The effect of soft palate reconstruction with the da Vinci robot on middle ear function in children: an observational study

Cleft palate is associated with a high prevalence of middle ear dysfunction, even after palatal repair. The aim of this study was to evaluate the effects of robot-enhanced soft palate closure on middle ear functioning. This retrospective study compared two patient groups after soft palate closure with a modified Furlow double-opposing Z-palatoplasty technique. Dissection of the palatal musculature was performed using a da Vinci robot in one group and manually in the other. Outcome parameters were otitis media with effusion (OME), tympanostomy tube use, and hearing loss during 2 years of follow-up. At 2 years post-surgery, the percentage of children with OME had reduced significantly to 30% in the manual group and 10% in the robot group. The need for ventilation tubes (VTs) decreased significantly over time, with fewer children in the robot group (41%) than those in the manual group (91%) needing new VTs during postoperative follow-up (P = 0.026). The number of children presenting without OME and VTs increased significantly over time, with a faster increase in the robot group at 1 year post-surgery (P = 0.009). Regarding hearing loss, significantly lower hearing thresholds were recorded in the robot group from 7 to 18 months postoperatively. To conclude, beneficial effects of robot-enhanced surgery were recorded, suggesting a faster recovery when the soft palate was reconstructed using the da Vinci robot.

Non-primary CMV infection not always innocent. A case-report and literature review

OBJECTIVES

Cytomegalovirus (CMV) is the most common infectious cause of congenital malformations. CMV infections are frequently symptomatic in case of a primary infection during pregnancy. Generally, maternal immunity protects the newborn against a symptomatic course of the CMV infection.

METHODS

We present clinical information and medical images of a neonate with non-primary congenital CMV infection.

RESULTS

We report the case of a severe congenital infection in a newborn clinically presenting with diffuse petechia, facial dysmorphisms, respiratory distress, hepatomegaly and hypotonia. The girl was born to a mother with CMV immunity. Blood results demonstrated thrombocytopenia and elevated transaminases. Brain MRI revealed ventricular dilatation and germinolytic cysts, compatible with CMV infection. Auditory brain stem response testing was abnormal. CMV culture of saliva was positive. This led to the diagnosis of a severe congenital CMV infection due to a non-primary maternal infection. Antiviral treatment with valganciclovir was initiated immediately and continued for 6 months.

CONCLUSION

Our case illustrates that, even when the mother was demonstrated CMV immune, congenital CMV infection is still an important differential diagnostic consideration in neonates presenting with congenital cerebral abnormalities, thrombocytopenia and/or hearing loss.

ABBREVIATIONS

ABR: auditory brainstem responses; CMV: Cytomegalovirus; CPAP: Continuous Positive Airway Pressure; CRP: C-Reactive Protein; dBnHL: Decibel Above Normal Adult Hearing Level; IV: intravenously; MRI: Magnetic Resonance Imaging; SGA: Small for Gestational Age; SNHL: Sensorineural Hearing Loss.

Treatment of sleep-disordered breathing with positional therapy: long-term results

PURPOSE

The aim of the present study was to assess the efficacy of a sleep position trainer (SPT) in patients with an established diagnosis of positional obstructive sleep apnea and to evaluate the adherence after 1-year follow-up.

METHODS

Polysomnography (PSG) was performed at baseline and after 1 year of SPT use. Patients received questionnaires to assess treatment satisfaction and subjective adherence. Data on objective adherence and number of vibrations initiated by the SPT were collected from the SPT device.

RESULTS

Nine out of 58 patients stopped using the SPT during the first year of treatment (16%). Thirty-four middle-aged and overweight patients underwent a PSG after 1 year of SPT use (male/female ratio, 28/6; overall apnea/hypopnea index (AHI), 16/h). A significant reduction in overall AHI to 6/h was observed using treatment (p < 0.001). The median percentage of supine sleep decreased significantly to 1% with SPT (p < 0.001). The mean objective SPT use in 28 patients was 7.3 ± 0.9 h/night and 69 ± 26% of the nights. Furthermore, 75% of the patients reported a better sleep quality since the start of SPT treatment.

CONCLUSIONS

Long-term treatment with the SPT was found to be effective in reducing overall AHI. Time spent sleeping in supine position was reduced to almost zero in the continuing users. Patient satisfaction was high when using the SPT.

Prevalence and etiology of sensorineural hearing loss in children with down syndrome: A cross-sectional study

BACKGROUND

The prevalence and causes of sensorineural hearing loss (SNHL) in children with Down syndrome (DS) are poorly delineated.

