Sherif M. Askar

Button battery foreign bodies in children: hazards, management, and recommendations.

Objective. The demand and usage of button batteries have risen. They are frequently inadvertently placed by children in their ears or noses and occasionally are swallowed and lodged along the upper aerodigestive tract. The purpose of this work is to study the different presentations of button battery foreign bodies and present our experience in the diagnosis and management of this hazardous problem in children. Patients and Methods. This study included 13 patients. The diagnostic protocol was comprised of a thorough history, head and neck physical examination, and appropriate radiographic evaluation. The button batteries were emergently extracted under general anesthesia. Results. The average follow-up period was 4.3 months. Five patients had a nasal button battery. Four patients had an esophageal button battery. Three patients had a button battery in the stomach. One patient had a button battery impacted in the left external ear canal. Apart from a nasal septal perforation and a tympanic membrane perforation, no major complications were detected. Conclusion. Early detection is the key in the management of button battery foreign bodies. They have a distinctive appearance on radiography, and its prompt removal is mandatory, especially for batteries lodged in the esophagus. Physicians must recognize the hazardous potential and serious implications of such an accident. There is a need for more public education about this serious problem.

Olfactory Bulb Volume Changes in Patients with Sinonasal Polyposis: A Magnetic Resonance Imaging Study

Objectives The olfactory bulb (OB) is thought to be a plastic structure with highly active afferent neurons. The aim of this study was to evaluate the effect of olfactory deprivation caused by sinonasal polyps on OB volume. Study Design Cross-sectional study. Setting Tertiary university hospital, Department of Otolaryngology. Subjects and Methods Twenty-two subjects were included: 11 adult patients with bilateral allergic sinonasal polyposis (patient group) and 11 adult healthy controls (control group). Both study groups were matched for age and sex. OB volumes in all study subjects were evaluated in T2-weighted coronal MRI images by planimetric manual contouring. Results In the patient group, OB volume measurements ranged from 5.2 to 19.5 mm3 (mean ± SD, 10.14 ± 3.8). In the control group, volume measurements ranged from 35 to 75.8 mm3 (mean ± SD, 47.66 ± 10.75). The difference in OB volumes between patient and control groups was statistically significant (P < .001). Conclusion Our study highlights the significant reduction in OB volume in patients with bilateral sinonasal polyposis as compared with its volume in healthy controls. Further studies are required to evaluate the impact of OB volume reduction on olfactory recovery postoperatively.

Powered instrumentation for transnasal endoscopic partial adenoidectomy in children with submucosal cleft palate

OBJECTIVES Partial adenoidectomy is the selective removal of the obstructing part of adenoid tissue, thus relieves obstruction symptoms and preserves the velopharyngeal valve action. Patients with palatal dysfunction are candidates for the technique. This study describes the use of microdebrider, transnasally (guided by the nasal endoscope) to perform partial adenoidectomy in patients with submucosal cleft palate, who presented with adenoidal hypertrophy and also it discusses its effects on nasal obstruction and speech. SUBJECTS AND METHODS This prospective study was carried out on twenty-three submucosal cleft palate patients who were referred to the ORL-HN department; Zagazig University Hospitals complaining of respiratory obstruction and sleep disturbances due to adenoids hypertrophy. After preoperative nasoendoscopic and speech evaluation, transnasal endoscopic, power-assisted partial adenoidectomy was done for all patients. All patients were followed up at regular visits including nasoendoscopy and speech evaluation. RESULTS The procedure insured fast, safe, reliable, under vision and well controlled steps. Intraoperatively no major complications were recorded. During follow up, nasal obstruction and respiratory obstruction symptoms were improved. Speech outcome results were reported. CONCLUSION The study demonstrates the feasibility of using the microdebrider for performing transnasal partial adenoidectomy (under endoscopic guidance). The procedure is precise, rapid, safe and well-tolerated with the advantage of direct visualization of a traditionally difficult-to-expose area. The study reported improvement of respiratory obstruction symptoms with good speech results.

Single Triangular Suture: A Modified Technique for Hyoid Suspension as a Treatment for Obstructive Sleep Apnea: our experience with twenty four patients

1 Hyoid suspension is a part of a multilevel surgery concept that is often combined with other procedures as uvulopalatopharyngoplasty to treat obstructive sleep apnea. 2 Between February 2012 and November 2016, twenty- four patients underwent the single triangular suture technique for hyoid suspension as a treatment for obstructive sleep apnea. 3.Successful outcome was reported in 12 patients, while 9 patients were responders (reduced cardiovascular risk). 4.Postoperatively, the mean AHI dropped significantly and the mean lowest oxygen saturation level increased significantly. 5.The procedure is safe, well-tolerated by patients and has a readily progressive learning curve. It is an economic and less traumatic maneuver. This article is protected by copyright. All rights reserved.

