Ramakrishnan Vidyasagar

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.

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.

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).

Long-Term Results after Endoscopic Sinus Surgery Involving Frontal Recess Dissection

Objective: To assess long‐term follow‐up on a cohort of patients who underwent endoscopic frontal sinus surgery with identification and preservation of the natural frontal outflow tract.

Intraoperative intact parathyroid hormone level monitoring as a guide to parathyroid reimplantation after thyroidectomy.

Objective: The goal of this study was to determine whether intraoperative intact parathyroid hormone (IOiPTH) levels can predict the functional status of remaining parathyroids at the end of total thyroidectomy and thereby be a guide for parathyroid autotransplantation when glands are deemed not functional.

Wireless upper esophageal monitoring for laryngopharyngeal reflux (LPR)

OBJECTIVES: To confirm feasibility of transnasal placement of a wireless pH-monitoring capsule in the upper esophagus, and to determine the positive predictive value of LPR and GERD signs and symptoms for diagnosis of LPR in patients with OSAHS. STUDY DESIGN: Prospective, nonrandomized, IRB-approved study of 89 OSAHS patients with and without symptoms and signs of LPR. METHODS: After complete history including QOL survey and fiberoptic laryngoscopy, patients underwent transnasal placement of the pH-monitoring capsule and wireless data collection for 24 hours. RESULTS: 77 of 89 consecutive patients underwent successful placement of wireless pH-monitoring capsule (86.5% success rate) and completed the study. 55 (71.4%) OSAHS patients had positive pH studies. 10.4% of these patients reported no symptoms or signs of LPR, indicating occult disease. CONCLUSION: Success rates of placement, tolerability, morbidity, and complications are excellent. Wireless upper esophageal pH monitoring is safe and effective for diagnosing LPR in patients with OSAHS.

Inspiratory and fixed nasal valve collapse: clinical and rhinometric assessment.

Background Acoustic rhinometry (AR) has been used to assess nasal valve obstruction. Standard AR measurement of the cross-sectional area (CSA) of the nasal valve is done in the apneic phase, whereas collapse often occurs on inspiration. We used the ratio of the CSA obtained during active inspiration and during apnea to compute a more meaningful method of diagnosing nasal valve collapse. Methods AR was performed in 40 patients without nasal valve obstruction and 47 patients diagnosed with nasal valve obstruction. Patients with septal deflection or anterior inferior turbinate hypertrophy were excluded. The internal and external nasal valve area was observed during apnea and on active inspiration. AR measurement of the CSA of both nasal valves was performed during the apneic phase and during active inspiration and the CSA (inspiratory)/CSA (apneic) ratio was calculated. Results The CSA (inspiratory)/CSA (apneic) ratio was ≥1 in normal patients and in patients with fixed nasal valve collapse. The ratio was <1 in patients with inspiratory collapse. Data from history, physical examination, and dual-mode AR testing successfully differentiated patients into (1) normal valves, (2) fixed valve collapse, and (3) inspiratory valve collapse. A large number of patients with collapse had both internal and external valve obstruction and a large number also had a combination of inspiratory and fixed collapse. Conclusion Dual-mode AR testing is an effective tool in more precisely identifying nasal valve obstruction and is the first objective test shown to be highly diagnostic of inspiratory nasal valve collapse.

Patient selection and efficacy of the pillar implant technique for snoring and OSAHS

Problem: Stiffening the soft palate using a palatal implant is an innovative technique, introduced for clinical practice in 2003. This is a simple, office-based procedure with minimal morbidity. Our objective was to identify (1) the success rate using subjective symptoms and objective improvement of OSAHS; (2) the success rate based on Friedmans clinical stage to develop patient selection criteria; and (3) the techniques value as an adjunctive or revision procedure. Methods: The study was a retrospective chart review of the first 100 patients undergoing the Pillar implant. Data collected included: previous treatments for snoring and/or OSAHS, adjunctive procedures, preoperative and two-month postoperative snore level, Epworth sleepiness scale (ESS), PSG, and complications. Charts were grouped as follows: group I had no adjunctive and previous treatments; group II received adjunctive nasal and/or tongue base procedures; and group III had previous UP3. Results: Patients with primary snoring and mild and moderate OSAHS were treated. The AHI level was not a predictor of success. Group I patients (n = 36) had significant improvement in snoring levels, but not in ESS or AHI. Twenty-six patients (72.2%) were considered successful based on elimination of symptoms. Group II patients (n = 43) had the best results. Mean AHI and ESS improved and snore level decreased. Thirty-five patients (81%) were rated as successful. Group III (n = 21) patients had no change in AHI or ESS but showed significantly decreased snoring. Twelve patients (57%) were rated as successful. Complications were limited to 4 patients with partial extrusion. Conclusion: The Pillar implant is an easy and effective office-based procedure to treat snoring and OSAHS in selected patients. Significance: This study demonstrates the efficacy of the palatal implant technique alone and in combination with adjunctive procedures in decreasing snoring levels and treating OSAHS. Support: None reported.

Reduction of cardiovascular risks with surgical treatment of OSAHS

Abstract Problem: To determine whether surgical treatment for obstructive sleep apnea/hypopnea syndrome (OSAHS) has an impact on C-reactive protein (CRP) and interleukin-6 (IL-6) levels, which are both predictors of increased risks of cardiovascular disease. Methods: This was a prospective study of 30 subjects scheduled for surgical treatment for OSAHS in university-affiliated medical centers. CRP and IL-6 levels were evaluated preoperatively and 2 months posttreatment. Patients underwent surgical treatment of OSAHS based on Friedman clinical staging. The most commonly performed procedure was uvulopalatopharyngoplasty with tongue base radiofrequency reduction. All patients underwent preoperative and postoperative polysomnography. Results: Eight patients were treated for mild and 22 were treated for moderate/severe OSAHS. Almost all of the patients with mild disease and all the patients with moderate/severe disease had relative elevation of preoperative CRP levels indicating increased risks of cardiovascular disease. Postoperative CRP levels were lower in most of the patients. IL-6 levels were less reduced but still show a significant reduction. Even patients who did not achieve complete “cure” by classical polysomnography criteria did benefit from lowered CRP and IL-6 levels. Conclusion: Levels of CRP and IL-6 were elevated preoperatively but were decreased by surgical treatment, as has been previously demonstrated following n-CPAP therapy. Significance: OSAHS surgical treatment may be useful in decreasing risks of cardiovascular morbidity and mortality in patients who will not or cannot accept CPAP therapy. Support: None reported.