[Tumorectomy by trans-oral approach of macrosis benign neoplasms in parapharyngeal space (reports of 6 cases)]

OBJECTIVE

To discuss the feasibility of tumorectomy by transoral approach of macrosis benign neoplasms in parapharyngeal space.

METHOD

Retrospective analyze 6 patients of macrosis benign neoplasms in parapharyngeal space from January 2005 to May 2008, and all neoplasms were removed by transoral approach. Tracheotomy was performed in 3 cases.

RESULT

The neoplasms were all removed completely and successfully, and postoperative recovery were good and no complications were found. There were 2 cases of neurofibroma, 2 cases of neurilemmoma, 2 cases of pleomorphic adenoma. There are no recurrence after 20 months to 5 years follow-up.

CONCLUSION

Preoperative imaging examination is very important for diagnosis and treatment of benign neoplasm in parapharyngeal space, which is especially helpful to understand the scope of the tumor, and the relationship with carotid artery and vein. On this basis, it is feasible to select the appropriate cases to resect huge benign neoplasm in parapharyngeal space.

Cone beam CT for diagnosis and treatment planning in trauma cases

Three-dimensional imaging offers many advantages in making diagnoses and planning treatment. This article focuses on cone beam CT (CBCT) for making diagnoses and planning treatment in trauma-related cases. CBCT equipment is smaller and less expensive than traditional medical CT equipment and is tailored to address challenges specific to the dentoalveolar environment. Like medical CT, CBCT offers a three-dimensional view that conventional two-dimensional dental radiography fails to provide. CBCT combines the strengths of medical CT with those of conventional dental radiography to accommodate unique diagnostic and treatment-planning applications that have particular utility in dentoalveolar trauma cases. CBCT is useful, for example, in identifying tooth fractures relative to surrounding alveolar bone, in determining alveolar fracture location and morphology, in analyzing ridge-defect height and width, and in imaging temporomandibular joints. Treatment-planning applications include those involving extraction of fractured teeth, placement of implants, exposure of impacted teeth, and analyses of airways.

Oropharyngeal airway in children with Class III malocclusion evaluated by cone-beam computed tomography

INTRODUCTION

Upper airway size is increasingly recognized as an important factor in malocclusion. However, children with Class III malocclusion are somewhat neglected compared with those with a Class II skeletal pattern. Therefore, the purpose of this study was to establish the characteristic shape of the oropharyngeal airway (OA) in children with Class III malocclusion.

METHODS

The sample comprised 45 children (average age, 8.6 +/- 1.0 years) divided into 2 groups: 25 with Class I and 20 with Class III malocclusions. OA size of each group was evaluated by cone-beam computed tomography. Cluster analysis, based on OA shape, redivided the subjects into wide, square, and long types. The distributions of Class I and Class III subjects were compared among the types.

RESULTS

The Class III group showed statistically larger OA area and width compared with the Class I group. Area was positively correlated with Class III severity. The square type included 84% of the Class I malocclusions but only 30% of the Class III malocclusions, indicating that the OA in Class III malocclusion tends to be flat.

CONCLUSIONS

The Class III malocclusion is associated with a large and flat OA compared with the Class I malocclusion.

Acute upper airway obstruction caused by Stenotrophomonas maltophilia soft tissue infection

A previously healthy 71-y-old male developed acute upper airway obstruction caused by a Stenotrophomonas maltophilia infection of the mucocutaneous and soft tissue of the neck. Ventilator support was provided via a small-calibre endotracheal tube. Stenotrophomonas was susceptible only to levofloxacin and cotrimoxazole. Antibiotic therapy rapidly improved the soft tissue oedema, allowing extubation and discharge from the intensive care unit.

Effects of mouthpiece use on airway openings and lactate levels in healthy college males

Research has described the use of mouthpieces not only in preventing oral-facial injuries, but linking use to improvements in muscular strength and endurance. However, the mechanisms by which these improvements occur have not been elucidated. The purpose of this study was to understand possible physiological explanations for improvements in exercise performance with the use of a mouthpiece. Specifically, this study focused on differences in lactate levels after 30 minutes of endurance exercise with and without a mouthpiece. In addition, computed tomography (CT) scans were taken of the cross-sectional area of the oropharynx in each participant (N = 10) with and without a mouthpiece. CT scans showed a significant difference in mean width (28.27 mm with the mouthpiece vs 25.93 mm without the mouthpiece, P = .029) and an increase in mean diameter with a mouthpiece (12.17 mm vs 11.21 mm, P = .096). Lactate levels were lowered with the mouthpiece at 1.86 mmol/L vs 2.72 mmol/L without mouthpiece. This research suggests that there is an improvement in endurance performance that may be linked to improved airway openings resulting from the use of a mouthpiece. Future studies should continue to clarify the possible mechanisms for these exercise outcomes as well as to understand the optimal mandibular advancement to elicit these exercise improvements.

Aggressive fibromatosis of the oropharynx: a multidisciplinary approach to a benign disease

We present the case of a 23-year-old woman with aggressive fibromatosis of the oropharynx that was initially treated elsewhere as a peritonsillar abscess. We discuss the characteristics of this rare tumor and review the literature, stressing the importance of postoperative follow-up for peritonsillar abscesses to avoid missing other important diagnoses, such as the one described here.

Anatomic development of the oral and pharyngeal portions of the vocal tract: an imaging study

The growth of the vocal tract (VT) is known to be non-uniform insofar as there are regional differences in anatomic maturation. This study presents quantitative anatomic data on the growth of the oral and pharyngeal portions of the VT from 605 imaging studies for individuals between birth and 19 years. The oral (horizontal) portion of the VT was segmented into lip-thickness, anterior-cavity-length, oropharyngeal-width, and VT-oral, and the pharyngeal (vertical) portion of the VT into posterior-cavity-length, and nasopharyngeal-length. The data were analyzed to determine growth trend, growth rate, and growth type (neural or somatic). Findings indicate differences in the growth trend of segments/variables analyzed, with significant sex differences for all variables except anterior-cavity-length. While the growth trend of some variables displays prepubertal sex differences at specific age ranges, the importance of such localized differences appears to be masked by overall growth rate differences between males and females. Finally, assessment of growth curve type indicates that most VT structures follow a combined/hybrid (somatic and neural) growth curve with structures in the vertical plane having a predominantly somatic growth pattern. These data on the non-uniform growth of the vocal tract reveal anatomic differences that contribute to documented acoustic differences in prepubertal speech production.