OBJECTIVE

To describe the prevalence, severity, laterality and underlying etiology of SNHL in a cohort of children with DS.

METHODS

A cross-sectional study was performed among all children with DS followed at the multidisciplinary Downteam of the Antwerp University Hospital. Patients' characteristics, risk factors for hearing loss, audiometric data and results of an etiological work-up were collected.

RESULTS

Among 291 patients in follow-up, 138 patients (47.4%) presented with hearing loss. In the majority this was caused by middle ear effusion and only 13 patients (4.5%) had sensorineural hearing loss, 7 boys and 6 girls with a mean age of 14.4 ± 7.4 years. Hearing loss was bilateral in 8 cases. Hearing loss severity was graded as mild in 38.5%, moderate in 30.8% and profound in 30.8% of the patients. An etiological work-up was completed in 9 children. Four patients presented with single sided deafness due to cochlear nerve deficiency. One patient had a genetic cause and in 2 patients the hearing loss was attributed to excessive noise exposure. The etiology of hearing loss was unknown in 6 patients.

CONCLUSION

Sensorineural hearing loss is uncommon in children with DS with a prevalence of 4.5%. Etiological work-up may allow identifying a specific underlying cause. Cochlear nerve deficiency was found in 4 children with DS and single sided deafness.

The Optiflow™ interface for chronic CPAP use in children

Continuous positive airway pressure (CPAP) is being increasingly used in children of all age ranges. The limited number of commercially available masks especially in infants and young children may complicate its use and compliance. In this report, we describe our experience with the use of the Optiflow™ (Fisher and Paykel Healthcare) Nasal Cannula attached to a regular CPAP device in the setting of chronic CPAP use. This interface consists of a nasal cannula and was originally designed for the delivery of high-flow oxygen therapy. We could show an objective improvement in breathing parameters in several children selected for CPAP mainly because of obstructive sleep apnea syndrome (OSAS). However, this interface cannot be used for bilevel non-invasive ventilation due to insufficient triggering.

Adenotonsillectomy to treat obstructive sleep apnea: Is it enough?

Although adenotonsillectomy is the first line treatment for children with obstructive sleep apnea syndrome (0SAS),¹ improvement in objectively documented outcomes is often inadequate and a substantial number of children have residual disease. Early recognition and treatment of children with persistent OSAS is required to prevent long-term morbidity. The management of these children is frequently complex and a multidisciplinary approach is required as most of them have additional risk factors for OSAS and comorbidities. In this paper, we first provide an overview of children at risk for persistent disease following adenotonsillectomy. Thereafter, we discuss different diagnostic modalities to evaluate the sites of persistent upper airway obstruction and the currently available treatment options. Pediatr Pulmonol. 2017;52:699-709. © 2016 Wiley Periodicals, Inc.

Stridor caused by a blue laryngeal mass in an infant: case report

Stridor caused by.a blue laryngeal mass in an infant: case report. We describe an infant who had inspiratory stridor that began a few weeks after birth. Flexible upper airway endoscopy while the infant was awake showed a large blue mass at the posterior glottis, above the esophageal inlet. The lesion was only visible upon crying or coughing; it was undetectable when we examined the infant in the supine position during spontaneous breathing and did not respond to systemic treatment with propranolol. Based upon these typical features, we established a diagnosis of pressure- dependent postcricoid mass.

Auditory neuropathy spectrum disorder (ANSD) in referrals from neonatal hearing screening at a well-baby clinic

Auditory neuropathy spectrum disorder (ANSD) is a particular kind of hearing disorder characterised by normal outer hair cell function and abnormal or absent auditory brain stem responses. Little data are available regarding the prevalence of this condition in healthy newborns. We performed a retrospective medical records review of 791 referrals from universal neonatal hearing screening (UNHS) at a well-baby clinic to investigate the prevalence of ANSD. Hearing screening was performed by automated auditory brain stem response (ABR) testing. A diagnosis of ANSD was established when ABR tracings were absent in the presence of otoacoustic emissions and/or a cochlear microphonic. Amongst 201 infants with confirmed congenital hearing loss, 13 infants were diagnosed with ANSD. The condition was unilateral in six and bilateral in seven infants. A risk factor for hearing loss could be identified in three infants. Abnormalities on magnetic resonance imaging were found in six infants; five of them had cochlear nerve deficiency.

CONCLUSION

The prevalence of ANSD was 6.5 % amongst well babies with confirmed congenital hearing loss identified through UNHS. The estimated incidence of ANSD in our population of newborns at the well-baby clinic was 0.09/1000 live births. Magnetic resonance revealed an underlying anatomical abnormality in about half of the patients.