Endoscopic-assisted sphincter pharyngoplasty (EASP)

OBJECTIVES Sphincter pharyngoplasty operation was designed for the treatment of velopharyngeal insufficiency via a transoral route. Few investigators used palatal stretching sutures or palatal splitting procedures (which may affect the performance of the palate) to overcome the problem of difficult visualization. The purpose of this study is to present and evaluate the role of intraoperative nasoendoscopy during sphincter pharyngoplasty. Although Vadodaria et al. (2004) (in a cadaver study) used the endoscope to perform SP operation, this study (to our knowledge) is the first report of intraoperative nasoendoscopy in sphincter pharyngoplasty. SUBJECTS AND METHODS This prospective study was conducted at ORL-HN Department, Zagazig University Hospitals, Zagazig University, Egypt. Seven patients with persistent postoperative hypernasality were enrolled in this work. They were prepared by head and neck physical examination and phonetic evaluation. Patients were subjected to treatment by endoscopic-assisted sphincter pharyngoplasty, a procedure that was designed to combine both a transoral and a transnasal routes via the aid of nasoendoscope. Postoperative nasoendoscopic and phonetic assessment was done for all of the patients. RESULTS The procedure is easily conducted, done by available instruments with no extra burden over patients or hospitals. The procedure insured an under vision and well controlled steps. No major complications were recorded. Good speech outcome results were reported. CONCLUSION Endoscopic-assisted sphincter pharyngoplasty is a new role the nasoendoscopy can play. The study demonstrates the feasibility of endoscopic assistance in sphincter pharyngoplasty, with the advantage of improved visualization of a traditionally difficult-to-expose area. There was neither increased risk to the patients nor added cost to the procedure since only widely-available instrumentation was used. The technique lessened the need for palatal stretching or splitting during the procedure.

5 years follow up after transnasal endoscopic surgery of Thornwaldt's cyst with powered instrumentation

OBJECTIVE To assess the long term results of a transnasal endoscopic, power-assisted marsupilization of Thornwaldts cyst (TC). METHODS Patients who were operated and followed up at our institution for the management of symptomatic TC in the period from February 2002 till May 2012 were included in the study. All the patients were operated through a transnasal endoscopic power-assisted marsupilization of the cyst. RESULTS Eleven patients with a diagnosis of TC (by nasaoendoscopy, CT and MRI) were included in this study. They included six males and five females with age ranging from 15 to 55 years. Transnasal endoscopic, power-assisted marsupilization was performed for all cases with no intra- or postoperative complications. Throughout 5 years follow up, no recurrence of the cyst or its related symptoms were reported. CONCLUSION Long term (5 years) follow up showed that transnasal endoscopic marsupilization of Thornwaldts cyst using micodebrider is a safe and effective maneuver with no cyst recurrence, eustachian tube affection or post-operative complications.

Hyoid Bone Suspension as a Part of Multilevel Surgery for Obstructive Sleep Apnea Syndrome

Introduction  Since oropharyngeal surgery alone is often insufficient to treat obstructive sleep apnea (OSA), advances have been developed in hypopharyngeal surgery. Objective  To assess hyoid suspension surgery as part of a multilevel OSA surgery, also including palatal surgery. Methods  The study included patients with OSA symptoms with apnea hypopnea index (AHI) > 15. They were scheduled for hyoid suspension after a nasoendoscopy during Müller maneuver and drug induced sleep endoscopy (DISE). All patients had body mass index (BMI) < 35 kg/m2. Hyoidothyroidopexy combined with tonsillectomy and palatal suspension was performed in all cases. Results  The mean AHI dropped significantly ( p  < 0.0001) from 68.4 ± 25.3 preoperatively to 25.6 ± 9.52 postoperatively. The mean lowest oxygen (O 2 ) saturation level increased significantly from 66.8 ± 11.3 to 83.2 ± 2.86 ( p  < 0.0001). In addition, the snoring score significantly decreased ( p  < 0.0001) from a preoperative mean of 3.4 ± 0.54 to 2 ± 0.7 at 6 months postoperatively. In regard to the Epworth sleepiness scale (ESS), it showed significant improvements ( p  < 0.0001) as its mean diminished from 13.8 ± 5.4 preoperatively to 5.2 ± 1.6 postoperatively. Conclusion  Hyoidothyroidopexy using absorbable suture seems to produce a good outcome in treating OSA. It could be effectively and safely combined with other palatal procedures in the multilevel surgery for OSA.

