Assessing the safety and tolerability of rhinologic surgery under local anesthetic: an 8-year retrospective analysis

PURPOSE

Office-based rhinologic procedures (OBRP) have become widely available in North America due to technological advances and appropriate patient selection. Nevertheless, the literature exploring the safety of these procedures remains limited. The objective of this study was to further evaluate the safety, tolerability and efficacy of these procedures with a more robust sample size to allow for capture of rare events.

METHODS

A retrospective chart review of all patients who underwent OBRP from May 2015 to March 2023. Information regarding patient demographics, the indication for surgery, wait time, tolerability, intra- and postoperative complications, need for revisions, and type of revision (if applicable) was recorded.

RESULTS

1208 patients underwent OBRP during the study period. No patients were excluded. These included turbinoplasties (35%), endoscopic sinus surgeries (ESS) (26%), septoplasties (15%), nasal fracture reductions (7%), and a variety of other procedures. For ESS procedures, the anterior ethmoids and the maxillary sinuses were the most common sinuses treated. 1.1% of procedures were aborted prior to completion. The post-operative complication rate was 3.2%, with 2 major complications (significant bleeding and sepsis) encountered. The mean follow-up overall was 11 months and for ESS it was 15.8 months.

CONCLUSION

Office-based rhinologic procedures are well tolerated and safe for the appropriate patient and associated with shorter wait-times as well as avoidance of general anesthesia. The complication rates are similar to or lower than previously reported rates for rhinologic surgeries done in the operating room. The low rates of revision surgery also demonstrate the efficacy of these procedures.

International Consensus Statement on Obstructive Sleep Apnea

BACKGROUND

Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA).

METHODS

Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus.

RESULTS

The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated.

CONCLUSION

This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.

Effect of low salicylate diet on clinical and inflammatory markers in patients with aspirin exacerbated respiratory disease - a randomized crossover trial

Background

Aspirin-exacerbated respiratory disease (AERD) is characterized by eosinophilic rhinosinusitis, nasal polyposis, and bronchial asthma, along with the onset of respiratory reactions after the ingestion of nonsteroidal anti-inflammatory drugs (NSAIDs) or acetylsalicylic acid (ASA). In addition to the therapeutic routines and surgical options available, a low dietary intake of food salicylate has been suggested as adjunctive therapy for this condition.

This study aimed to assess the influence of a short-term low salicylate diet on inflammatory markers in patients with AERD and whether that would result in symptomatic improvement.

Methods

Prospective study with randomization to either a high or low salicylate diet for 1 week, followed by cross-over to the other study arm. Participants were asked to record their dietary salicylate for each week of the study. Urinary creatinine, salicylate and leukotriene levels were measured at the time of recruitment, end of week one and end of week two and the SNOT-22 questionnaire was filled out at the same time points.

Results

A total of seven participants completed the study. There was no statistical difference in the urinary salicylate and leukotriene levels between the two diets; nevertheless, participants on low salicylate diet reported improved SNOT-22 symptoms scores (p = 0.04), mainly in the rhinologic, ear/facial, and sleep dysfunction symptom domains. In addition, these last two domains outcomes were more significant than the minimal clinically important difference.

Conclusions

A short-term low salicylate diet may not result in biochemical outcomes changes but seems to provide significant symptomatic relief for patients with AERD.

Trial registration

NCT01778465 (www.clinicaltrials.gov)

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s40463-021-00502-4.

The subtle nuances of intranasal corticosteroids

Background

In the specialty of Otolaryngology – Head and Neck Surgery, intranasal corticosteroids are the mainstay treatment for inflammatory processes within the nasal cavity. All too often, physician prescribing patterns are based on previous training, personal experience, and interactions with industry. The purpose of this commentary is to review the nuances of each intranasal corticosteroid.

Commentary

There are nine intranasal corticosteroids approved for use in Canada. Each are discussed in detail, including their indication, bioavailability, effects on intranasal environment, and factors around patient adherence. Off-label use of budesonide irrigations is also discussed and cost information is presented in reference format for all available intranasal corticosteroids.

Conclusion

Although the efficacy of each intranasal corticosteroid has been shown to be similar, prescribing should be tailored based on bioavailability, intranasal environment, and factors that impact patient adherence such as dosing, cost and tolerability.