WHAT IS KNOWN

• Auditory neuropathy dyssynchrony spectrum disorder (ANSD) is a particular form of hearing loss, mostly encountered in neonatal intensive care unit (NICU) graduates. • Little data are available on the prevalence and risk factors for ANSD in healthy newborns. What is new: • The estimated prevalence of ANSD in healthy newborns is 0.09/1000 live births. • In about half of the healthy newborns with ANSD, a structural abnormality was detected on magnetic resonance imaging of the posterior fossa/brain.

Nasal symptoms in patients with obstructive sleep apnea and their impact on therapeutic compliance with continuous positive airway pressure

Continuous positive airway pressure (CPAP) is the first line treatment for moderate to severe obstructive sleep apnea syndrome. Despite the high effectiveness of this treatment, its use is often limited by suboptimal compliance and/or intolerance. Nasal side effects are considered a major cause of low therapeutic compliance. At present, there are no data to predict which patients will develop CPAP intolerance caused by nasal symptoms and only few studies looked at the effect of treatment of nasal symptoms on CPAP compliance. The first section of this review focuses on the impact of nasal symptoms (pre-existing or as a side effect of CPAP) on CPAP compliance/intolerance. The second section deals with the effect of nasal symptom treatment on CPAP compliance.

Functional respiratory imaging as a tool to assess upper airway patency in children with obstructive sleep apnea

OBJECTIVE

We aim to investigate if anatomical and functional properties of the upper airway using computerized 3D models derived from computed tomography (CT) scans better predict obstructive sleep apnea (OSA) severity than standard clinical markers.

METHODS

Consecutive children with suspected OSA underwent polysomnography, clinical assessment of upper airway patency, and a CT scan while awake. A three-dimensional (3D) reconstruction of the pharyngeal airway was built from these images, and computational fluid dynamics modeling of low inspiratory flow was performed using open-source software.

RESULTS

Thirty-three children were included (23 boys; mean age, was 6.0±3.2y). OSA was diagnosed in 23 patients. Children with OSA had a significantly lower volume of the overlap region between tonsils and the adenoids (median volume, 1408 mm compared to 2173 mm; p=0.04), a lower mean cross-sectional area at this location (median volume, 69.3mm(2) compared to 114.3mm2; p=0.04), and a lower minimal cross-sectional area (median volume, 17.9 mm2 compared to 25.9 mm2; p=0.05). Various significant correlations were found between several imaging parameters and the severity of OSA, most pronounced for upper airway conductance (r=-0.46) (p<0.01) for correlation between upper airway conductance and the apnea-hypopnea index. No differences or significant correlations were observed with clinical parameters of upper airway patency. Preliminary data after treatment showed that none of the patients with residual OSA had their smallest cross-sectional area located in segment 3, and this frequency was significantly lower than in their peers whose sleep study normalized (64%; p=0.05).

CONCLUSION

Functional imaging parameters are highly correlated with OSA severity and are a more powerful correlate than clinical scores of upper airway patency. Preliminary data also showed that we could identify differences in the upper airway of those subjects who did not benefit from a local upper airway treatment.

Auditory neuropathy: a challenge for diagnosis and treatment

In current terminology, auditory neuropathy spectrum disorder (ANSD) is a disease involving the disruption of the temporal coding of acoustic signals in auditory nerve fibres, resulting in the impairment of auditory perceptions that rely on temporal cues. There is debate about almost every aspect of the disorder, including aetiology, lesion sites, and the terminology used to describe it. ANSD is a heterogeneous disease despite similar audiological findings. The absence of an auditory brainstem response (ABR) and the presence of otoacoustic emissions (OAE) suggest an ANSD profile. However, to determine the exact anatomical site of the disorder, more in-depth audiological and electrophysiological tests must be combined with imaging, genetics and neurological examinations. Greater diagnostic specificity is therefore needed to provide these patients with more adequate treatment.

Intracranial complications of acute otitis media and Gradenigo's syndrome

We describe the case of a 12-year-old girl with acute otitis media complicated by acute mastoiditis, epidural empyema, thrombosis of the sigmoid sinus and paralysis of the abducens nerve. The patient underwent a mastoidectomy on the left side combined with drainage of the epidural empyema through an extended burr holl and received intravenous antibiotics for 6 weeks and anticoagulation for 12 weeks. This report discusses the intracranial complications of acute otitis media, which were a common problem before the advent of adequate antibiotic drugs but have become rare since their introduction.

