Wolfgang Pirsig

Effect of Nasal Surgery on Sleep-Related Breathing Disorders

Objective/Hypothesis Single cases of patients who have experienced obstructive sleep apnea (OSA) and who recovered completely after nasal surgery have been described in various studies. The purpose of this study was to evaluate the efficacy of only nasal surgery 1) in a group of patients with obstructive sleep apnea and 2) in simple snorers.

Surgery of choanal atresia in infants and children: historical notes and updated review.

This review of the surgical treatment of congenital choanal atresia starts with the first descriptions of the disease and its successful operations in the 19th century. Then, data concerning the facial development of the untreated and surgically corrected disease are presented. After that, advantages and drawbacks of the transnasal, transpalatal and transseptal approaches are discussed.

Tonsillectomy as a treatment of obstructive sleep apnea in adults with tonsillar hypertrophy.

Objectives High surgical success rates for adenotonsillectomy in children with sleep‐related breathing disorders have been described in various studies. The purposes of the present study were to observe how often a substantial tonsillar hypertrophy is associated with obstructive sleep apnea (OSA) in adults and to evaluate the efficiency of a bilateral tonsillectomy.

Impact of Impaired Nasal Breathing on Sleep-Disordered Breathing

Objective: The role of the nose and its importance in the development and severity of sleep-disordered breathing (SDB) is still a matter of discussion. In the first part of this study, often-controversial data and theories about the nose are reviewed concerning its influence on the pathophysiology of SDB and to interpret certain clinical findings connected with impaired nasal breathing. In the second part, the effectiveness of some nonsurgical and surgical therapies is evaluated. Method: A worldwide literature research (Medline) was the basis for this review. Results: The study of the literature on nasal resistance and clinical findings about the effects of incomplete or complete nasal blockage, particularly in comparison of healthy persons and persons with SDB, allows the assumption of the existence of two different groups of responders: a larger group where the importance of the nose for SDB is negligible and a smaller group where the influence of the nose on SDB is crucial. The same seems to hold true for the responses to nonsurgical and surgical treatments with only a few surgical results available in the literature. While the success rate of nasal surgery for patients with obstructive sleep apnea, for instance, seems to be less than 20%, the normalization of nasal resistance often leads to a positive impact on the well-being and the sleep quality of these patients. However, because criteria to identify responders are lacking, the prediction of success of any treatment for the individual with SDB is not possible.

Long-term results in the treatment of obstructive sleep apnea

Abstract No recent update is available on long-term results of the various types of treatment of obstructive sleep apnea (OSA) which can help the physician in evaluating the individually tailored treatment for patients with OSA in the long term. We arbitrarily defined “long-term” results as those after at least 3 years and reviewed the literature from the past 25 years for reports on conservative, apparative, and surgical therapy of OSA in children and adults. Another inclusion criterion was that the diagnosis was also confirmed by polysomnography before treatment and at follow-up. Only relatively few long-term studies meeting the criteria of ‘evidence based medicine’ were found, comparing the findings of these was difficult or impossible due to varying criteria for success. Long-term data were available about the effect of weight reduction, nasal ventilation therapy, oral devices, tonsillectomy, uvulopalatopharyngoplasty, maxillomandibular advancement osteotomies, and tracheotomy. After approx. 25 years many treatment modalities in sleep medicine are still experimental concerning the long-term use for the individual. In particular, randomized controlled trials in surgery are lacking. Late results show that at least 50% of patients with OSA can be treated effectively by one or a combination of treatments. Nasal continuous positive airway pressure, tracheotomy, maxillomandibular advancement osteotomy, and tonsillectomy are the most effective treatments of OSA.

Turbinate hypertrophy in habitual snorers and patients with obstructive sleep apnea: Findings of acoustic rhinometry

Forty‐five habitual snorers (mean respiratory disturbance index = 6) and 22 patients with obstructive sleep apnea syndrome (mean respiratory disturbance index = 36) were examined by polysom‐nography, radiocephalometry, rhinomanometry, na‐sopharyngeal videoendoscopy, and acoustic rhinometry. In 97% of these patients, hypertrophy of the inferior nasal turbinates was found by acoustic rhinometry, while increased nasal resistance of various degrees was measured in 93% of all patients by active anterior rhinomanometry.

