure. STUDY DESIGN AND SETTING: Retrospective review of 125 patients who underwent the PIT for snoring and OSAHS. Patients were grouped: Group I had PIT only (n = 29); Group II received adjunctive nasal procedures (n = 37), Group III received adjunctive oropharyngeal procedures (n = 55); and Group IV had failed previous UPPP (n = 4). RESULTS: Overall subjective and objective “cure” rates were 88.0% and 34.4%, respectively. Group IIb had the best objective cure rate of 46.7%. Neither AHI nor BMI correlated with outcome measures, whereas FTP did correlate. (FTP I and II had improved success vs FTP III and IV). Ten patients had partial extrusion of the PIT. These were removed and new PIT were carried out at a later date. CONCLUSIONS: Based on a short-term study, the Pillar implant is an effective treatment for snoring and OSAHS in selected patients and can be combined with adjunctive procedures to treat OSAHS.

Preoxygenation with tidal volume and deep breathing techniques : The impact of duration of breathing and fresh gas flow

Various techniques of “preoxygenation” before anesthetic induction have been advocated, including tidal volume breathing (TVB) for 3–5 min, four deep breaths (DB) in 0.5 min, and eight DB in 1 min. However, no study has compared the effectiveness of these techniques, assessed extending deep breathing beyond 1 min, or investigated the influence of fresh gas flow (FGF) in the same subjects using a circle absorber system. In 24 healthy adult volunteers breathing oxygen from a circle absorber system by tight-fitting mask, we compared TVB/5 min and deep breathing at a rate of 4 DB/0.5 min for 2 min at 5, 7, and 10 L/min FGF. Inspired and end-tidal respiratory gases were measured at 0.5-min intervals. During TVB, end-tidal oxygen (ETO2) increased rapidly and plateaued by 2.5 min at 86%, 88%, and 88% with 5, 7 and 10 L/min FGF, respectively. ETO2 values of ≥90% were attained between 3 and 4 min. Four DB/0.5 min increased ETO2 to 75%, 77%, and 80% at 5, 7, and 10 L/min FGF. Eight DB/min resulted in ETO2 values of 82% and 87% at 7 and 10 L/min, respectively. Extending deep breathing to 1.5 and 2 min with 10 L/min FGF increased ETO2 by ≥90%, although a decrease in ETco2 was noted. We concluded that TVB/3–5 min was effective in achieving maximal “preoxygenation” whereas 4 DB/0.5 min resulted in submaximal “preoxygenation,” and thus should be used only when time is limited. Increasing FGF from 5 to 10 L/min does not enhance “preoxygenation” with either TVB or 4 DB/0.5 min. Deep breathing yields maximal “preoxygenation” when extended to 1.5 or 2 min, and only when high (10 L/min) FGF is used.

Evaluation of submucosal minimally invasive lingual excision technique for treatment of obstructive sleep apnea/hypopnea syndrome.

Objective Submucosal minimally invasive lingual excision (SMILE) is a novel approach to address hypopharyngeal obstruction. This study compares the efficacy, morbidity, and complications of this technique to radiofrequency reduction of the tongue base (RFBOT), the current standard in minimally invasive tongue base reduction. Study Design Retrospective analysis of data extracted from a prospective database. Methods Ninety-six patients who underwent SMILE (n = 48) or RFBOT (n = 48) were studied. Efficacy and safety of the procedures were compared on the basis of polysomnography results, morbidity measures, and complications. Results Patients in both groups demonstrated a significant reduction in the apnea/hypopnea index. Success rates for SMILE and RFBOT were 64.6 percent and 41.7 percent, respectively (P = 0.024). SMILE, however, was associated with increased morbidity and complications. Conclusion In a comparable surgical protocol for obstructive sleep apnea-hypopnea syndrome, SMILE technique for tongue base reduction demonstrated increased efficacy over RFBOT but resulted in more complications. Additional experience with the procedure may reduce complications and increase overall efficacy.

A randomized, prospective, double-blind study on the efficacy of dead sea salt nasal irrigations

Objective: The objective of this randomized, prospective, double‐blind study was to compare nasal irrigation using hypertonic Dead Sea salt (DSS) solution with hypertonic saline in the treatment of chronic rhinosinusitis and improvement of quality of life (QOL).

Minimally invasive single-stage multilevel treatment for obstructive sleep apnea/hypopnea syndrome.

Objectives: To assess subjective and objective improvement after single‐stage multilevel minimally invasive treatment for obstructive sleep apnea/hypopnea syndrome (OSAHS).

Preoperative Pregnancy Testing in Ambulatory Surgery: Incidence and Impact of Positive Results

Background The incidence of unrecognized early pregnancy and its influence on the surgical and anesthetic course in patients presenting for elective ambulatory surgery have not been previously determined. The current study was designed to determine the incidence of unrecognized pregnancy in women presenting for ambulatory surgery. In addition, it examined how discovery of the pregnancy altered the anesthetic or surgical course.