Specific medical and surgical treatment for chronic inflammatory diseases in children

Treatment for chronic inflammatory conditions in children should take into account the specific pathophysiological and clinical processes underlying these disorders. These guidelines provide a framework for both the medical and surgical treatment of chronic inflammatory diseases such as otitis media, allergic rhinitis and chronic rhinosinusitis, chronic inflammation of tonsils and adenoids, and laryngitis. In addition, the role of vaccinations and immunomodulatory therapies is discussed. Whenever possible, the evidence levels for specific treatments comply with the Oxford Levels of Evidence.

An unusual tumour causing neonatal respiratory distress

PROBLEM

We present the case of a term neonate referred shortly after birth because of breathing and feeding difficulties.

METHODOLOGY

Fiber-endoscopic examination of the nasal cavity showed a pendulating mass in the nasopharynx.

RESULTS

A complete surgical resection was performed and the baby recovered completely. Microscopic examination of the mass showed an overlying non-keratinized squamous cell lining with an atypical cell population in some fragments. Histological features were compatible with a high-grade epithelial tumour like a midline carcinoma, but a final diagnosis of a salivary gland anlage tumour was established.

CONCLUSION

Flexible fiber endoscopy is the method of choice for examining the nasal passages and oropharynx in neonates with respiratory distress. Congenital salivary gland anlage tumour is a rare cause of neonatal nasal obstruction; it is benign and complete excision results in a cure. Histologically, it may mimic a malignant tumour owing to the high mitotic index.

Non-CPAP therapies in obstructive sleep apnoea

In view of the high prevalence and the relevant impairment of patients with obstructive sleep apnoea syndrome (OSAS) lots of methods are offered which promise definitive cures for or relevant improvement of OSAS. This report summarises the efficacy of alternative treatment options in OSAS. An interdisciplinary European Respiratory Society task force evaluated the scientific literature according to the standards of evidence-based medicine. Evidence supports the use of mandibular advancement devices in mild to moderate OSAS. Maxillomandibular osteotomy seems to be as efficient as continuous positive airway pressure (CPAP) in patients who refuse conservative treatment. Distraction osteogenesis is usefully applied in congenital micrognathia or midface hypoplasia. There is a trend towards improvment after weight reduction. Positional therapy is clearly inferior to CPAP and long-term compliance is poor. Drugs, nasal dilators and apnoea triggered muscle stimulation cannot be recommended as effective treatments of OSAS at the moment. Nasal surgery, radiofrequency tonsil reduction, tongue base surgery, uvulopalatal flap, laser midline glossectomy, tongue suspension and genioglossus advancement cannot be recommended as single interventions. Uvulopalatopharyngoplasty, pillar implants and hyoid suspension should only be considered in selected patients and potential benefits should be weighed against the risk of long-term side-effects. Multilevel surgery is only a salvage procedure for OSA patients.

Pneumoparotid: a rare cause of parotid swelling in a 7-year-old child

PROBLEMS/OBJECTIVES

Pneumoparotid is a rare condition in which air is insufflated through Stensen's duct into the parotid gland. This causes mostly painless swelling in the parotid region.

CASE REPORT

We report on a 7-year old girl presenting with painless unilateral swelling of the left parotid region, present for one month. Computer tomography showed the presence of air in the left parotid gland and in both the left and right Stensen's duct. A thorough history revealed the girl was insufflating the parotid glands intentionally as a response to stress. The patient was comforted and instructed to avoid insufflation manoeuvres, which resulted in complete resolution.

CONCLUSION

Pneumoparotid should be considered part of a differential diagnosis in children and adolescents presenting with painless uni- or bilateral swelling of the parotid gland. Supportive and conservative treatment is advocated.

Outcome of sleep endoscopy in obstructive sleep apnoea: the Antwerp experience

OBJECTIVES

Snoring and obstructive sleep apnoea (OSA) result from upper airway (UA) collapse during sleep. Sleep endoscopy is a dynamic evaluation of the UA that can be used to determine the site(s) of collapse during respiratory events. This study evaluates the feasibility and outcome of sleep endoscopy in patients with OSA, compares the findings with the literature, and reviews the therapeutic advice given to patients.

METHODOLOGY

A retrospective analysis was conducted of the data for 70 OSA patients in whom UA surgery was considered. Sleep endoscopy was performed after IV administration of midazolam and propofol. The UA was visualised and assessed for the location of UA flutter, narrowing or collapse. Feasibility and safety were evaluated retrospectively. Outcome data were described as type and pattern of flutter and/or collapse. Treatment advice given to the patients was reviewed.

