Rıza Murat Karasen

Low-Temperature Bipolar Radiofrequency Ablation (Coblation) of the Tongue Base for Supine-Position-Associated Obstructive Sleep Apnea

Objective: To assess the effectiveness of low-temperature bipolar radiofrequency ablation for Coblation of the tongue base in the multilevel management of supine-position-associated obstructive sleep apnea syndrome (OSAS). Study Design and Setting: A retrospective analysis of the data of 16 subjects undergoing uvulopalatopharyngoplasty and tongue base Coblation. The efficacy of the procedure was investigated on the basis of polysomnographic results. Results: The success rate was 62.5% in 16 patients who underwent surgery for OSAS, with decreases in the mean Apnea Hypopnea Index of 20.1–8.9. The success rate was separately evaluated according to the subjects’ posture. A rate of 87.5% was found for the supine position, while the rate was 56.6% in non-supine positions. The minimum postoperative O2 saturation was significantly increased for REM and non-REM stage 3 sleep rates. Conclusion: It is important to evaluate the relation of the disease to the body position in sleep apnea subjects. Coblation of the tongue base is an applicable method of therapy for patients who have sleep apnea that is more marked in the supine position.

Comparison of Minimally Invasive Techniques in Tongue Base Surgery in Patients with Obstructive Sleep Apnea

Objective. To compare the effectiveness and morbidity of 3 microinvasive tongue base surgical procedures combined with uvulopalatopharyngoplasty (UPPP) in supine-dependent obstructive sleep apnea (OSA) patients. Study Design. A prospective, randomized clinical study. Setting. A tertiary referral center. Methods. Fifty OSA patients were randomly advised to undergo UPPP combined with low-temperature bipolar radiofrequency (group 1), submucosal minimally invasive lingual excision with radiofrequency (SMILE-R; group 2), or submucosal minimally invasive lingual excision with a harmonic scalpel (SMILE-H; group 3). The Epworth Sleepiness Scale, the visual analog scale (VAS) for snoring, the pre- and postoperative 3-month polysomnography (PSG) findings, and the decrease in tongue volume using magnetic resonance imaging (MRI) were compared. The operation times, the postoperative pain VAS score, the analgesic requirement, and the time in commencing a normal diet were compared in the 3 groups. Results. The decrease in apnea-hypopnea index (AHI) and supine AHI values at the postoperative 3-month time point was significant in group 2 (P < .05). The decrease in tongue volume at the 3-month postoperative time point according to the MRI evaluations was higher in groups 1 and 2 (P < .05). In the subjective comparison of effectiveness, there was no significant difference. The operation time was significantly lower in group 3. In the assessment of postoperative pain, no significant difference was found between the groups. Conclusion. When the PSG findings and MRI were evaluated, UPPP + SMILE-R were found to be more effective. No significant difference was found between the 3 techniques when morbidity and complications were compared.

Audiologic evaluation in pediatric patients with type 1 diabetes mellitus

Abstract Objective: The aim of this study was to perform audiological evaluation of children with type 1 diabetes mellitus (DM). Methods: One hundred DM patients (200 ears) were included in the study. Pure-tone audiometry at frequencies of 0.25, 0.5, 1, 2, 4, and 8 kHz; immittance measures including tympano\xadmetry and acoustic reflex testing; transient evoked otoacoustic emission (TEOAE); and auditory brainstem response (ABR) testing were performed in the patients. The results were statistically compared with metabolic control of DM, positive and negative autoantibodies, duration of DM, and present concomitant Hashimoto and celiac diseases. Results: The proportion with a result of ‘fail’ for the TEOAE test in the DM patients was not statistically significant among all groups (p>0.05). The autoantibodies, blood glucose level, and present concomitant Hashimoto and celiac diseases were not associated with prolonged ABR latencies. However, ABR peripheral transmission time (wave I) was significantly delayed with the increasing duration of DM (p<0.05). Conclusion: Pediatric patients with type 1 DM do not frequently present with cochleovestibular symptoms, but show higher audiometric thresholds and the absence of or reduction in TEOAE amplitudes. In ABR testing, the increase in the peripheral transmission time (wave I) is more suggestive of retrocochlear alterations in pediatric cases of type 1 DM compared with conventional audiometric tests (e.g., pure-tone audiometry and OAEs), which may indicate possible initial auditory neuropathy. Further longitudinal investigations on a wide range of control and pediatric subjects with DM will be necessary to confirm the present data and to detect initial auditory neuropathy.