Graphical abstract

Nasal Lymphoma Presenting With Contralateral Proptosis and Vision Changes: A Case Report and Literature Review

Non-Hodgkin lymphoma (NHL) is a hematological malignancy that can sometimes originate from the nasal cavities and paranasal sinuses. Patients who present with these tumors typically report sinonasal symptoms. However, a diagnostic challenge can arise when a patient’s primary complaints include unique complex symptoms limited to the contralateral side of the tumor. This report describes the case of an 83-year-old man who presented to our center with a left-sided mass and right-sided proptosis with vision loss. After a nasal biopsy was taken, the patient was referred to the ophthalmology department to diagnose the cause of his ocular symptoms, which were not believed to be related to the mass. When biopsy results later returned as diffuse large B-cell lymphoma (DLBCL), an emergent repeat biopsy following lymphoma protocol was performed to confirm the diagnosis. A CT scan of the head and orbits showed generalized enlargement of the right optic nerve and extraocular muscles, and a positron emission tomography (PET) scan showed increased 18F-fluorodeoxyglucose (FDG) uptake in the right ethmoid sinus and orbit. The left-sided mass and right-sided symptoms resolved simultaneously with chemotherapy. This is the first documented case of a sinonasal mass causing ocular symptoms exclusively on the contralateral side. The presented diagnostic challenge highlights the importance of thorough investigations.

Predictors of difficulty in intubation in patients with obstructive sleep apnoea

OBJECTIVE

To evaluate predictors of difficult intubation in patients with obstructive sleep apnoea (OSA).

METHODOLOGY

Prospective series of 405 OSA patients (350 males/55 females) who had upper airway surgery. Procedures included functional endoscopic sinus surgery, septoplasty, turbinate reduction, palate/tonsil surgery, and/or tongue base surgery. Intubation difficulty (ID) was assessed using Mallampati grade, Laryngoscopic grade (Cormack and Lehane), and clinical parameters including BMI, neck circumference, thyromental distance, jaw adequacy, neck movements and glidescope grading.

RESULTS

Mean age was 41.6 years old; mean BMI 26.6; mean neck circumference 44.5cm; mean Apnea Hypopnea Index (AHI) was 25.0; and mean LSAT 82%. The various laryngeal grades (based on Cormack and Lehane), grade 1 - 53 patients (12.9%), grade 2A - 127 patients (31.0%), grade 2B - 125 patients (30.5%), grade 3 - 93 patients (22.7%) and grade 4 - seven patients (1.7%); hence, 24.4% had difficulties in intubation. Parameters that adversely affected intubation were, age of the patient, opening of mouth, retrognathia, overbite, overjet, limited neck extension, thyromental distance, Mallampati grade, and macroglossia (p<0.001). Body mass index (BMI) (p=0.087), neck circumference (p=0.645), neck aches (p=0.728), jaw aches (p=0.417), tonsil size (p=0.048), and AHI (p=0.047) had poor correlation with intubation. BMI-adjusted for Asians and Caucasians, showed that Asians were more likely to have difficulties in intubation (adjusted OR = 4.6 (95%Confidence Interval: 1.05 to 20.06) (p=0.043), compared to the Caucasian group.

CONCLUSION

This study illustrates that difficult intubation can be predicted pre-surgery in order to avert any anaesthetic morbidity.

Postoperative Continuous Positive Airway Pressure Use and Nasal Saline Rinses After Endonasal Endoscopic Skull Base Surgery in Patients With Obstructive Sleep Apnea: A Practice Pattern Survey

BACKGROUND

Endoscopic skull base surgery continues to evolve in its indications, techniques, instrumentation, and postoperative care. As surgery of the skull base will often violate dura, intraoperative and postoperative cerebrospinal fluid (CSF) leak is not uncommon and represents a potential conduit for air and bacterial contamination. Patients with obstructive sleep apnea (OSA) requiring continuous positive airway pressure (CPAP) therapy undergoing skull base surgery represent a challenging group. However, there appears to be a paucity of consensus regarding the postoperative management of this patient population. The objective of this study is to examine practice patterns and expert opinion on the use of postoperative CPAP and nasal saline in patients with OSA.

METHODS

A 14-item survey was generated by consensus among expert authors and distributed online to members of the North American Skull Base society and other international skull base community members. Data were analyzed for median, mean, and standard deviation variables. Subgroup analysis was completed between surgeons from different geographical locations and operative experience. SPSS22 was utilized for all complex statistical analysis and figures.