Value of lateral neck radiography for ingested foreign bodies using the likelihood ratio

OBJECTIVE

To determine the diagnostic accuracy of lateral neck radiography and its value in related radiographic findings in the detection of foreign bodies using the likelihood ratio.

PATIENTS AND METHODS

This retrospective study comprised 114 patients who had neck radiography followed by rigid esophagoscopy. Interpretations of the radiographs were correlated with esophagoscopic findings and clinical follow-up for at least 1 month. Data were mainly assessed by likelihood ratio and detection rate.

RESULTS

Plain radiography had a positive likelihood ratio of 2.4 (95% confidence interval [CI] 1.8-3.1) and a negative likelihood ratio of 0.6 (95% CI 0.40-0.7). It had a sensitivity of 57.4% (95% CI 45.6-69.1) and a specificity of 76.1% (95% CI 63.8-88.4). Positive likelihood ratios for each radiographic finding (foreign body shadow, air, and soft tissue swelling) were 3.4 (95% CI 2.6-4.4), 1.5 (95% CI 0.9-2.6), and 4.1 (95% CI 1.9-8.7), respectively. Plain radiography had a high detection rate (72.5%) when foreign bodies were lodged in the hypopharynx and cervical esophagus. On the contrary, the detection rate was poor (0%) in the oropharynx.

CONCLUSIONS

A lateral neck radiograph is better taken after a negative finding in a thorough oral examination and fibre-optic laryngoscopy. Judging from the possible site of impacted foreign body and radiographic findings, we can better predict the presence of foreign bodies.

Formant frequencies of normal breath sounds of snorers may indicate the risk of Obstructive Sleep Apnea Syndrome

Several differences between the airway of normal subjects and those with OSAS are well known. The characteristics of the upper airway may be indirectly studied through the formant frequencies of breathing sounds. In this work we analyze the formants of inspiration and exhalation sounds in snoring subjects with and without OSAS. Formant frequencies of inspiration and exhalation appear in the same bands as snores. Formant F1 is significantly lower in inspiration episodes of OSAS patients (p=0.008) with a decreasing tendency as the AHI increases (r=-0.705). In addition, this formant has a significantly higher variability SF1 in pathological subjects, for both inspiration (p=0.022) and exhalation (p=0.038) episodes, as was previously found in snores. A higher variability of formant frequencies seems to be an indicator of the presence of OSAS. The proposed technique could allow the identification of OSAS patients from normal breathing alone.

Dimensions for midline and paramidline andibulotomy: a radiographic study in the dentate Thai population

BACKGROUND

Mandibulotomy is an important surgical approach of the oral cavity, oropharynx, and parapharyngeal space.

OBJECTIVE

To provide dimensions for placement of bone cuts for midline (between two central incisors) and paramidline (between lateral incisor and canine) mandibulotomy.

MATERIAL AND METHOD

Two hundred and sixteen periapical radiographs with the mandibular anterior teeth of 72 healthy Thai dental patients (30 males, 42 females) were selected. The angles between the long axes of the two central incisors (M) and between the lateral incisor and canine (PM) were bilaterally measured using computerized imaging. The horizontal distances (at crestal, middle, and apical levels) between the roots and the alveolar bone heights of the aforementioned teeth were also measured.

RESULTS

The angles between the PM (0.00-9.26 degrees) were less convergent than those between the M (0.00-11.66 degrees) (p < 0.05). The distances between the PM were 0.60-8.03 mm, whereas those between the M were 0.47-6.63 mm (p < 0.05). Mean alveolar bone height is 15.88 +/- 1.72 mm in the canine.

CONCLUSION

The paramidline mandibulotomy is done in a wider space than the midline cut and could have a better chance to avoid the extraction of a central incisor and preserve the origin of the genioglossus, geniohyoid, and digastric muscles.

Assessment of swallowing by oropharyngoesophageal scintigraphy in patients with amyotrophic lateral sclerosis

Amyotrophic lateral sclerosis (ALS) is the most common degenerative motor neuron disease in adults, and dysphagia is one of its most frequent and disabling symptoms. Oropharyngoesophageal scintigraphy (OPES) permits a functional and semiquantitative study of the various stages of swallowing. We studied 28 ALS patients (12 females and 16 males; mean age = 63.57 +/- 10.39 yr SD), who were clinically rated against the ALSFRS scale (Amyotrophic Lateral Sclerosis Functioning Rating Scale) and underwent OPES with (99m)Tc-nanocolloid using either a liquid or a semisolid bolus. The semiquantitative parameters we analyzed were Oral Transit Time (OTT), Pharyngeal Transit Time (PTT), Esophageal Transit Time (ETT), Retention Index (RI), and Esophageal Emptying Rate (EER(10s)). Hence, the OPES performed with a semisolid bolus produced a higher proportion of pathologic values for the swallowing variables than when liquid bolus was used. Analyzed by grouping the patients into classes according to their bulbar ALSFRS scores, we found a significant increase in the OTT (p < 0.005), PTT (p < 0.02), and Oropharyngeal Retention Index (OPRI) (p < 0.0004) variables in ALS patients with more severe bulbar involvement. OPES has turned out to be a very important examination for detecting tracheal-bronchial inhalation and it also offers the possibility of acquiring a semiquantitative evaluation of the amount of food inhaled. In our experience, OPES in patients with ALS has been easy to use, economic, well tolerated, and capable of supplying precise indications with regard to the extent of the swallowing disorder, which permits a better clinical definition of the ALS patient.

Radiation doses to children during modified barium swallow studies

BACKGROUND

There are minimal data on radiation doses to infants and children undergoing a modified barium swallow (MBS) study.

OBJECTIVE

To document screening times, dose area product (DAP) and effective doses to children undergoing MBS and to determine factors associated with increased screening times and effective dose.

MATERIALS AND METHODS

Fluoroscopic data (screening time, DAP, kVp) for 90 consecutive MBS studies using pulse fluoroscopy were prospectively recorded; effective dose was calculated and data were analyzed for effects of behavior, number of swallow presentations, swallowing dysfunction and medical problems.