Recent Developments in the Treatment of Obstructive Sleep Apnea

Modern sleep medicine has been in existence for only 20 years and therefore has to be regarded as a comparatively recent field of specialization. For this reason it is not surprising that there are numerous new trends and developments concerning the treatment of sleep-related breathing disorders. This review focuses on developments in the treatment of obstructive sleep apnea (OSA) over the last 5 years.The review is based on a Medline bibliographic search using the key words ‘treatment’, ‘obstructive sleep apnea’ and ‘sleep-related breathing disorders’ and covers papers published since 1997, including references in these articles.In respect to conservative treatments the following important developments were found. Oral devices were shown to be effective in about 50–70% of patients with OSA, but at this stage it is not possible to predict in which patients successful treatment can be expected. As subjective compliance averages only about 50%, thermoplastic devices used as trial devices provide a reasonable alternative to reduce costs. Automatic continuous positive airway pressure (CPAP) units have been shown to cut costs when used for pressure titration in severe sleep apneics during the day or when used in so-called split-night procedures in appropriate cases. Nasal CPAP has proven to be effective in children, showing higher compliance rates than in adults. The development of mouth-pieces provides the possibility of using CPAP orally, e.g. after nasal surgery. Electrical stimulation of the tongue muscles shows promising preliminary results. Nevertheless, further research in this field is necessary.In the field of surgery, the most valuable development has been tissue reduction using radiofrequency energy, which has been shown to be effective and minimally invasive. Other fundamentally new surgical techniques have not been attempted within the last 5 years; instead, development in this area appears to be defined by a combination of previously known methods (so-called multilevel surgery) and optimized methods of patient selection. Such combined surgical procedures has achieved success rates of about 70%.Taking all these developments into account, CPAP therapy remains the gold standard for treatment of patients with OSA; yet the low long-term compliance rates of 60–70% have to be regarded as a major challenge warranting further effort.

Patterns of growth in human septal cartilage: a review of new approaches

Recent results of the growth activities of the septal cartilage in children, adolescents, and adults are reviewed. Cartilaginous biopsies were obtained during septoplasty . Matrix synthesis was measured by in vitro incorporation of labeled sulphate; DNA synthesis was measured by in vitro incorporation of labeled thymidine. The cell density of the septal cartilage was determined by cell counting, and chondrocytes were grown in culture in an assay to determine the number of chondrocytes capable of proliferation. With data from these 4 types of experiments 5 different areas could be distinguished in human septal cartilage: (1) anterior free end, (2) suprapremaxillary area, (3) central area, (4) posterior area, and (5) caudal prolongation. Metabolic activities, degree of cell replication, and proliferative capacity are highest in childhood in all areas; they decline with age, but remain surprisingly high in the central area and in the anterior free end, even in adults. These results help to explain some clinical observations and may help the rhinosurgeon in his decision to resect the septal cartilage, especially in children.

Uvulopalatopharyngoplasty changes fundamental frequency of the voice - a prospective study

The aim of the study was to find whether a muscle-sparing uvulopalatopharyngoplasty (UPPP) and tonsillectomy cause a measurable change in the voice. The fundamental frequency and the first two formants of five sustained vowels were measured before and nine (six to 15) months following operation. The operation consisted of tonsillectomy and UPPP with preservation of the musculature of the soft palate. All patients received a pre- and post-operative 12-canal polysomnography (level-I sleep study). No patient showed signs of any post-operative velopharyngeal insufficiency. Acoustic analysis showed a significant raising of the fundamental frequency of up to 10 Hz. There was also a lowering of the second formant in two of the five vowels. This was correlated with the volume of the excised tissue. The minimal changes will probably have no significance for those who place no special reliance on their voice, but the possible post-operative changes should be made clear to singers and those relying on their voice for professional reasons.

Reconstruction of Anterior Nasal Septum: Back‐to‐Back Autogenous Ear Cartilage Graft

Objectives/Hypothesis The ideal material for reconstructing the nasal septum in the deficient nose has not been found. Since 1986, the authors have used autogenous cartilage from the cavum conchae to successfully correct the anterior septum and the associated cartilaginous saddle. The long‐term results in 26 patients with a destroyed septum and a saddle nose are reported.