RESULTS

Seventy-one responses were collected from skull base surgeons. In patients with OSA, respondents would resume patients' CPAP therapy after a mean of 10.1 days (median, 7; standard deviation [SD], 10.2), without a CSF leak. In the presence of a small CSF leak, the mean duration would increase to 14.3 days (median, 14; SD, 9.8) and to 20.7 days (median, 21; SD, 11.8) in the presence of a larger leak. A surgeon's choice to attribute the relationship between delaying the start of nasal saline and CPAP after the endoscopic skull base surgery with progressively more challenging skull base repair was found to be statistically significant ( P < .001).

CONCLUSION

Saline and CPAP therapies are initiated after the endoscopic skull base surgical repairs by surgeons at an increasing temporal delay in relation to the degree and complexity of the skull base defect repaired.

Estimation of the Young's moduli of fresh human oropharyngeal soft tissues using indentation testing

Finite element (FE)-based biomechanical simulations of the upper airway are promising computational tools to study abnormal upper airway deformations under obstructive sleep apnea (OSA) conditions and to help guide minimally invasive surgical interventions in case of upper airway collapse. To this end, passive biomechanical properties of the upper airway tissues, especially oropharyngeal soft tissues, are indispensable. This research aimed at characterizing the linear elastic mechanical properties of the oropharyngeal soft tissues including palatine tonsil, soft palate, uvula, and tongue base. For this purpose, precise indentation experiments were conducted on freshly harvested human tissue samples accompanied by FE-based inversion schemes. To minimize the impact of the probable nonlinearities of the tested tissue samples, only the first quarter of the measured force-displacement data corresponding to the linear elastic regime was utilized in the FE-based inversion scheme to improve the accuracy of the tissue samples' Young's modulus calculations. Measured Young's moduli of the oropharyngeal soft tissues obtained in this study are presented. They include first estimates for palatine tonsil tissue samples while measured Young's moduli of other upper airway tissues were obtained for the first time using fresh human tissue samples.

Office-based rhinologic surgery: A modern experience with operative techniques under local anesthetic

BACKGROUND

Office-based rhinologic procedures have become popularized in recent years with the advent of several minimally invasive techniques. There is a paucity of literature, however, that supports more robust in-clinic procedures, e.g., true endoscopic sinus surgery (ESS). There is a high volume of this work being done at our center, and the objective of this article was to review the safety and tolerability of in-clinic surgeries.

METHODS

A retrospective chart review was conducted. All the adult patients who underwent in-clinic sinonasal procedures and surgery with a minimum of 3 months of follow-up were included. Information regarding intra- and postoperative complications and revision procedures were recorded. For the ESS procedures, the indication, sinuses operated on, and type of revision were also collected.

RESULTS

A total of 315 patients met the inclusion criteria. There were 166 turbinoplasties, 118 ESS, 35 septoplasties, 34 rhinoplasties, and 4 septorhinoplasties performed. For the ESS procedures, 74 (62.7%) were bilateral, and experience was had operating in all paranasal sinuses. All ESS work involved opening diseased ostia and was more than just polypectomies. The mean follow-up for the ESS cases was 13.4 months (range, 12-65 months). Complication rates and tolerability measures were comparable with those of other reported in-office sinonasal procedures performed with the patient under local anesthetic.

CONCLUSION

Office-based rhinologic surgery was safe and well tolerated by the patients. The need for revision ESS in our series was low when considering the extent of surgery that was performed. An in-clinic procedure may avoid a general anesthetic in the operating room for appropriately selected patients.

Bilateral caudate nucleus infarcts: A case report of a rare complication following endoscopic resection of a tuberculum sellae meningioma

Background:

We present a rare complication of bilateral caudate infarcts and necrosed nasoseptal flaps after endoscopic transsphenoidal resection of tuberculum sellae meningioma. This case highlights the importance of early and accurate diagnosis and treatment of a postoperative cerebrospinal fluid (CSF) leak and associated bacterial meningitis, and reviews any existing guidelines regarding its management.

Case Description:

A 54-year-old otherwise healthy man presented with progressive bitemporal hemianopsia. Magnetic resonance imaging of the head revealed a large, homogeneously enhancing sellar and suprasellar mass consistent with a meningioma. An endoscopic endonasal transsphenoidal approach was performed to resect the tuberculum sellae meningioma. The patient developed basal bacterial meningitis secondary to a CSF leak, requiring repair on two separate occasions. At the time of both repairs, there was evidence of necrosis of the nasoseptal flaps used for the repairs. Soon after the diagnosis of meningitis, the patient developed bilateral caudate infarcts.