RESULTS

Mean effective dose for the entire group was 0.0826 +/- 0.0544 mSv, screening time 2.48 +/- 0.81 min, and DAP 28.79 +/- 41.72 cGy cm2. Significant differences were found across three age groups (<or=1.0, >1.0-3.0 and >3.0 years) for effective dose (mean 0.1188, 0.0651 and 0.0529 mSv, respectively; P < 0.001), but not for screening time or DAP. Effective dose was correlated with screening time (P = 0.007), DAP (P < 0.001), number of swallow presentations (P = 0.007), lower age (P = 0.017), female gender (P = 0.004), and height (P < 0.001). Screening time was correlated with total number of swallow presentations (P < 0.001) and DAP (P < 0.001).

CONCLUSION

Screening times, DAP, effective dose, and child and procedural factors associated with higher effective doses are presented for children undergoing MBS studies.

Spacer inhalation technique and deposition of extrafine aerosol in asthmatic children

The aim of the present study was to measure airway, oropharyngeal and gastrointestinal deposition of (99m)Tc-labelled hydrofluoroalkane-beclomethasone dipropionate after inhalation via a pressurised metered-dose inhaler and spacer (Aerochamber Plus) in asthmatic children. A group of 24 children (aged 5-17 yrs) with mild asthma inhaled the labelled drug. A total of 12 children took five tidal breaths after each actuation (tidal group). The other 12 children used a slow maximal inhalation followed by a 5 - 10-s breath-hold (breath-hold group). Simultaneous anterior and posterior planar gamma-scintigraphic scans (120-s acquisition) were recorded. For the tidal group, mean+/-sd lung deposition (% ex-actuator, attenuation corrected) was 35.4+/-18.3, 47.5+/-13.0 and 54.9+/-11.2 in patients aged 5-7 (n = 4), 8-10 (n = 4) and 11-17 yrs (n = 4), respectively. Oropharyngeal and gastrointestinal deposition was 24.0+/-10.5, 10.3+/-4.4 and 10.1+/-6.2. With the breath-hold technique, lung deposition was 58.1+/-6.7, 56.6+/-5.2 and 58.4+/-9.2. Oropharyngeal and gastrointestinal deposition was 12.9+/-3.2, 20.1+/-9.5 and 20.8+/-8.8. Inhalation of the extrafine formulation with the breath-hold technique showed significantly improved lung deposition compared with tidal breathing across all ages. Oropharyngeal and gastrointestinal deposition was markedly decreased, regardless of which inhalation technique was applied, compared with a previous paediatric study using the same formulation delivered via a breath-actuated metered-dose inhaler.

Biopsy of deep-seated head and neck lesions under intraoral ultrasound guidance

Although transcutaneous ultrasound combined with fine-needle aspiration is often used as initial modality for evaluating superficial neck masses, its role in management of deep-seated neck masses is limited. Intraoral ultrasound and guided biopsy helps in obtaining tissue from deep-seated neck masses for an accurate histologic diagnosis, providing useful information in treatment planning. This article discusses the role of intraoral ultrasound and presents 3 cases in which biopsy of deep-seated neck masses under intraoral ultrasound guidance helped in diagnosis and management.

Brief report: a red streak in the lateral recess of the oropharynx predicts acute sinusitis

OBJECTIVE

To evaluate the oropharyngeal red streak sign for diagnosing acute sinusitis.

DESIGN

Exploratory cohort study.

SETTING

A Veterans Affairs medical center urgent care center.

PARTICIPANTS

Sixty consecutive subjects presenting with nasal symptoms lasting 4 weeks or less.

MEASUREMENTS AND MAIN RESULTS

Each subject underwent a structured history and physical examination, followed by a sinus computed tomography (CT) scan. Acute sinusitis was defined by an air-fluid level or opacification of 1 or more sinuses on CT imaging. Twenty-seven subjects were diagnosed with sinusitis. A localized red streak in the lateral recess of the oropharynx was associated with sinusitis, with a positive likelihood ratio (LR+) and 95% confidence interval (CI) of 2.11 (1.23, 3.63) and a negative likelihood ratio (LR-) and 95% CI of 0.44 (0.24, 0.83). Opacity on maxillary or frontal sinus transillumination was also associated with sinusitis (LR+ of 1.89; CI 1.03, 3.32 and LR- of 0.56; CI 0.32, 0.96). Symptom duration > 10 days was associated with acute sinusitis with an LR+ of 1.89 (1.06, 3.59). A history of facial pain (LR+ of 0.59; CI 0.39, 0.90 and LR- of 2.85; CI 1.27, 6.41) and the finding of sinus percussion tenderness (LR+ of 0.22; CI 0.05, 0.90 and LR- of 1.88; CI 1.17, 3.03) were inversely associated with sinusitis.

CONCLUSIONS

The oropharyngeal red streak may be an accurate physical sign for diagnosing acute sinusitis. This sign should be included in future studies of clinical diagnostic criteria for acute sinusitis.

Pre-anesthetic evaluation can play a crucial role in the determination of airway management in a child with oropharyngeal tumor

We experienced a case of a huge hemangioma occupying the oropharyngeal space in an 11-year-old child. Although urgent surgical tracheostomy under local anesthesia was suggested initially, medical interview and findings of computerized tomography and fiberoptic laryngoscopy revealed that the airway of the patient was relatively stable when she was in the semi-left decubitus position. General anesthetic induction would have had potential risks of airway obstruction. Thus, after placing the patient in the semi-left decubutus position, we chose semi-awake induction to secure the airway. With a small dose of fentanyl, we accomplished orotracheal intubation. In this report, we discuss the importance of referring to an airway management algorithm when encountering a difficult airway.

Sex differences in prenatal oral-motor function and development

The aim of this study was to investigate sex-related differences in the prenatal development of early oral, lingual, pharyngeal, and laryngeal motor activities. Sonographic images of oral-upper airway regions were observed in 85 healthy fetuses (43 males, 42 females; mean gestational age 24wks 3d [SD 0.69]; range 15-38wks). Biometric data on morphologic development and associated motor patterns were compared across second and third trimesters. Results showed that while males and females demonstrated statistically similar patterns of general physical growth (p>0.05), significant differences in development of specific lingual and pharyngeal structures were present (p<0.05). Significant differences were found for laryngeal and pharyngeal motor activity, and oral-lingual movements (p<0.05). Complex oral-motor and upper airway skills emerged earlier in females, suggesting a sex-specific trajectory of motor development. It was concluded that differential patterns of prenatal motor development may be important in defining sex-specific indices of oral skill maturation.

