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Every JD, Mackay SG, Sideris AW, Do TQ, Jones A, Weaver EM. Mean disease alleviation between surgery and continuous positive airway pressure in matched adults with obstructive sleep apnea. Sleep 2023; 46:zsad176. [PMID: 37395677 DOI: 10.1093/sleep/zsad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 05/19/2023] [Indexed: 07/04/2023] Open
Abstract
STUDY OBJECTIVES Polysomnography parameters measure treatment efficacy for obstructive sleep apnea (OSA), such as reduction in apnea-hypopnea index (AHI). However, for continuous positive airway pressure (CPAP) therapy, polysomnography measures do not factor in adherence and thus do not measure effectiveness. Mean disease alleviation (MDA) corrects polysomnography measures for CPAP adherence and was used to compare treatment effectiveness between CPAP and multilevel upper airway surgery. METHODS This retrospective cohort study consisted of a consecutive sample of 331 patients with OSA managed with multilevel airway surgery as second-line treatment (N = 97) or CPAP (N = 234). Therapeutic effectiveness (MDA as % change or as corrected change in AHI) was calculated as the product of therapeutic efficacy (% or absolute change in AHI) and adherence (% time on CPAP of average nightly sleep). Cardinality and propensity score matching was utilized to manage confounding variables. RESULTS Surgery patients achieved greater MDA % than CPAP users (67 ± 30% vs. 60 ± 28%, p = 0.04, difference 7 ± 3%, 95% confidence interval 4% to 14%) in an unmatched comparison, despite a lower therapeutic efficacy seen with surgery. Cardinality matching demonstrated comparable MDA % in surgery (64%) and CPAP (57%) groups (p = 0.14, difference 8 ± 5%, 95% confidence interval -18% to 3%). MDA measured as corrected change in AHI showed similar results. CONCLUSIONS In adult patients with OSA, multilevel upper airway surgery and CPAP provide comparable therapeutic effectiveness on polysomnography. For patients with inadequate CPAP use, surgery should be considered.
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Affiliation(s)
- James D Every
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Stuart G Mackay
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
- Illawarra ENT Head and Neck Clinic, Wollongong, NSW, Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Anders W Sideris
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Timothy Q Do
- Department of Otolaryngology, Head and Neck Surgery, The Wollongong Hospital, Wollongong, NSW. Australia
| | - Andrew Jones
- Department of Respiratory Medicine, The Wollongong Hospital, Wollongong, NSW. Australia
- School of Medicine, University of Wollongong, Wollongong, NSW, Australia
| | - Edward M Weaver
- Department of Otolaryngology, University of Washington, Seattle, Washington, USA
- Surgery Service, Seattle Veterans Affairs Medical Center, Seattle, Washington, USA
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Every JD, Sideris AW, Sarkis LM, Lam ME, Mackay SG, Pearson SJ. Hypocalcaemia in pharyngolaryngectomy: Preservation or autotransplantation of parathyroid glands. Laryngoscope Investig Otolaryngol 2021; 6:1208-1213. [PMID: 34667866 PMCID: PMC8513446 DOI: 10.1002/lio2.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 07/09/2021] [Accepted: 07/19/2021] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To describe transient and permanent hypocalcaemia following partial and total pharyngolaryngectomy with parathyroid gland preservation or autotransplantation. METHODS Thirty patients underwent partial or total pharyngolaryngectomy by a single surgeon during the period 2009-2020. Intraoperative parathyroid gland preservation or autotransplantation (where the gland appeared devascularized) was routinely performed. Calcium levels performed on day 1, 3 months, and at 12 months postoperatively were collected. Rates of transient and permanent hypocalcaemia were calculated. RESULTS A total of 13% of patients had transient hypocalcaemia, and 10% permanent hypocalcaemia. Rates of transient and permanent hypocalcaemia in total pharyngolaryngectomy were 14% and 14%, respectively. Partial pharyngectomy hypocalcaemia rates were 13% for transient and 0% for permanent. The majority of patients underwent salvage surgery for oncological resection, often following radiotherapy (63%). Ipsilateral hemithyroidectomy was preferred to total (57% vs 7%), with high rates of concurrent neck dissection (67%) and reconstruction (87%). CONCLUSION This data supports preservation or autotransplantation of parathyroid glands as a means of reducing permanent postoperative hypocalcaemia. LEVEL OF EVIDENCE Level IV, case series, retrospective.