Conclusion:

This report discusses the possible underlying etiologies for the bilateral caudate infarcts and necrosed flaps including bacterial meningitis with associated local vasospasm of nearby vessels resulting in infarction. This case emphasizes the importance of concise management of postendoscopic CSF leak and discusses the guidelines regarding antimicrobial therapy and the management of lumbar drains.

Upper airway surgery for obstructive sleep apnea reduces blood pressure

OBJECTIVES/HYPOTHESIS

To evaluate if upper airway surgery reduces blood pressure in patients with obstructive sleep apnea (OSA).

STUDY DESIGN

Prospective series.

METHODS

A prospective series of 112 consecutive OSA patients with hypertension (HTN). All patients were > 18 years old, respiratory disturbance index >5, all levels of apnea-hypopnea index (AHI), with a history of HTN treated with medication for at least 6 months. Surgical procedures included septoplasty, turbinate reduction, palate surgery, and tongue base reduction.

RESULTS

There were 92 men and 20 women, with a mean age of 48.6 years, mean body mass index (BMI) was 27.5 (range, 19.7-34.7). Mean follow-up was 16.1 months. The mean preoperative AHI was 32.6 (range, 1.2-104), with the mean lowest oxygen saturation (LSAT) of 79.9% (range, 52%-93%). The mean adjusted preoperative and postoperative systolic blood pressure (SBP) was reduced from 146 ± 15.3 mm Hg to 122 ± 12.5 mm Hg (P < .001), and diastolic blood pressure (DBP) was reduced from 91 ± 10.2 mm Hg to 76 ± 7.8 mm Hg (P < .001). There was a decrease in overall BMI from 27.5 ± 3.6 to 25.5 ± 3.0 (P < .001); however, based on multivariate analysis, the reduction in SBP and DBP was not affected by this BMI reduction. Fifty-eight patients (51.8%) did not require their antihypertensive after surgery. There was poor correlation noted between HTN with AHI, LSAT, and oxygen duration <90%.

CONCLUSIONS

Upper airway surgery does reduce SBP and DBP in patients with OSA.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:523-527, 2018.

Development of a novel T-tube frontal sinus irrigation catheter

BACKGROUND

The problem of postoperative management after frontal sinus surgery remains a challenge. The bilateral opening created in the Draf III procedure does not fit any currently available stent, and patients find rinsing the frontal sinus difficult, which thus decreases compliance. The objective of this study was to demonstrate the successful use of a novel frontal sinus catheter fashioned from a biliary T tube by addressing these issues in patients with complicated sinus disease.

METHODS

This was a review of 30 patients who underwent a Draf III procedure between January and October 2014, and who had a T-tube stent inserted at the end of the procedure. Patient charts were analyzed for complications such as bleeding, infection, and restenosis as well as indications of ease of rinsing ability after surgery.

RESULTS

From the chart data, there was only one intraoperative bleed and only one postoperative bleed that required packing. Four patients had infections that required antibiotics after surgery. At the time of data collection, only one patient had signs of restenosis as judged by the operating surgeon. Patients reported an ease of rinsing ability with the T-tube stent.

CONCLUSIONS

The novel biliary T-tube stent use presented in this article is a promising future direction for postoperative care after extended frontal sinus surgery.

Publication trends in obstructive sleep apnea: Evidence of need for more evidence

Objective

Published research in obstructive sleep apnea (OSA) appears limited despite OSA being a highly prevalent adult and pediatric disease leading to many adverse outcomes if left untreated. We aimed to quantify the deficit in OSA scientific literature in order to provide a novel way of identifying gaps in knowledge and a need for further research inquiry.

Methods

This was a Bibliometric analysis study. Using Ovid Medline database we analyzed and compared research output (medical and surgical) between adult OSA and similarly prevalent chronic conditions (Type II diabetes (T2DM), coronary artery disease (CAD) and osteoarthritis (OA)) from December 2016 up to fifty years prior. Linear graphs were utilized to trend collected data. Utilizing same strategy, we compared publication trends for pediatric OSA to asthma and gastroesophageal reflux (GER).

Results

Adult OSA publications (n = 9314) were significantly underrepresented when compared to T2DM (n = 66,023), CAD (n = 31,526) and OA (n = 34,123). Linear plots demonstrated that despite increasing number of publications this disparity persisted annually. Surgical literature composed 10.4% (n = 972) of adult OSA publications and reached a plateau in the last ten years. Pediatric OSA (n = 2994) had less research output when compared to asthma (n = 47,442) and GER (n = 6705). However, over past five years pediatric OSA surpassed GER in annual number of publications. Surgical literature represented 23.1% (n = 693) of pediatric OSA publications and continued increasing over past ten years. Study methodologies for both adult and pediatric OSA showed a lack of randomized controlled trials and meta-analyses in comparison to other diseases.