The effect of oral isotretinoin (13-cis retinoic acid) on hearing systems in patients with acne vulgaris: a prospective study.

Isotretinoin is widely used in the treatment of extensive and nodulocystic acne. The objective of this prospective study was to investigate whether oral isotretinoin could affect the hearing system. Thirty‐eight patients with acne vulgaris (76 ears) who were diagnosed and treated at the Department of Dermatology were included in the current study. Study evaluation visits were performed at baseline and at Weeks 1, 2 and 3. Pure‐tone averages (PTAs) of air conduction thresholds at 250 Hz (PTA1); 500, 1000, and 2000 Hz (PTA2); 4000, 8000, and 10, 000 Hz (PTA3); and 12, 500, 16, 000, 18, 000 and 20, 000 Hz (PTA4) for each ear were calculated separately. Assessment of the efficacy was based on the audiometric findings. Compared with pre‐treatment evaluation, the PTAs of patients were found to be significantly different at the first week for PTA2 (P = 0.033) and PTA3 (P = 0.001), at the second week for PTA1 (P = 0.036), and at the third week for PTA4 (P = 0.002). Our results suggest that the oral isotretinoin (13‐cis retinoic acid), which is a derivative of retinol (vitamin A), improved the hearing level of the patients in all audiometric frequencies in a short‐period follow‐up.

Allergic rhinitis (AR) in geriatric patients

Allergic rhinitis (AR) can be defined as an inflammatory disease of the nose and the paranasal sinuses, characterized by a specific IgE-mediated hypersensitivity reaction. The aim of this study was to evaluate the correlation between the symptoms of AR and the prick test results in geriatric patients presenting with symptoms of AR by comparing these with those of a young control group. Thirty-two geriatric patients (Group 1) were analyzed retrospectively, and 37 patients (Group 2) were selected as the control group. Diagnosis of AR was made based upon the physical examination findings, nasal endoscopic examination findings and the skin prick test results. While the skin prick test positivity was 50% in Group 1, this rate was found as 75.7% in Group 2. The difference was found to be statistically significant (p=0.044). A statistically significant difference was found between the two groups in terms of susceptibility to mugwort pollen and fish (p=0.048, p=0.033). In conclusion, in geriatric patients presenting with AR symptoms, systemic treatment should not be initiated before performing skin prick test, due to the adverse effects of the drugs.

An Unusual Epiglottis Synechiae Managed With Transoral Robotic Surgery in a Patient With Pemphigus Vulgaris

To the Editor: A previously healthy 44-year-old man presented with a 5-month history of progressive dysphagia, hoarseness, and/or dysphonia. He had no tobacco or alcohol consumption. No systemic problems were noted as well. An indirect laryngoscopy revealed a thickened and strictured epiglottis (Fig. 1), and so were the mucosa of the arytenoids, aryepiglottic fold. The lump, rough supraglottis was surgically detached and removed en bloc under general anesthesia with transoral robot-assisted surgery and submitted for histopathologic analysis. The immunohistochemical and histopathologic examinations demonstrated the clinical diagnosis of pemphigus vulgaris. Approximately one month after the treatment, the patient’s speech, swallowing, and breathing were acceptable without significant sequelae (Fig. 2). Pemphigus vulgaris is a life-threatening autoimmune bullous disease that is characterized by the development of intraepithelial blisters on the skin and/or mucosa secondary to immunoglobulin G antibody synthesis against desmoglein, a desmosomal glycoprotein present in keratinocytes. The frequency of laryngeal involvement in pemphigus vulgaris is not known, and most rare reports describe only the presence of such lesions, not their endoscopic location. The robotic da Vinci Surgical System is an evolution in minimally invasive surgery. These advantages enable protection of anatomic structures. The postoperative period is improved in terms of pain, and the healing process and the return of the patient to a normal diet are shorter than those with other methods. A shorter recovery period and a shorter hospital stay are other significant advantages. We report a most surprising finding in this case related to supraglottic manifestation of pemphigus vulgaris. To the best of our knowledge, the massive involvement of the larynx has not been previously described in the upper airways.