Dynamic swallowing study and radiation dose to patients

PURPOSE

The purpose of this study was to define an optimal radiological procedure to evaluate the results of rehabilitation therapy for swallowing disorders and to calculate both the effective and organ dose to the patient to provide a measure of the radiation risk associated with the procedure.

MATERIALS AND METHODS

In order to define the optimal radiological procedure, kerma-area product (KAP) measurements and evaluations of image quality in fluoroscopy and fluorography mode were made using dedicated phantoms. Twenty-two patients were included in the study, and the values of KAP, screening time and average voltage selected were individually recorded. The recorded KAP values were used to estimate radiation risk with the use of dedicated calculation software.

RESULTS

Median, first and third quartiles of the KAP distribution were, respectively, 2.1, 1.5 and 2.7 Gy cm2, with a corresponding effective dose of 0.35, 0.26 and 0.46 mSv. A good correlation between KAP and exposure time was also found (R2=0.85). Exposure of the thyroid, which is inside the radiation field, accounts for the greatest share to the effective dose, with a calculated median dose of 6 mGy.

CONCLUSIONS

With the defined radiological procedure, the obtained KAP values are lower than recorded doses in interventional radiology, and the corresponding values of entrance skin dose are lower than the threshold dose for deterministic effects. Considering the effective dose at the median KAP value, the probability for stochastic effects is shown to be low, at approximately 1 in 39,000.

CT and MRI findings of a solitary extramedullary plasmacytoma of the oropharynx: case report

We report a case of solitary extramedullary plasmacytoma (SEP) of the oropharynx. A 53-year-old man presented who had had bloody phlegm and a sore throat for a few days. A mass was endoscopically detected in his right posterior oropharyngeal wall, and biopsy revealed a neoplasm consisting of a uniform population of plasma cells. Computed tomography (CT) showed a broad-based papillary soft tissue density mass projecting into the oropharynx from the right posterior wall of the pharynx, and post-contrast CT showed marked enhancement of the tumor. The tumor showed slightly higher signal intensity compared with surrounding muscle on MR Tl-weighted images (T1WI) and high signal intensity on MR T2-weighted images (T2WI). The mass showed homogeneous enhancement on post-contrast T1WI. Further clinical examination showed an absence of multiple myeloma (MM). The patient was diagnosed as having SEP. Following radiation therapy, a reduction in tumor size was observed. Although SEP is a rare tumor, it should be included in the differential diagnosis of tumors of the oropharynx because of its imaging similarities to other, more common malignant tumors, such as squamous cell carcinoma and lymphoma.

High lung deposition of 99mTc-labeled ciclesonide administered via HFA-MDI to patients with asthma

OBJECTIVE

To examine the deposition and pharmacokinetics of ciclesonide administered via hydrofluoroalkane-metered dose inhaler (HFA-MDI) in patients with asthma.

METHODS

Twelve patients with mild asthma (FEV1, 95% predicted) inhaled a single dose of 99mtechnetium (Tc)-ciclesonide 320 microg ex-actuator (400 microg ex-valve). Deposition of ciclesonide in the lung and oropharynx was quantified using two-dimensional (2D)-gamma scintigraphy. Three-dimensional single photon emission computed tomography (3D SPECT) was used to assess the regional distribution of ciclesonide in the lung. The pharmacokinetics of ciclesonide and its active metabolite, desisobutyryl-ciclesonide (des-CIC), were determined by liquid chromatography-tandem mass spectrometry. Ciclesonide and des-CIC concentrations were determined in mouth-rinsing solutions.

RESULTS

2D-gamma scintigraphy indicated that ciclesonide deposition was higher in the whole lung (52%) than in the oropharynx (32.9%). Furthermore, 3D SPECT revealed that ciclesonide deposition within the lungs was highest in the peripheral regions that contain the small airways and alveoli. The pharmacokinetic profile of Tc-labeled ciclesonide and des-CIC was similar to that obtained after inhalation of non-labeled formulations in previous studies. Des-CIC accounted for 14.9% of the total molar concentration of ciclesonide/des-CIC in mouth-rinsing solutions obtained between 7 and 12min after inhalation.

CONCLUSION

Inhalation of ciclesonide via HFA-MDI results in high pulmonary deposition, especially in the peripheral regions of the lung. High pulmonary deposition contributes to ciclesonide's ability to maintain lung function and control symptoms in patients with asthma. Deposition and activation of ciclesonide in the oropharynx is low, consistent with previous reports of low oropharyngeal deposition and a reduced incidence of local side effects in patients receiving ciclesonide therapy.

Evaluation of the upper airway cross-sectional area changes in different degrees of severity of obstructive sleep apnea syndrome: cephalometric and dynamic CT study

BACKGROUND AND PURPOSE

The upper airway lumen is narrower in patients with obstructive sleep apnea syndrome (OSAS) than normal subjects. In this study, we examined changes of the upper airway cross-sectional area in each phase of respiration in different degrees of severity of OSAS with dynamic CT and investigated whether these changes have any correlation with sleep apnea severity parameters, including polysomnography (PSG) and cephalometry.

MATERIALS AND METHODS

Between May and November 2004, 47 patients who had at least 2 of 3 major symptoms of snoring, daytime somnolence, and apnea with witness were included in this prospective study. As control group, 24 habitual snorers were studied. All patients underwent PSG and upper airway CT. The average number of episodes of apnea and hypopnea per hour of sleep (the apnea-hypopnea index, AHI) was calculated. An AHI of 5 -29 represented mild/moderate OSAS and an AHI > or = 30 represented severe OSAS. Cross-sectional area of the airway at the level of oropharynx and hypopharynx were obtained in each phase of quiet tidal breathing and at the end of both the forced inspiration and expiration. Six standard cephalometric measurements were made on the lateral scout view. All parameters were compared between controls and mild/moderate and severe OSAS groups.

RESULTS

Twenty-seven patients had mild/moderate OSAS, and 20 patients had severe OSAS. Patients with severe OSAS had significantly narrower cross-sectional area at the level of uvula in expiration, more inferiorly positioned hyoid bone, and thicker soft palate compared with patients with mild/moderate OSAS (P < .05) and the control group (P < .05). In addition, severe OSAS patients had bigger neck circumference than those in the control group (P < .05).