RESULTS

Sleep endoscopy showed monolevel palatal collapse in 31.9%, monolevel tongue/hypopharyngeal collapse in 27.8% and multilevel collapse in 31.9% of patients. In 5.6% of patients, no collapse was found. In all patients except 2, reliable assessment proved possible of the site(s) of obstruction. No side effects were reported.

CONCLUSION

Sleep endoscopy is feasible and safe in daily practice when sedation is performed by an anaesthesiologist and can be used to locate the site of collapse in the UA. Sleep endoscopy findings in our study sample, as well as in the literature, differ according to the content of the study sample and the method of sedation. Treatment advice may differ from sleep endoscopy findings since other factors such as age and patient preferences need to be considered.

Evolution of Vocal Fold Nodules from Childhood to Adolescence

SUMMARY

Bilateral (quasi) symmetrical lesions of the anterior third of the vocal folds, commonly called vocal fold nodules (VFNs) are the most frequent vocal fold lesions in childhood caused by vocal abuse and hyperfunction. This study evaluates their long-term genesis with or without surgery and voice therapy. A group of 91 postmutational adolescents (mean age, 16 years), in whom VFNs were diagnosed in childhood, were questioned to analyze the evolution of their complaints. Thirty four of them could be clinically reexamined by means of the European Laryngological Society-protocol, including a complete laryngological investigation and voice assessment. A total of 21% of the questioned group (n=91) had voice complaints persisting into postpubescence with a statistically significant difference (P <or= 0.001) between boys (8%) and girls (37%). VFNs were still present in 47% of the girls and 7% of the boys of the clinically evaluated group (n=34). Analysis of the data before and after puberty shows that the variables gender, allergy, and degree of dysphonia ("G") in childhood enable a fairly correct prediction of persisting voice complaints in adolescence (sensitivity of 89% and specificity of 67%). The results of this study show a clearly different evolution for both sexes, with significant higher long-term risks for dysphonic girls with allergy.

Tinnitus: a multidisciplinary clinical approach

This article provides a clinical step-by-step approach for assessing a patient with tinnitus as primary complaint. The medical diagnosis of the disease provoking the tinnitus has to be made first in a comprehensive evaluation, including imaging. The psycho-acoustic characteristics and the influence on health-related quality of life is a compulsory complementary assessment to establish a complete picture of the patient.

Management of stridor in neonates and infants

Stridor is the sound caused by abnormal air passage into the lungs and can exist in different degrees and be caused by obstruction located anywhere in the extra-thoracic (nose, pharynx, larynx, trachea) or intra-thoracic airway (tracheobronchial tree). Stridor may be congenital or acquired, acute, intermittent or chronic. Laryngotracheal inflammation (croup) is the most common cause of acute stridor. Laryngotracheomalacia is the most common cause of congenital, chronic stridor. Stridor is a clinical sign and not a diagnosis. The golden standard in the workup of stridor is an upper and lower airway endoscopy under general anaesthesia. Endoscopic examination under general anaesthesia requires a multidisciplinary approach and close cooperation between anaesthesiologist, paediatrician, ENT surgeon and nursing staff. Following this procedure, a place in the intensive care unit should be available for those cases presenting with stridor in which a definite diagnosis could not yet be established. Although important, pre-endoscopy assessment including history, physical examination and radiological examination, is only a guide to the type and degree of pathology found during endoscopy. About 1 out of 10 infants are found to have lesions in more than one anatomical site of the upper aerodigestive tract.

Management of otitis media with effusion in children

Otitis media with effusion in children: B-ENT Guidelines. OME is highly prevalent among young children, with peak prevalences at around two and five years of age. Although serious complications are rare, the burden of OM is large with impaired quality of life and high direct and indirect socio-economic costs. To date, medical treatment of OME is not recommended because of the limited scientific evidence that this treatment is effective in the long term. Surgical candidacy for OME depends largely on hearing status, associated symptoms, the child's developmental risk and the anticipated chance of spontaneous resolution of the effusion. Ultimately, the recommendation for surgery must be individualized.