Ipsilateral Reduced Olfactory Bulb Volume in Patients with Unilateral Nasal Obstruction

Objectives To evaluate the effect of unilateral nasal obstruction (by nasal polyps of different histopathology) on olfactory bulb volume using MRI technique. Study Design Cross-sectional study. Setting Tertiary university hospitals, Departments of Otolaryngology and Radiology. Subjects and Methods Eleven patients with a few months of complete unilateral nasal obstruction of different pathological etiologies were selected. MRI assessment of olfactory bulb volume was performed using planimetric manual contouring. The contralateral olfactory bulb was used as a comparative control for the same patient. Eleven healthy controls constituted the control group. Results Mean olfactory bulb volume ±SD of obstructed side = 14.3 ± 3.7 mm3, mean olfactory bulb volume ±SD of nonobstructed side = 43.49 ± 10.7 mm3. The difference between the 2 sides was significant (P = .003). The difference in olfactory bulb volume between normal subjects and nonobstructed nasal side was statistically nonsignificant (t = .9118, P = .3727), while the difference between normal subjects’ olfactory bulb volume and obstructed nasal side olfactory bulb volume in our patients was extremely statistically significant (t = 9.7320, P < .0001). A strong negative correlation was found between duration of obstruction and olfactory bulb volume (R = −0.9761). Conclusion This study shows that unilateral nasal obstruction may be associated with a lateralized ipsilateral difference of olfactory bulb volume.

Cephalic de-mucosalized superiorly-based pharyngeal flap: A modified mucosa-preserving technique for velopharyngeal insufficiency

INTRODUCTION Superiorly-based pharyngeal flap (PF) is the most frequently employed surgical technique to correct velopharyngeal insufficiency (VPI). Bared posterior pharyngeal wall might prolong the period of convalescence with throat pain and discomfort. Delayed donor site healing problems and subsequent fibrosis with downward migration of the transposed flap might be one a cause of failure and might necessitate revision. AIM OF THE WORK To present a modified technique of PF aiming at dealing with the problems of donor site defects via immediate self-mucosal covering of the cephalic portion of the bed. METHODS This case series study was conducted on patients with persistent VPI. All patients underwent the new modified technique of cephalic de-mucosalized pharyngeal flap (CDPF). The basic premise was to harvest a laterally-based mucosal flap from the upper part of the posterior pharyngeal wall. A superiorly-based pharyngeal flap (with a bared cephalic segment and a mucosalized caudal segment) was elevated off the posterior pharyngeal wall and inserted in the soft palate. Then the laterally-based mucosal flap was spread over the superior part of donor site of the posterior pharyngeal wall. RESULTS 13 VPI patients were included in this study. Their age ranged from 5 to 12 years with a mean of 5.6 ± 1.2. The follow-up period ranged from 8 to 14 months. All flaps and beds were completely healed within 2-3 weeks and no patients showed flap dehiscence, infection or palatal fistula. Postoperative speech assessment showed significant improvement of velopharyngeal function, resonance balance, and reduction in nasal emission. CONCLUSIONS The modified technique provides an immediate self-mucosa cover to the superior part of the posterior pharyngeal wall, thus it could promote primary healing at the donor site with a short period of convalescence. CDPF separates the two opposing raw surfaces of the flap and the posterior pharyngeal wall. The mucosal flap might guard against downward migration of the flap.

De-mucosalized pharyngeal flap: a modified technique for selected cases of velopharyngeal insufficiency

Background and purposeSuperiorly based posterior pharyngeal flap is performed via rotation of tissues of the posterior pharyngeal wall anteriorly and anchoring it to the soft palate. Unfortunately, bad healing of the donor site defect might be a considerable cause of morbidity of the surgery. With some modifications of flap elevation we could achieve better surgical outcomes. The aim of this study was to present the new modification of the conventional maneuver and its surgical/functional outcomes.Subjects and methodsThe study design is a case series. 17 patients underwent the de-mucosalized superiorly based pharyngeal flap for the treatment of velopharyngeal insufficiency. A wide laterally based (mucosa-only) flap was elevated off the submucosa of the posterior pharyngeal wall and then a superiorly based posterior pharyngeal flap (bared of its covering mucosa) was elevated and sutured to the palate. The mucosal flap was draped over the bed and sutured.ResultsNo significant complications as airway problems, infection and bleeding were reported. Also, the postoperative pain was tolerable and there were no reports of neck rigidity with early ambulation; VAS showed significant improvement. No patients showed flap dehiscence or palatal fistula. Speech assessment showed improvement.ConclusionThe modified de-mucosalized, superiorly based pharyngeal flap technique ensured self-mucosal draping of the bed, thus it would enhance primary healing and decrease postoperative pain with the resultant early ambulation. We believe that the new modified technique could correct VPI, in addition to the improvement of patients’ comfort and decrease the morbidity of the procedure.