Conclusion

Our review shows substantial deficit in total, annual and surgical adult OSA published research compared to similarly prevalent diseases. This trend is not entirely observed in pediatric OSA literature.

Oral corticosteroid prescribing habits for rhinosinusitis: The American Rhinologic Society membership

BACKGROUND

In the field of otolaryngology, oral corticosteroids (OCS) are widely prescribed for rhinosinusitis. Although there is evidence in the literature regarding specific OCS dosing protocols, it is not known to what extent these recommendations are being followed.

OBJECTIVE

To examine the current state of OCS prescribing habits for rhinosinusitis by American Rhinologic Society members.

METHODS

An anonymous online survey was sent to all American Rhinologic Society members. Dosing, frequency, tapering, and overall prescribing habits for OCS were assessed in chronic rhinosinusitis with polyposis (CRSwP) and in chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis. The CRSwP group was subdivided into aspirin-exacerbated respiratory disease, allergic fungal sinusitis, and not otherwise specified. Results were compared with current guidelines. Descriptive statistics were used to analyze data.

RESULTS

Ninety-three surveys were completed (response rate, 12.9%). Prednisone was the most common OCS prescribed. In the CRSwP-aspirin-exacerbated respiratory disease group (n = 86), the median starting dose was 60 mg (range, 4-80 mg) and the average duration was 8 days (range, 2-28 days). In the CRSwP-allergic fungal sinusitis group (n = 81), the median starting dose was 50 mg (range, 20-60 mg), and the average duration was 6 days (range, 2-35 days). In the CRSwP-not otherwise specified group (n = 84), the median starting dose was 50 mg (range, 20-80 mg) and the average duration was 5 days (range, 1-21 days). OCS were prescribed for chronic rhinosinusitis without polyposis and acute bacterial rhinosinusitis by 66.0 and 62.4% of respondents, respectively.

CONCLUSION

Significant heterogeneity existed in OCS prescribing habits for rhinosinusitis. Discrepancies were observed between survey results and evidence-based recommendations. Developing standardized OCS treatment protocols for rhinosinusitis may improve the quality of care by optimizing clinical outcomes and reducing the risk of complications.

Factors associated with lingual tonsil hypertrophy in Canadian adults

Background

Hypertrophy of the lingual tonsil tissue in the adult patient is thought to contribute to the pathophysiology of obstructive sleep apnea. The underlying etiology of lingual tonsil hypertrophy (LTH) in the adult patient is unclear and likely multifactorial. Previous studies have suggested that the lingual tonsils may undergo compensatory hyperplasia post-tonsillectomy in children, although it is unknown if this occurs or persists into adulthood. The purpose of this study was to determine what factors are associated with LTH in a population of Canadian adults.

Methods

Adult patients presenting for consultation to an academic Rhinology/General Otolaryngology practice were eligible for enrollment. Demographic data including age, body mass index (BMI), Reflux Symptom Index (RSI), history of allergy, and history of tonsillectomy was collected via questionnaire. Endoscopic photographs of the base of tongue and larynx were captured. These were graded for LTH and Reflux Finding Scale (RFS) by blinded examiners. Statistical analysis was performed by comparing the mean LTH value to the variables of interest using two-tailed T-test. P < .05 was considered significant.

Results

One hundred two subjects were enrolled. Age ranged from 18 to 78. 28 patients had previous tonsillectomy. This was not associated with a significant increase in lingual tonsil tissue (r = −0.05, p = 0.61). RFS >7 or RSI >13 was considered positive for laryngopharyngeal reflux. There was no difference in LTH based on RSI positivity (p = 0.44). RFS positivity correlated with increased lingual tonsil tissue (p < 0.05). BMI >30 was associated with increased lingual tonsil hypertrophy (p < 0.05).

Conclusions

An elevated body mass index and positive Reflux Finding Score are associated with lingual tonsil hypertrophy in adults. Reflux symptom index, history of allergy and history of childhood tonsillectomy are not associated with LTH.