CONCLUSION

Patients with severe OSAS had significant differences in the parameters. Measurement of the cross-sectional area of oropharynx in expiration can especially be useful for diagnosis of severe OSAS as a new key point.

Pediatric oropharyngeal trauma: what is the role of CT scan?

OBJECTIVES/HYPOTHESIS

Pediatric oropharyngeal trauma (OPT) is a common injury in children with rare, but at times severe complications including carotid injury and dissection of air/micro-organisms into the deep tissues of the neck or chest. Cervical CT scan with contrast (CT angiography (CTA)) is nearly universally available and may enhance the evaluation of OPT patients by screening for these potentially devastating complications.

STUDY DESIGN

Retrospective record review, systematic review of the literature.

METHODS

Twenty-three patients diagnosed with OPT from 1997 to 2003 at Boston Children's Hospital were identified by database review. Records were reviewed for site and mechanism of injury, use of diagnostic studies, management, and outcomes. Results were compared to previously published reports. The current literature was reviewed to assess the level of evidence pertaining to the evaluation of OPT patients with CT scan. An extrapolation was made to the general trauma literature to further evaluate the ability of CT angiography to detect carotid injury.

RESULTS

Demographics and mechanism of injury in the current series were unchanged from previous reports. CT demonstrated superior detection and localization of free air. Systematic review of OPT literature revealed data on the use of CT scan as evaluation tool were lacking. Extrapolations to the trauma literature strongly indicate helical CTA has high sensitivity and specificity in detecting carotid injury.

CONCLUSIONS

Pediatric oropharyngeal trauma is a common injury with rare, but severe complications. The routine use of CT scan with contrast may assist in the evaluation of these patients to detect injuries that could lead to severe complications. Collection of prospective data on the ability of CT scan to detect carotid injuries is needed but may not be feasible.

Dynamic upper airway soft-tissue and caliber changes in healthy subjects and snoring patients

BACKGROUND AND PURPOSE

The oropharyngeal airways are smaller in those who snore than in those who do not. We sought to determine which soft-tissue component surrounding the airways contributes to upper airway narrowing in those who snore.

METHODS

Ten control subjects and 19 snoring patients underwent CT, with 2-mm-thick axial sections obtained every 0.6 seconds during the respiration cycle at the same oropharyngeal level. We selected two sections with the widest and narrowest parts of the oropharyngeal airway to measure the anteroposterior and lateral dimensions of the airway and the thickness of the bilateral parapharyngeal fat pads, pterygoid muscles, and parapharyngeal walls. Mean values were calculated for each phase. For each subject, differences were calculated by subtracting the values in narrowest phase from those in the widest phase.

RESULTS

Changes in airway dimension (P < .05) and lateral parapharyngeal wall thickness (P < .01) were significantly different between snorers and control subjects. Changes in parapharyngeal wall thickness and transverse oropharyngeal airway diameter changes were significantly related (P < .01) in those who snored but not in control subjects.

CONCLUSION

Airway narrowing predominantly occurs in the lateral dimension in people who snore. Changes in the lateral pharyngeal wall are more important than the parapharyngeal fat pads in airway calibration. Narrowing of the upper airway area at the end of the expirium and the beginning of the inspirium is thought to be the cause of snoring and due to augmented muscle mass and prolonged laxity rather than inadequate activation of the pharyngeal dilating muscles.

Computerized tomographic evaluation of effects of mandibular anterior repositioning on the upper airway: a pilot study

STATEMENT OF PROBLEM

Snoring is related to narrowing of the upper airway. Treatment options for snoring may have potential side effects or discomfort which may not be tolerated by some patients. Mandibular advancement devices may cause fewer negative side effects than other treatment modalities and have been advocated as a treatment for snoring.

PURPOSE

The aim of the pilot study was to evaluate effects of the anterior mandibular positioner (AMP) on upper airway structures in patients with a snoring problem.

MATERIAL AND METHODS

Fifteen subjects with snoring problems as identified by spouses or close relatives were selected to complete a questionnaire related to snoring, respiratory symptoms, body mass index (BMI), and smoking habits. Computerized tomography (CT) scans were obtained with and without AMP device fabricated as a monoblock of acrylic resin. Measurements of the oropharynx including length (mm), cross-sectional area (mm2), and plane angle (degrees) were made using anatomic landmarks on standardized CT images and lateral scanograms. The data were statistically evaluated using Wilcoxon signed rank test (alpha=.05).

RESULTS

When the AMP was inserted, the cross-sectional area of the oropharynx increased by 60 mm2 on average (P<.05). A mean increase of 2.4 mm (range 1-7 mm) was observed in the posterior airway space on lateral scanograms (P<.005). The range for mandibular advancement was between 4 and 8 mm (mean 5.73 mm).

CONCLUSION

The primary effect of the AMP was enlargement of the oropharyngeal airway. Within the limitations of this pilot study, the results suggest that CT evaluation of the upper airway structures may be helpful in determining treatment modality and monitoring the effectiveness of the positioner.

Does the oropharyngeal fat tissue influence the oropharyngeal airway in snorers? Dynamic CT study

Objective

The aim of this study was to determine if snorers have a narrower oropharyngeal airway area because of fat infiltration, and an elevated body mass index.

Materials and Methods

Ten control subjects and 19 patients that snored were evaluated. We obtained 2-mm-thick axial CT scan images every 0.6 seconds during expiration and inspiration at the same level of the oropharynx. We selected the largest and the smallest oropharyngeal airway areas and found the differences. From the slice that had the smallest oropharyngeal airway area, the thickness of the parapharyngeal and subcutaneous fat was measured. The measurements from the left and right side were added together and single values for parapharyngeal and subcutaneous fat tissue thickness were then found.

Results

The conventional measure of body mass index was significantly higher in the snorers (p < 0.05). The difference in the smallest oropharyngeal airway area between snorers and the controls was statistically significant (p < 0.01). The average difference between the largest and the smallest oropharyngeal area in the control group and the snorer group was statistically significant (p < 0.05). There was no significant difference in the largest oropharyngeal airway area, the total subcutaneous fat width and the total parapharyngeal fat width between snorers and control subjects (p > 0.05).

Conclusion

We concluded that the oropharyngeal fat deposition in snorers is not an important factor, and it does not predispose a person to the upper airway narrowing.