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Affiliation(s)
- James D. Every
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
| | - Anders W. Sideris
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
| | - Leba M. Sarkis
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
| | - Matthew E. Lam
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
| | - Stuart G. Mackay
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
- Illawarra ENT Head & Neck ClinicWollongongAustralia
| | - Stephen J. Pearson
- Department of Otolaryngology, Head and Neck SurgeryThe Wollongong HospitalWollongongAustralia
- Illawarra ENT Head & Neck ClinicWollongongAustralia
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Sideris AW, Sarkis LM, Lam ME, Mackay SG. Low morbidity high anterior neck approach for removal of a deep intraglossal foreign body: A case report. Int J Surg Case Rep 2021; 81:105823. [PMID: 33887867 PMCID: PMC8044697 DOI: 10.1016/j.ijscr.2021.105823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/20/2021] [Accepted: 03/20/2021] [Indexed: 12/03/2022] Open
Abstract
The literature scarcely describes high anterior neck approaches to deep intra-glossal foreign bodies, tending to focus on transoral removal. This case describes an approach that is utilised in insertion of bilateral hypoglossal nerve stimulators. The approach includes midline transcervical incision, and exposure and midline separation of mylohyoid and geniohyoid muscles to expose genioglossi muscles. This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches.
Introduction and importance In the era of both new bilateral hypoglossal nerve stimulator and long-standing experience with Sistrunk’s procedures, it is notable that the literature scarcely describes high anterior neck approaches, tending to focus on transoral removal of intra-glossal foreign bodies. Herein we describe a case of a low morbidity anterior approach for access to an intra-glossal foreign body and discuss the implications. Case presentation A morbidly obese 73 year old lady presented acutely after inadvertent ingestion of a sewing needle. Initial assessment demonstrated an intraglossal foreign body which subsequently migrated into the deep substance of the tongue. Endoscopic retrieval was attempted but was unsuccessful. A midline transcervical anterior neck incision was made, exposure and midline separation of mylohyoid, and midline dissection of geniohyoid muscles was performed to expose genioglossi muscles and the foreign body removed. The patient recovered well without complication. Clinical discussion This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches. Such approaches have recently been developed for implantation of bilateral hypoglossal nerve stimulators. Conclusion Otolaryngologists should consider midline transcervical approach to retrieve deep intra-glossal foreign bodies, particularly in scenarios where other options may not provide adequate access or may enhance intra-oral morbidity.
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Affiliation(s)
- Anders W Sideris
- Department of Otolaryngology-Head and Neck Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia.
| | - Leba M Sarkis
- Department of Otolaryngology-Head and Neck Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Matthew E Lam
- Department of Otolaryngology-Head and Neck Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia
| | - Stuart G Mackay
- Department of Otolaryngology-Head and Neck Surgery, The Wollongong Hospital, Wollongong, New South Wales, Australia; Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, New South Wales, Australia; University of Wollongong School of Medicine, Wollongong, New South Wales, Australia
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Dow CL, Sideris AW, Singh R, Giles MH, Banks C, Meller C, Choroomi S, Havas TE. A Non-inferiority Trial: Safety and Efficacy of Topical 1:1000 versus 1:10 000 Epinephrine in Sino-nasal Surgeries. Ann Otol Rhinol Laryngol 2020; 130:563-570. [PMID: 33030020 DOI: 10.1177/0003489420962825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE This study aimed to test the non-inferiority of topical 1:1000 epinephrine compared to topical 1:10 000 with regard to intraoperative hemodynamic stability, and to determine whether it produced superior visibility conditions. METHODS A single-blinded, prospective, cross-over non-inferiority trial was performed. Topical 1:1000 or topical 1:10 000 was placed in 1 nasal passage. Hemodynamic parameters (heart rate, systolic and diastolic blood pressures, and mean arterial pressure) were measured prior to insertion then every minute for 10 minutes. This was repeated in the contralateral nasal passage of the same patient with the alternate concentration. The surgeon graded the visualization of each passage using the Boezaart Scale. The