Standard ENT clinical evaluation of the sleep-disordered breathing patient; a consensus report

Sleep disordered breathing (SDB) patients usually undergo an ENT clinical examination before any therapeutic decision. This clinical examination would be predictive about the occurrence of Obstructive Sleep Apnea Syndrome, cost effective, reproducible and would determine the sites of obstruction in the upper airways. To achieve this, ENT specialists from Belgium, representatives of academic hospitals in the country, have tried to establish an updated work-up in the clinical evaluation of the SDB patients. History, risk factors evaluation, excessive daytime sleepiness, static and dynamic evaluation of the upper airways (velopharynx aspect, tonsils grading, Mallampati score, Müller's maneuver, fiberoptic evaluation) have been standardized in a consensus report easily accessible to the vast majority of ENT specialists. This consensus must be understood as a clinical work-up to perform before the monitoring of breathing during sleep.

Upper airway collapsibility: measurement techniques and therapeutic implications

Several techniques are currently available that aim to characterize upper airway function/mechanics during wakefulness or sleep. Based on the concept of a Starling resistor, we propose a standardized protocol to measure the critical pressure (Pcrit) (an indicator of upper airway collapsibility) during sleep. The effect of therapeutic interventions such as weight loss, positional changes or uvulopalatopharyngoplasty on Pcrit is illustrated by data from the literature. We propose that measurement of Pcrit become implemented in the diagnostic work-up of selected patients with sleep-related breathing disorder to help making a correct therapeutic decision.

Surgical treatment of the sleep-disordered breathing patient; a consensus report

Sleep disordered breathing patients may undergo surgical treatment after history, clinical examination and polysomnographic study if they demonstrate upper airway obstruction. This article focus on the surgical treatment designed for these patients. Sino-nasal surgery, rhinopharyngeal procedure, velopharyngeal procedures (Uvulopalato-pharyngoplasty, Laser assisted uvulopalatoplasty, Radiofrequency tissue volume reduction) as well as base of the tongue procedures were discussed among a panel of Belgian ENT specialists offering their experience in this field. Algorithm on corrective surgery as well as guidelines for postoperative management are proposed in the management of sleep disordered breathing patients.

Acute cochleovestibular toxicity due to topical application of potassium iodide

We present a case report of a patient who suffered from an acute cochleovestibular deficit after topical application of potassium iodide solution into the left ear. Although the vestibular symptoms progressively disappeared, severe sensorineural hearing loss persisted after treatment with hyperbaric oxygen therapy and intravenous administration of corticosteroids and vasodilating agents. The mechanisms of ototoxicity after topical application of solutions are discussed with emphasis on the particular features of the present case: a patulous Eustachian tube syndrome and the presence of a tympanostomy tube in the left ear.

Therapeutic electrical stimulation of the hypoglossal nerve in obstructive sleep apnea

BACKGROUND

Hypoglossal nerve stimulation has been demonstrated to relieve upper airway obstruction acutely, but its effect on obstructive sleep apnea is not known.

OBJECTIVE

To determine the response in obstructive sleep apnea to electrical stimulation of the hypoglossal nerve.

METHODS

Eight patients with obstructive sleep apnea were implanted with a device that stimulated the hypoglossal nerve unilaterally during inspiration. Sleep and breathing patterns were examined at baseline before implantation and after implantation at 1, 3, and 6 months and last follow-up.

RESULTS

Unilateral hypoglossal nerve stimulation decreased the severity of obstructive sleep apnea throughout the entire study period. Specifically, stimulation significantly reduced the mean apnea-hypopnea indices in non-rapid eye movement (mean +/- SD episodes per hour, 52.0 +/- 20.4 for baseline nights and 22.6 +/- 12.1 for stimulation nights; P<.001) and rapid eye movement (48.2 +/- 30.5 and 16.6 +/- 17.1, respectively; P<.001) sleep and reduced the severity of oxyhemoglobin desaturations. With improvement in sleep apnea, a trend toward deeper stages of non-rapid eye movement sleep was observed. Moreover, all patients tolerated long-term stimulation at night and did not experience any adverse effects from stimulation. Even after completing the study protocol, the 3 patients who remained free from stimulator malfunction continued to use this device as primary treatment.

CONCLUSION

The findings demonstrate the feasibility and therapeutic potential for hypoglossal nerve stimulation in obstructive sleep apnea.

Wegener's granulomatosis triggered by infection?

Wegener's granulomatosis is a systemic disease of unknown origin, although recent studies suggest that auto-immune mechanisms and infection play a role in the pathogenesis of this disease. Wegener is characterized by a necrotizing vasculitis involving the lungs (pulmonary infiltrates), the upper airways and the kidneys (rapidly progressive glomerulonephritis). We present a case of a male patient admitted because of progressive deterioration of the general condition with weight loss, a unilateral neck mass, unilateral purulent rhinorrea and fever. CT-scan evaluation demonstrated a unilateral expanding mass in the sing-nasal cavity, obliterating the ethmoid complex. MRI revealed signs of intracranial inflammatory reaction and onset of absedation. A malignancy was suspected but a diagnosis of Wegener's granulomatosis was established based on histologic criteria (nasal biopsy) and a positive titer for anti-cytoplasmic antibodies (cANCA). During follow-up, nasal carriage of Staphyloccocus Aureus could be documented. An overview of Wegener's granulomatosis will be provided with emphasis on the potential role of acute infections as a trigger for Wegener's granulomatosis and the head and neck manifestations.