Silent sinus syndrome after facial trauma: A case report and literature review

OBJECTIVE

The accepted definition of silent sinus syndrome (SSS) excludes posttraumatic cases. To challenge current exclusion criteria of antecedent facial trauma, we have identified all published cases of posttraumatic SSS in English literature, including a new representative case from our institution.

DATA SOURCES

MEDLINE, EMBASE, and Scopus databases.

REVIEW METHODS

All case reports and case series published in English literature from 1964 through August 2016 were sequentially identified. Authors of cases with missing information were contacted for completion.

RESULTS

Thirteen documented cases of posttraumatic SSS were identified through the literature review. An additional case from our institution was presented, bringing the total reported case count to 14. Time from initial trauma to presentation ranged from 2 months to 32 years, with a median duration of 6 months. Endoscopic sinus surgery (ESS) with either concurrent or staged orbital floor implant repair was used to treat posttraumatic SSS in 64% of reported cases. Three patients had ESS alone, with one case showing postoperative improvement in enophthalmos.

CONCLUSION

Recent emergence of case reports of SSS postorbital and facial trauma challenge the current exclusion criteria of precedent facial trauma. Posttraumatic SSS is rare, but the availability of cross-sectional imaging pre- and postdevelopment of SSS makes a strong case for a causal relationship. Laryngoscope, 127:1520-1524, 2017.

Quantitative evaluation of vision-related and health-related quality of life after endoscopic transsphenoidal surgery for pituitary adenoma

OBJECTIVE Endoscopic resection of pituitary adenomas has been reported to improve vision function in up to 80%-90% of patients with visual impairment due to these adenomas. It is unclear how these reported rates translate into improvement in visual outcomes and general health as perceived by the patients. The authors evaluated self-assessed health-related quality of life (HR-QOL) and vision-related QOL (VR-QOL) in patients before and after endoscopic resection of pituitary adenomas. METHODS The authors prospectively collected data from 50 patients who underwent endoscopic resection of pituitary adenomas. This cohort included 32 patients (64%) with visual impairment preoperatively. Twenty-seven patients (54%) had pituitary dysfunction, including 17 (34%) with hormone-producing tumors. Patients completed the National Eye Institute Visual Functioning Questionnaire and the 36-Item Short Form Health Survey preoperatively and 6 weeks and 6 months after surgery. RESULTS Patients with preoperative visual impairment reported a significant impact of this condition on VR-QOL preoperatively, including general vision, near activities, and peripheral vision; they also noted vision-specific impacts on mental health, role difficulties, dependency, and driving. After endoscopic resection of adenomas, patients reported improvement across all these categories 6 weeks postoperatively, and this improvement was maintained by 6 months postoperatively. Patients with preoperative pituitary dysfunction, including hormone-producing tumors, perceived their general health and physical function as poorer, with some of these patients reporting improvement in perceived general health after the endoscopic surgery. All patients noted that their ability to work or perform activities of daily living was transiently reduced 6 weeks postoperatively, followed by significant improvement by 6 months after the surgery. CONCLUSIONS Both VR-QOL and patient's perceptions of their ability to do work and perform other daily activities as a result of their physical health significantly improved by 6 months after endoscopic resection of pituitary adenoma. The use of multidimensional QOL questionnaires provides a precise assessment of perceived outcomes after endoscopic surgery.

Combined Expansion Pharyngoplasty and Anterior Palatoplasty for the Treatment of OSA

To evaluate the success rates of combined Expansion Sphincter Pharyngoplasty and the Anterior Palatoplasty in the treatment of OSA. A two center prospective series of 73 patients with OSA. All patients were >18 years old, retro-palatal obstruction, concentric velo-pharyngeal collapse, BMI < 33, Friedman clinical stage II, with all grades of AHI. The procedure involved the anterior palatoplasty, tonsillectomy and expansion sphincter pharyngoplasty with or without nasal surgery. There were 68 men and 5 women, the mean age was 46.8 years old (range of 25-67 years), mean BMI was 25.5 (range of 20.3-31.2). All patients had pre-operative and post-operative PSG. The AHI improved in all patients, mean AHI improved from 26.3 ± 17.7 to 12.6 ± 5.8 (p < 0.001). There were 20 mild OSA, 33 moderate OSA and 20 severe OSA patients. Twenty-three patients had pre-operative DISE, and 61 patients had nose/palate surgery, while only 12 had palate surgery alone. The overall success rate (50 % reduction and AHI < 20) was 86.3 %. The mean snore scores (VAS) improved from 8.8 ± 1.2 to 2.0 ± 1.3 (p < 0.001). The mean Epworth score improved from 11.5 ± 2.2 to 2.9 ± 2.1 (p < 0.001). Lowest oxygen saturation also improved in all patients. Subjectively, all the patients felt less tiredness. Pre-operative DISE assessment did not seem to confer any advantage over the patients who had no pre-operative DISE (p = 0.027), and patients who had nose/palate surgery seemed to have better success rates compared to those who only had palate surgery (p = 0.081). This combined technique has been shown to be effective in selected group of OSA patients. Level of evidence IV.