Congenital cervical teratomas

Congenital cervical teratomas are rare, representing 3% of teratomas in childhood. Although mostly benign, they are associated with a high mortality rate due to respiratory distress and require immediate surgical excision. The diagnosis is usually suggested on the physical examination. The imaging investigation is essential for the proper diagnosis and preoperative planning. We present the imaging characteristics of cervical teratomas identified in five neonates over a 10-year-period. The masses were surgically resected. Histopathology revealed the presence of congenital teratomas (three immature, two mature). Two neonates died soon after surgery, while the remaining were discharged from the hospital without symptoms.

Oropharyngeal Dysphagia: Surveying Practice Patterns of the Speech?Language Pathologist

The present study was designed to obtain a comprehensive view of the dysphagia assessment practice patterns of speech-language pathologists and their opinion on the importance of these practices using survey methods and taking into consideration clinician, patient, and practice-setting variables. A self-administered mail questionnaire was developed following established methodology to maximize response rates. Eight dysphagia experts independently rated the new survey for content validity. Test-retest reliability was assessed with a random sample of 23 participants. The survey was sent to 50 speech-language pathologists randomly selected from the Canadian professional association database of members who practice in dysphagia. Surveys were mailed according to the Dillman Total Design Method and included an incentive offer. High survey (64%) and item response (95%) rates were achieved and clinicians were reliable reporters of their practice behaviors (ICC>0.60). Of all the clinical assessment items, 36% were reported with high (>80%) utilization and 24% with low (<20%) utilization, the former pertaining to tongue motion and vocal quality after food/fluid intake and the latter to testing of oral sensation without food. One-third (33%) of instrumental assessment items were highly utilized and included assessment of bolus movement and laryngeal response to bolus misdirection. Overall, clinician experience and teaching institutions influenced greater utilization. Opinions of importance were similar to utilization behaviors (r = 0.947, p = 0.01). Of all patients referred for dysphagia assessment, full clinical assessments were administered to 71% of patients but instrumental assessments to only 36%. A hierarchical model of practice behavior is proposed to explain this pattern of progressively decreasing item utilization.

Infection of the facial area, oral cavity, oropharynx, and retropharynx

Radiologists play an important role in the evaluation of upper neck infections. Although most oral cavity infections arise from diseased teeth, several other sources of infection need to be considered. The distinction between abscess and phlegmon is of particular importance. Cross-sectional imaging is frequently used to identify complications of the initial infection.

[A case branchogenic cyst of oro- and hypoharynx]

In this work was described one case branchiogenic cyst of the oro- et hypopharynx. Provisional diagnosis was tumor of the neck, because of similar symptoms. In the case of brianchiogenic cysts a full diagnostics should be formed. The procedures, which enable us to estimate character and extent of a lesion and determine the proper surgical treatment, should include ultrasonography or CT.

Oropharyngeal Scintigraphy: A Reliable Technique for the Quantitative Evaluation of Oral–Pharyngeal Swallowing

A valid and reliable technique to quantify the efficiency of the oral-pharyngeal phase of swallowing is needed to measure objectively the severity of dysphagia and longitudinal changes in swallowing in response to intervention. The objective of this study was to develop and validate a scintigraphic technique to quantify the efficiency of bolus clearance during the oral-pharyngeal swallow and assess its diagnostic accuracy. To accomplish this, postswallow oral and pharyngeal counts of residual for technetium-labeled 5- and 10-ml water boluses and regional transit times were measured in 3 separate healthy control groups and in a group of patients with proven oral-pharyngeal dysphagia. Repeat measures were obtained in one group of aged (> 55yr) controls to establish test-retest reliability. Scintigraphic transit measures were validated by comparison with radiographic temporal measures. Scintigraphic measures in those with proven dysphagia were compared with radiographic classification of oral vs. pharyngeal dysfunction to establish their diagnostic accuracy. We found that oral ( p = 0.04), but not pharyngeal, isotope clearance is swallowed bolus-dependently. Scintigraphic transit times do not differ from times derived radiographically. All scintigraphic measures have extremely good test-retest reliability. The mean difference between test and retest for oral residual was -1% (95% CI -3%-1%) and for pharyngeal residual it was -2% (95% CI -5%-1%). Scintigraphic transit times have very poor diagnostic accuracy for regional dysfunction. Abnormal oral and pharyngeal residuals have positive predictive values of 100% and 92%, respectively, for regional dysfunction. We conclude that oral-pharyngeal scintigraphic clearance is highly reliable, bolus volume-dependent, and has a high predictive value for regional dysfunction. It may prove useful in assessment of dysphagia severity and longitudinal change.

The Relationship between Wearing Complete Dentures and Swallowing Function in Elderly Individuals: a Videofluorographic Study

The role of complete dentures in masticatory function is well established, but their effect on swallowing has been little examined. This study investigated the effect of complete dentures on swallowing in the elderly. Lateral projection videofluorography (VF) was performed for nine healthy edentulous elderly volunteers (mean age 73.9 +/- 2.9 years) while they swallowed 8 ml of liquid and paste barium with and without complete dentures. A total of 35 VF records were analyzed for temporal and spatial measurements of oropharyngeal motion during swallowing. The tongue tip contacted the inside of the lip between the upper and lower alveolar ridges during swallowing without but not with complete dentures. The hyoid moved further upward (P = 0.002) during swallowing without dentures (liquid: 5.85 +/- 3.99 mm, paste: 6.41 +/- 5.25 mm) than with dentures (liquid: 3.70 +/- 4.57 mm, paste: 3.69 +/- 4.07 mm). The larynx moved further forward (P = 0.044) during swallowing without dentures (liquid: 6.39 +/- 2.58 mm, paste: 6.46 +/- 2.87 mm) than with dentures (liquid: 5.34 +/- 2.04 mm, paste: 5.93 +/- 1.50 mm). The timing of the movements of these structures was not affected by the presence of the dentures or bolus consistency. These results showed that the hyoid and larynx moved more in swallowing without than with complete dentures, perhaps because of tongue tip protrusion when not wearing dentures. These findings suggest that complete dentures have a significant effect on swallowing function as well as masticatory function in elderly individuals.