Temperature-controlled radiofrequency tissue volume reduction of the soft palate (somnoplasty) in the treatment of habitual snoring: results of a European multicenter trial

Temperature-controlled radiofrequency tissue volume reduction of the soft palate has been introduced as a minimally invasive, outpatient procedure for the treatment of habitual snoring and mild obstructive sleep apnea. A prospective, non-randomized multi-center European clinical study was conducted to investigate the efficacy of Somnoplasty in reducing snoring. Each patient underwent a pre- and post-treatment full-night polysomnography. TCRFe of the soft palate (1 midline lesion/session) was carried out under local anesthesia with a maximum of 3 consecutive treatment sessions. Forty-five, nonapneic snorers (RDI 5.1 +/- 4.3, BMI 26.6 +/- 3.2 kg/m2) completed the protocol. A mean of 692.3 +/- 67.7) J was delivered/treatment session. There was a significant improvement in the snoring index 7.6 (+/- 2.1 ) vs 4.1 (+/- 2.9). p < 0.001 and in the Epworth Sleepiness Score 8.5 (+/- 5.0) versus 6.0 (+/- 4.3), p = 0.001. No major adverse events were reported and postoperative pain was minimal. Overall, 45% of patients had a post-treatment snoring index < 3 (success) and 84% of the patients reported an improvement in snoring. It was concluded that Somnoplasty, following a protocol with I midline lesion of maximal 700 J/lesion for 1-3 treatment sessions, improves snoring in the majority of patients. Further studies are required to investigate whether treatment efficacy can be improved by utilizing multiple lesions/session or by increasing the amount of energy/lesion. The absence of serious adverse events and the findings of minimal postoperative pain support the use of TCRFe (Somnoplasty) as a minimally invasive surgical procedure for snoring.

Abbreviated method for assessing upper airway function in obstructive sleep apnea

STUDY OBJECTIVES

Previous studies have shown that the level of flow through the upper airway in patients with obstructive sleep apnea (OSA) is determined by the critical closing pressure (Pcrit) and the upstream resistance (RN). We developed a standardized protocol for delineating quasisteady-state pressure-flow relationships for the upper airway from which these variables could be derived. In addition, we investigated the effect of body position and sleep stage on these variables by determining Pcrit and RN, and their confidence intervals (CIs), for each condition.

DESIGN

Pressure-flow relationships were constructed in the supine and lateral recumbent positions (nonrapid eye movement [NREM] sleep, n = 10) and in the supine position (rapid eye movement [REM] sleep, n = 5).

SETTING

University Hospital Antwerp, Belgium.

PATIENTS

Ten obese patients (body mass index, 32.0+/-5.6 kg/m(2)) with severe OSA (respiratory disturbance index, 63.0+/-14.6 events/h) were studied.

INTERVENTIONS

Pressure-flow relationships were constructed from breaths obtained during a series of step decreases in nasal pressure (34.1+/-6.5 runs over 3.6+/-1.2 h) in NREM sleep and during 7.8+/-2.2 runs over 0.8+/-0.6 h in REM sleep.

RESULTS

Maximal inspiratory airflow reached a steady state in the third through fifth breaths following a decrease in nasal pressure. Analysis of pressure-flow relationships derived from these breaths showed that Pcrit fell from 1.8 (95% CI, -0.1 to 2.7) cm H(2)O in the supine position to -1.1 cm H(2)O (95% CI, -1.8 to 0.4 cm H(2)O; p = 0.009) in the lateral recumbent position, whereas RN did not change significantly. In contrast, no significant effect of sleep stage was found on either Pcrit or RN.

CONCLUSIONS

Our methods for delineating upper airway pressure-flow relationships during sleep allow for multiple determinations of Pcrit within a single night from which small yet significant differences can be discerned between study conditions.

Two months follow up of auto-CPAP treatment in patients with obstructive sleep apnoea

BACKGROUND

Continuous positive airway pressure (CPAP) with fixed mask pressure is the current standard treatment for obstructive sleep apnoea (OSA). Auto-CPAP devices apply at any time the minimally required pressure to normalise breathing and may improve patient comfort and compliance. We present an open descriptive study of auto-CPAP treatment at home in patients previously managed with conventional CPAP.