Trends in CPAP adherence over twenty years of data collection: a flattened curve

Background

Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so.

Methods

A comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994–2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling.

Results

Eighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average.

Conclusions

The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.

Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations

BACKGROUND

Chronic rhinosinusitis (CRS) in aspirin-exacerbated respiratory disease (AERD) represents a recalcitrant form of sinonasal inflammation for which a multidisciplinary consensus on patient management has not been reached. Several medical interventions have been investigated, but a formal comprehensive evaluation of the evidence has never been performed. The purpose of this article is to provide an evidence-based approach for the multidisciplinary management of CRS in AERD.

METHODS

A systematic review of the literature was performed and the guidelines for development of an evidence-based review with recommendations were followed. Study inclusion criteria included: adult population >18 years old; CRS based on published diagnostic criteria, and a presumptive diagnosis of AERD. We focused on reporting higher-quality studies (level 2 or higher) when available, but reported lower-quality studies if the topic contained insufficient evidence. Treatment recommendations were based on American Academy of Otolaryngology (AAO) guidelines, with defined grades of evidence and evaluation of research quality and risk/benefits associated with each treatment.

RESULTS

This review identified and evaluated the literature on 3 treatment strategies for CRS in AERD: dietary salicylate avoidance, leukotriene modification, and desensitization with daily aspirin therapy.

CONCLUSION

Based on the available evidence, dietary salicylate avoidance and leukotriene-modifying drugs are options following appropriate treatment with nasal corticosteroids and saline irrigation. Desensitization with daily aspirin therapy is recommended following revision endoscopic sinus surgery (ESS).

Comparing surgical trays with redundant instruments with trays with reduced instruments: a cost analysis

BACKGROUND

When prearranged standard surgical trays contain instruments that are repeatedly unused, the redundancy can result in unnecessary health care costs. Our objective was to estimate potential savings by performing an economic evaluation comparing the cost of surgical trays with redundant instruments with surgical trays with reduced instruments ("reduced trays").

METHODS

We performed a cost-analysis from the hospital perspective over a 1-year period. Using a mathematical model, we compared the direct costs of trays containing redundant instruments to reduced trays for 5 otolaryngology procedures. We incorporated data from several sources including local hospital data on surgical volume, the number of instruments on redundant and reduced trays, wages of personnel and time required to pack instruments. From the literature, we incorporated instrument depreciation costs and the time required to decontaminate an instrument. We performed 1-way sensitivity analyses on all variables, including surgical volume. Costs were estimated in 2013 Canadian dollars.

RESULTS

The cost of redundant trays was $21 806 and the cost of reduced trays was $8803, for a 1-year cost saving of $13 003. In sensitivity analyses, cost savings ranged from $3262 to $21 395, based on the surgical volume at the institution. Variation in surgical volume resulted in a wider range of estimates, with a minimum of $3253 for low-volume to a maximum of $52 012 for high-volume institutions.

INTERPRETATION

Our study suggests moderate savings may be achieved by reducing surgical tray redundancy and, if applied to other surgical specialties, may result in savings to Canadian health care systems.

Changing Trends in the Success Rate of Anterior Cricoid Split

Objectives:

We determined the historical trends at our institution in the extubation success rate, defined as avoiding tracheostomy, for infants with acquired laryngotracheal stenosis (LTS) who undergo anterior cricoid split (ACS) as primary treatment.

Methods:

We performed a retrospective chart review of all neonates with acquired LTS treated with ACS between 1989 and 2005. Successful extubation rates were assessed over the study's time period. Student's t-test was used to compare identified subgroups.

Results:

Thirty-one neonates (14 male, 17 female) were identified, with an average gestational age of 27.6 weeks. During 1989 to 1995, a successful cumulative extubation rate of 71.4% was achieved in 14 children. By 2005, though, following a further 17 children, the successful cumulative extubation rate had dropped to 54.8%. The extubation rate in the time period 1996 to 2005 specifically was only 41.2%. The factor identified that most significantly correlated with this change was the difference in average duration of preoperative intubation. Relatively higher numbers of significant neurologic, respiratory, and cardiac comorbidities were identified both in the 1996 to 2005 grouping and in the ACS failure grouping.