Surgical management of obstructive sleep apnea

Nasal CPAP is and should be the first-line treatment for OSA. Any physician who uses nasal CPAP undoubtedly recognizes that this treatment modality has limitations, however. The authors believe that surgery offers a viable alternative to nasal CPAP in patients who are intolerant of nasal CPAP. Potential risks and complications must be explained fully to any potential surgical candidate. The selection of surgical procedure(s) should be determined based on a patient's airway anatomy, medical status, severity of sleep apnea, and his or her desire and preference.

Evaluation of Pediatric Lateral Oropharyngeal Trauma

OBJECTIVE: We reviewed the mechanism of injury, presentation, and evaluation of children with trauma to the lateral oropharynx.

STUDY DESIGN AND SETTING: We conducted a retrospective review of patients in an urban pediatric emergency department with trauma to the lateral oropharynx over a 5-year period.

RESULTS: Forty-eight patients were identified with documented injuries of the lateral oropharynx placing the internal carotid artery at risk of injury. The average age was 42 months, with a male-to-female ratio of 1.5:1. Seventy-seven percent of patients had a documented neurologic examination. Examinations were normal in all cases. Computed tomography scans were obtained in 14 patients, identifying 3 patients with carotid abnormalities. Angiography subsequently diagnosed intimal injuries in 2 of the 3 patients. There were no known cases of neurovascular compromise.

CONCLUSION: Contrast-enhanced computed tomography may be an effective screening examination in this patient population, helping to determine which children should be admitted for angiography and observation.

Esophageal contractions and oropharyngeal and esophageal transits in patients with iron deficiency anemia

OBJECTIVE

Patients with iron deficiency may have reduced power of the pharyngeal muscle for bolus propulsion into the esophagus. We hypothesized that esophageal muscle is similarly impaired.

METHODS

We studied the oropharyngeal and esophageal transits and esophageal motility of 12 patients (11 women) aged 31-50 yr (median 36 yr) with iron deficiency anemia (serum iron less than 40 microg/dl) and 17 normal volunteers (16 women) aged 26-52 yr (median 37 yr) with serum iron greater than 60 microg/dl. The esophageal motility was studied by the manometric method, with continuous perfusion and 10 swallows of a 2-ml bolus of water alternated with 10 swallows of a 7-ml bolus; and the oropharyngeal and esophageal transits were studied by scintigraphy, with swallows of a 10-ml bolus for the study of oropharyngeal transit and of a 10-ml bolus for the study of esophageal transit. Motility and transit were studied in the supine position.

RESULTS

The amplitude, duration and area under the curve of contractions were lower in patients than in volunteers. There were no differences in peristaltic contraction velocity, lower esophageal sphincter pressure, and lower esophageal sphincter relaxation duration. There was no difference in oropharyngeal transit. In the esophagus the transit was slower in patients than in volunteers. The time needed by the scintigraphic activity to reach a peak in the proximal esophagus was longer in patients than in volunteers.

CONCLUSIONS

Iron deficiency may decrease esophageal contractions and impair esophageal transit.

Emergence of oropharyngeal, laryngeal and swallowing activity in the developing fetal upper aerodigestive tract: an ultrasound evaluation

The developing fetal upper aerodigestive system provides the structural support for respiratory and ingestive functions necessary to sustain life at birth. This study investigated prenatal development of upper aerodigestive anatomy and the association of emerging functions as predictors of postnatal feeding skills. Biometric measures of oral, lingual, pharyngeal and laryngeal structures were obtained in fetuses 15-38 weeks gestational age using a four-plane sonographic technique. Accompanying ingestive behaviors were tallied across development. The data from 62 healthy controls were compared to seven cases at risk for postnatal feeding and swallowing dysfunction (Type II Arnold Chiari Malformation, trisomy 18, polyhydramnios, intrauterine growth restriction, Brachmann-de Lange Syndrome). Significant (p<0.001) linear regressions occurred in pharyngeal and lingual growth across gestation while ingestive behavior such as suckling emerged in a sequence of basic to complex movement patterns. Jaw and lip movements progressed from simple mouth opening to repetitive open-close movements important for postnatal suckling. Lingual movements increased in complexity from simple forward thrusting and cupping to anterior-posterior motions necessary for successful suckling at term. Laryngeal movements varied from shallow flutter-like movements along the lumen to more complex and complete adduction-abduction patterns. Fetal swallowing primarily occurred in the presence of concomitant oral-facial stimulatory activity. Significant variations (p<0.01) in the form and function of the ingestive system occurred in comparisons of gestational age-matched controls to at-risk cases. We postulate that prenatal developmental indices of emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance the care of the premature, medically fragile neonate.

[The significance of CT measurement of craniopharyngeal cavity in healthy person]

OBJECTIVE

In order to investigate where is the most part in upper airway of patients with obstructive sleep apnea syndrome (OSAS). The craniopharyngeal cavity in 50 healthy persons was measured by CT.

METHOD

The 50 volunteers were instructed on supine position. The Scanning was made taken with SCT-7000 spiral computer (Philips company Holland). Scanning was from cupular part of nasopharyngeal cavity to an apex of epiglottis cartilage on the datum line of lower eye socket, every stratum was 5 mm, every lamella distance was 8 mm. Scanned and took photographs up and down using RIO-MAN key (Region of interesting Management). Some irregular area were selected to measure such as 1. the lamella of nasopharyngeal cavity(the pharynges and opening of auditory tube were showed clearly); 2. the lamella of oropharyngeal cavity(the narrowest place of oropharyngeal cavity); 3. the lamella of laryngolpharyngeal cavity(epiglottis cartilage was just appeared). T test was used to analyze.

RESULT

The areas of oropharyngeal, nasopharyngeal and pharyngolaryngeal cavity were (2.28 +/- 1.17) cm2. (4.39 +/- 1.52) cm2 and (3.83 +/- 1.57) cm2 respectively (P < 0.05).

CONCLUSION

The oropharyngeal cavity is the physiologic narrow place of pharyngeal cavity in normal adults and it is easily obstructed and lead to a chain of pathologic and physiologic manifestations.

Imaging the treated oral cavity and oropharynx

Cross-sectional imaging has become essential in the evaluation of the treated oral cavity and oropharynx. The purpose of this paper is to review the imaging guidelines for the evaluation of this region and to detail the typical changes encountered on imaging following surgical and radiation treatment for cancer.