METHODS

Fifteen patients with obstructive sleep apnoea (OSA), previously treated for at least one year with standard CPAP, were followed prospectively for a two month period on auto-CPAP. Outcome measures were both subjective evaluation by the patients and objective (polysomnographic) data obtained at one and two months of follow up.

RESULTS

The Epworth sleepiness score did not change significantly between baseline and follow up after one and two months and no systematic changes in CPAP related side effects were reported. Compared with the baseline polysomnographic values without treatment, a significant improvement in both respiratory and sleep parameters was observed during auto-CPAP. These results were not significantly different from those obtained with standard CPAP. A significant correlation was found between the effective CPAP pressure (Peff) and the amount of time spent below Peff during auto-CPAP treatment (r = 0.6, p = 0.01).

CONCLUSION

Long term auto-CPAP treatment in these patients with severe OSA appears to provide comparable efficacy to that of standard CPAP treatment.

Assessment of respiratory effort by means of strain gauges and esophageal pressure swings: a comparative study

We characterized apneas by a quantitative method (esophageal pressure measurements) and by a qualitative method (strain gauges) at the same time in 22 patients with sleep-related breathing disorders. Detection of respiratory effort by strain gauges significantly overestimated the total number of central apneas in each patient. Despite this overestimation, none of the patients was wrongly diagnosed as having pure central sleep apnea syndrome. Strain gauges are sufficiently reliable for the characterization of apneas in most patients. When strain gauges reveal that most apneas are central in origin, verification by esophageal pressure measurements is recommended.

Influence of uvulopalatopharyngoplasty on alpha-EEG arousals in nonapnoeic snorers

Arousals are more numerous in heavy snorers than in nonsnorers and might be a cause of excessive daytime sleepiness (EDS) in these patients. The present study investigated whether treatment of snoring by uvulopalatopharyngoplasty (UPPP) had an influence on sleep microstructure in nonapnoeic snorers. The polysomnographic records of 10 nonapnoeic snorers were reviewed retrospectively and arousals scored according to the American Sleep Disorders Association (ASDA) 3 s definition. Scores for snoring, EDS and polysomnographic data were compared before and after UPPP (mean (+/-SD) time interval 249 +/- 183 days). UPPP resulted in a subjective improvement of snoring and a significant decrease in the arousal index (mean 14.6, 95% confidence interval (95% CI) 8.5-20.8 vs mean 9.1, 95% CI 6.6-11.5) (p = 0.01). EDS and the amount of slow-wave sleep remained unchanged. Uvulopalatopharyngoplasty resulted in an improvement of subjective snoring and a significant decrease of arousals in nonapnoeic snorers. Although these data do not provide any insight into whether the improvement observed can be maintained on a long-term basis, uvulopalatopharyngoplasty can be considered as a useful treatment modality to reduce sleep fragmentation and snoring in nonapnoeic snorers.

Respiratory effort during sleep apneas after interruption of long-term CPAP treatment in patients with obstructive sleep apnea

Apneas generally reappear in patients with obstructive sleep apnea (OSA) when treatment with continuous positive airway pressure (CPAP) is interrupted. However, a single-night treatment interruption may be associated with a lesser severity of sleep apneas than before treatment. We hypothesized that this decrease in severity of sleep apneas reflects changes in the respiratory response to upper airway obstruction. Therefore, we compared indexes of respiratory effort during sleep in 25 patients with OSA before and after 1 year of CPAP treatment. Respiratory effort was assessed by means of an esophageal balloon. After 1 year of CPAP treatment, there was a decrease in the maximal end-apneic esophageal pressure swings (Pes) (from 56.7 +/- 5.4 to 30.3 +/- 2.6 cm H2O; p = 0.000; mean +/- SEM), in the overall increase in Pes during an apnea (35.2 +/- 3.6 vs 16.5 +/- 1.5 cm H2O; p = 0.000), as well as the rate of increase in Pes (1.1 +/- 0.1 vs 0.6 +/- 0.1 cm H2O/s; p = 0.000). Although body mass index (BMI) did not change significantly, the individual changes in BMI significantly correlated with the changes in respiratory effort after 1 year of CPAP treatment. Apnea duration and apnea-related oxygen desaturation also decreased significantly. We conclude that long-term CPAP treatment induces changes in respiratory control that persist at least on the first night of treatment interruption.