Treatment of Recurrent Mixed Infected Laryngocele with Extramucosal Thyrotomy Around Theurepatic Dilemma

Laryngopyocele is a fairly rare disease which is a complication of laryngocele. It is a emergency situation so it needs fast differential diagnosis and treatment. Management of laryngopyoceles include observation, endoscopic resection and resection via an external approach. An external approach is indicated for large or external laryngoceles. The incidence of association between laryngocele and laryngeal carcinoma varies from 1% to 10%. Extramucosal thyrotomy to thyroid cartilage lamina provides adequate visibility of the laryngocele sac.

Apnea/hypopnea index in the evaluation of tongue base procedures: is it enough for the determination of surgical success?

ated with supine as well as total AHI, and there is no significant correlation between the degree of retroglossal narrowing and lateral AHI. In addition, it has been reported to have a significant correlation between lateral AHI and the degree of pharyngeal narrowing at the retropalatal level [3, 4] . Taking all these factors into account, we consider that the sole use of AHI is inappropriate to evaluate retroglossal narrowing. Therefore, AHI and supine AHI should be analyzed separately to evaluate hypopharyngeal airway obstruction. Additionally, in figure 1a, c it looks like the patient had his lingual tonsils removed. Dear Editor, We have read the article by Vicini et al. [1] published in an earlier issue of this journal with great interest. The authors reported an improvement in the apnea/hypopnea index (AHI) following transoral robotic tongue base resection, with a mean AHI reduction from 38.3 to 20.6. It was surprising to see that the authors described few results from polysomnography parameters for hypopharyngeal airway obstruction. However, we think that the sole use of AHI is not enough to evaluate hypopharyngeal airway obstruction [2] . It is well known that the grade of posterior glossal narrowing is significantly associPublished online: July 30, 2010

Multilevel surgery in patients with rapid eye movement-related obstructive sleep apnea

Dr Shemen and colleagues report their experience with Ethicon Endo-Surgery Harmonic ACE (ACE23E model) in thyroid surgery. They also state that our paper, “Modified lateral neck lymphadenectomy: Prospective randomized study comparing harmonic scalpel with clamp-and-tie technique,” failed to mention the potential pitfalls of this device. We would like to point out that the ACE23E model was never mentioned in our paper. All the patients were operated on by a different device, the Harmonic Scalpel CS14C. These shears were designed for videoscopic surgery of the neck, with a 5-mm tip. Their application to lateral neck lymphadenectomy seemed therefore to be a natural evolution in the field of neck surgery. There is an important difference, in fact, between ACE23E and CS14C in terms of coagulation power, the first one being more powerful than the latter. As an obvious consequence, residual heat generated by ACE23E will be higher and more hazardous than that generated by CS14C. For this reason we agree with Dr Shemen’s concern about the use of ACE23E model during thyroid surgery, especially for new users switching from conventional to “energy” techniques. As Dr Shemen found in his previous study, and as we confirmed later, Harmonic Scalpel CS14C can be considered safe, effective, and advantageous in thyroid surgery, significantly reducing operative time, allowing a shorter incision, and minimizing intraoperative and postoperative blood loss. In our study, we found similar results when dealing with neck lymphadenectomy, thus confirming the safety and effectiveness of this device (CS14C) in head and neck surgery. On the other hand, in using ACE23E (probably more useful and effective in abdominal than in head and neck surgery) instead of CS14C during our routine activity, we also encountered the same problems evidenced by Dr. Shemen: burning of adjacent tissues and fracture of the instrument in two cases. The potential hazard of the shears temperature was so evident to the surgical community that a new instrument with different characteristics was recently developed for a specific use in thyroid surgery: Harmonic FOCUS Shear (Ethicon Endo-Surgery Inc, Cincinnati, OH). One of the main differences is that the shears are aluminum, a material that allows much speedier heat dispersion. This makes it possible to dissect, coagulate, and divide vessels with a single instrument, because the hazard of high residual heat is dramatically reduced. Paolo Miccoli, MD Gabriele Materazzi, MD Piero Berti, MD Department of Surgery, University of Pisa Pisa, Italy E-mail, gmaterazzi@yahoo.com