medians of the greatest absolute change in parameters were compared using a Wilcoxon Rank-Signed test and confidence intervals were calculated using a Hodges-Lehman test. The non-inferiority margin was pre-determined at 10 bpm for heart rate and 10 mmHg for blood pressures. A Wilcoxon Rank-Signed test was used to assess superiority in visualization. RESULTS Thirty-two patients were enrolled and after exclusions, nineteen were assessed (mean age = 35.63 ± 12.49). Differences in means of greatest absolute change between the 2 concentrations were calculated (heart rate = 2.49 ± 1.20; systolic = -1.51 ± 2.16; diastolic = 2.47 ± 1.47; mean arterial pressure = 0.07 ± 1.83). In analyses of medians, 1:1000 was non-inferior to the 1:10 000. There was a significant difference (-0.58 ± 0.84; P = .012) in visualization in favor of topical 1:1000. CONCLUSION Topical 1:1000 epinephrine provides no worse intraoperative hemodynamic stability compared to topical 1:10 000 but affords superior visualization and should be used to optimize surgical conditions.
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Affiliation(s)
- Cassie L Dow
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Anders W Sideris
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Ravjit Singh
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Mitchell H Giles
- Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Catherine Banks
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Catherine Meller
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Sim Choroomi
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
| | - Thomas E Havas
- Otorhinolaryngology Head and Neck Research Group, Prince of Wales Hospital, Randwick, NSW, Australia.,Otolaryngology - Head and Neck Surgery Department, Prince of Wales Hospital, Randwick, NSW, Australia.,Prince of Wales Clinical School, Faculty of Medicine, University of New South Wales, Kensington, NSW, Australia
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Holmes TR, Cumming BD, Sideris AW, Lee JW, Briggs NE, Havas TE. Multidisciplinary Tracheotomy Teams: An Analysis of Patient Outcomes and Resource Allocation. Ear Nose Throat J 2019; 98:232-237. [PMID: 30939910 DOI: 10.1177/0145561319840103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We sought to establish the effect of introducing a multidisciplinary tracheotomy management team (MDT). Tracheotomies are high-cost interventions with potentially devastating complications. Multidisciplinary teams have been introduced in many hospitals with the aim of reducing complications, however, data supporting them are lacking. There is currently insufficient evidence to conclude MDTs reduce length of hospital or intensive care unit (ICU) stay, and there is little information on cost analysis. A chart review identified patients who had a tracheotomy inserted at a major metropolitan teaching hospital with an acute spinal medicine service 2 years before and after the MDT was implemented. The primary outcome was time to decannulation. Other outcomes included tracheotomy complications, the proportion of patients decannulated, length of ICU and hospital stay, and admission cost. Our search identified 174 (78 prior and 96 post-MDT) patients. Baseline demographics were similar between groups. There was no difference in time to decannulation, the decannulation rate, or the length of hospital or ICU stay. Complication rates were low in both groups. There was an increase in the proportion of patients who received speaking valves and a reduction in cost of admission in a subgroup of patients who did not undergo head and neck surgery. There is insufficient evidence to support the widespread introduction of tracheotomy MDTs. Institutions considering introducing a tracheotomy team should carefully consider their case-mix, volume, and available resources as well as the structure and responsibilities of the team, and the timing of its activities within the working week. The potential benefits of MDTs including teaching of staff, and collaboration of teams should be acknowledged. Given the potentially significant implications for cost to the health system, a randomized trial is needed to guide policy in this area.
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Affiliation(s)
- Timothy R Holmes
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Benjamin D Cumming
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Anders W Sideris
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Jennifer W Lee
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Nancy E Briggs
- 2 Mark Wainwright Analytical Centre, University on New South Wales, Sydney, New South Wales, Australia
| | - Thomas E Havas
- 1 Department of Otolaryngology-Head and Neck Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
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