Postural variation in oropharyngeal dimensions in subjects with sleep disordered breathing: a cephalometric study

This radiographic study analysed the changes that occurred in the airway and surrounding structures when subjects with sleep disordered breathing moved from the upright to the supine position. Radiographs of 100 dentate, Caucasian males were examined. Fifty individuals were non-apnoeic snorers and in 50 a diagnosis of obstructive sleep apnoea (OSA) had been confirmed by polysomnography. Radiographs were traced and digitized and comparisons were made of the behaviour of the oropharynx, soft palate, tongue, and hyoid between the two groups. When moving from the upright to the supine position, both OSA and snoring subjects showed a similar pattern of change. The antero-posterior dimensions of the oropharyngeal airway decreased highly significantly (P < 0.001) at all levels, with a concomitant reduction in cross-sectional area (P < 0.001). The narrowing was most severe behind the soft palate, where the minimum airway reduced by approximately 40 per cent. Behind the tongue, a 20 per cent decrease was seen. The soft palate showed small but significant increases in area, whilst the tongue altered in shape but not in its overall cross-sectional area. In non-apnoeic snorers only, tongue proportion increased (P < 0.05). At the same time, the hyoid dropped and moved anteriorly, maintaining a constant relationship with the lower border of the mandible. There were no differences between the non-apnoeic snorers and the OSA subjects in any of the postural changes recorded.

Airway assessment by volumetric computed tomography in snorers and subjects with obstructive sleep apnea in a Far-East Asian population (Chinese)

OBJECTIVES

To evaluate the airway dimension of simple snorers and subjects with obstructive sleep apnea (OSA) in a Far-East Asian population (Chinese).

STUDY DESIGN

Prospective study of 117 near-consecutive patients evaluated for snoring and possible OSA from January 1998 to December 1998 in a sleep laboratory. Overnight polysomnography (PSG) was performed on all patients and the sleep parameters, including respiratory disturbance index (RDI), snoring index, minimal oxygen saturation (min O2), percentage of slow wave sleep (SWS), and rapid eye movement (REM) were recorded. Three-dimensional computerized tomography (CT) during awake periods was performed. The anteroposterior (AP) and the lateral distance of the retropalatal (RP) region in the oropharynx, the smallest area of RP, and retroglossal (RG) regions, and the total volume of the oropharynx were measured.

RESULT

Ninety-eight patients were diagnosed with OSA (mean RDI, 41.48 +/- 26.45 events per hour; min O2, 72.82 +/- 12.86%), whereas 19 were simple snorers. The AP and the lateral distance of the RP region, as well as the smallest area of the RP region, are significantly smaller in subjects with OSA. However, no differences in the RG region and the total volume of the oropharynx were found between the two groups. Linear regression analysis demonstrated that the lateral dimension and the smallest RP area in overweight subjects inversely correlated with the RDI, but only the AP dimension of the RP area was found to have an inverse correlation with the RDI in the underweight subjects.

CONCLUSION

In Far-East Asians (Chinese), the RP airway was found to be the primary site of narrowing in subjects with OSA, and the narrowest RP area was inversely correlated with RDI. Furthermore, weight may influence the pattern of RP narrowing by contributing to lateral collapse.

Comparison of beclomethasone dipropionate delivery by easyhaler dry powder inhaler and pMDI plus large volume spacer

Dry powder inhalers (DPIs) provide a means of delivering inhaled asthma drugs without the use of propellants. Easyhaler is a multidose DPI, delivering 200 doses of beclomethasone dipropionate (BDP), 200 microg/dose. A gamma scintigraphic study has been carried out in 10 healthy volunteers to compare the deposition of BDP from Easyhaler with that from a pressurized metered dose inhaler (pMDI) coupled to a Volumatic spacer device delivering 250 microg BDP per dose. The spacer was used without any pretreatment to reduce static charge on the spacer walls. The study was conducted according to an open, randomized, crossover design. The volunteers inhaled the study drug using optimal inhalation technique for both devices. Lung deposition of 99mTc-labeled BDP averaged 18.9% (SD 9.5%) of the metered dose for Easyhaler, and 11.2% (SD 5.3%) for pMDI plus spacer (p < 0.05); when the data were expressed as mass of BDP deposited in the lungs, the difference in lung deposition just failed to reach statistical significance (Easyhaler 37.8 microg; pMDI plus spacer 28.0 microg). Oropharyngeal deposition was significantly reduced by use of the spacer. The results of this study show that Easyhaler delivers drug more efficiently to the lungs than pMDI plus Volumatic spacer when no measures are taken to eliminate static charge on the spacer walls.

Respiratory deposition patterns of salbutamol pMDI with CFC and HFA-134a formulations in a human airway replica

This paper describes a technique that uses a well-defined human airway replica and gamma counting as a standard method for evaluating and comparing the performance of medical inhalers and spacers. High-fidelity replicas reproduced as needed from master casts made from human cadavers include the oropharyngeal cavity, larynx, trachea, and five to nine generations of bronchi. Deposition in the small airways and alveoli region of the cast is simulated by material that passes through the upstream airways and is collected on foam filters. Deposition patterns in the respiratory tract replica were obtained by using radiolabel in the medical inhaler and by gamma scintigraphy. This technique was used to determine respiratory deposition patterns of salbutamol in a pressurized metered dose inhaler (pMDI) with chlorofluorocarbon (CFC, in-house formulation) and HFA-134 formulations (Proventil hydrofluoroalkane [HFA]). At an inspiration flow of 30 L/min, patterns in the salbutamol/CFC formula showed a high deposition in the oropharyngeal airway (78%) and a 16% deposition in the lung, similar to in vivo measurements reported in the literature. However, the salbutamol/HFA formula showed lower oral deposition (56%) but higher lung deposition (24%). The difference in the oral deposition patterns may be attributed to lower initial spray velocity, initial droplet evaporation rate, and possibly initial droplet sizes of Proventil HFA. The small orifice diameter (0.25 mm) of the Proventil HFA actuator produced a softer plume with a smaller impact force, resulting in lower oropharyngeal deposition. Cascade impactor measurements showed similar aerodynamic particle size distribution of the CFC and HFA formulations. We also showed that using spacers in the Proventil HFA resulted in a lower oropharyngeal deposition and higher lung deposition, indicating beneficial effects. Comparison of oropharyngeal deposition and those predicted by artificial throats used in the impactor measurements showed that, in general, the artificial throat predicted a lower deposition.