Conclusions:

The success rate of ACS as a means of avoiding neonatal tracheostomy appears to have declined over the past 10 years at our institution. A prolonged period of preoperative intubation, as well as associated increasingly significant comorbidities, may be explanatory for this change. Revising the accepted selection criteria for ACS, or broadening the indications for alternative techniques, may be warranted.

A novel implantable device for the treatment of obstructive sleep apnea: clinical safety and feasibility

OBJECTIVE

Many cases of obstructive sleep apnea (OSA) involve collapse of the tongue base and soft palate during sleep, causing occlusion of the upper airway and leading to oxygen desaturation. Existing therapies can be effective, but they are plagued by patient adherence issues and the invasiveness of surgical approaches. A new, minimally invasive implant for OSA has been developed, which is elastic and contracts a few weeks after deployment, stabilizing the surrounding soft tissue. The device has had good outcomes in preclinical testing; this report describes the preliminary feasibility and safety of its implementation in humans.

PATIENTS AND METHODS

A prospective, multicenter, single-arm feasibility study was conducted. Subjects were adults with moderate-to-severe OSA who had previously failed or refused conventional continuous positive airway pressure treatment. Intraoperative feasibility data, postoperative pain, and safety information were collected for a 30-day postoperative period.

RESULTS

Forty subjects participated (37 men, three women; average age of 46.1 years); each received two tongue-base implants and two soft-palate implants. Surgical procedure time averaged 43 minutes. Postsurgical pain resolved readily in most cases; at 30 days post implantation, <20% of subjects reported pain, which averaged less than two out of ten. Adverse events were generally the mild and expected sequelae of a surgical procedure with general anesthesia and intraoral manipulation. The device was well tolerated. Implant extrusions were reported with soft-palate implants (n=12), while tongue-base implants required few revisions (n=2). Quantitative and qualitative sleep effectiveness outcomes (including full-night polysomnographic and quality-of-life measures) will be presented in a subsequent report.

CONCLUSION

Implantation of the device was feasible. Although a relatively high rate of extrusions occurred in the now-discontinued palate implants, tongue-base implants were largely stable and well tolerated. The minimally invasive and maintenance-free implant may provide a new alternative to higher morbidity surgical procedures.

Reconsidering first-line treatment for obstructive sleep apnea: a systematic review of the literature

BACKGROUND

Continuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study's objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic.

METHODS

A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP.

RESULTS

A total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP.

CONCLUSIONS

When considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study's results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence.

Timing of endoscopic surgical decompression in traumatic optic neuropathy: a systematic review of the literature

BACKGROUND

Traumatic optic neuropathy (TON) represents a rare but devastating complication of closed head injuries. No accepted guidelines are available for medical and surgical management algorithms. A systematic review of the literature was performed to determine the optimal timing and candidacy for endoscopic surgical intervention.

METHODS

A systematic review of multiple databases was performed including Medline-Ovid, EMBASE, and PubMed. Data was extracted and patients stratified based on surgical delay from trauma (≤3 days, >3 days, ≤7 days, or >7 days) as well as preoperative and postoperative vision testing (no light perception [NLP]; light perception [LP]; hand motion [HM]; or finger counting [FC] or better).

RESULTS

The literature review identified 24 studies meeting inclusion criteria. In the group of patients receiving surgery ≤3 days after the antecedent event, 57% (105/183) had visual improvement, whereas in the >7-days group 51% (145/283) of patients improved. In those with NLP preoperatively, 41% (172/411) saw improvement, whereas those with LP (89%), HM (93%), or FC (85%) fared better.

CONCLUSION

The literature suggests that surgical intervention for TON is indicated despite delayed presentation, and is a better choice than no intervention at all. Patients with complete blindness on presentation (NLP) tend to have a poorer surgical outcome.

Epistaxis in hereditary hemorrhagic telangiectasia: an evidence based review of surgical management

Patients with Hereditary Hemorrhagic Telangiectasia (HHT) frequently present with epistaxis. Up to 98 % of these patients will have epistaxis at some point in their life. There are multiple ways to deal with this problem, including conservative, medical and surgical options. We present a case and an update on the treatment options for HHT, with a focus on the newer and experimental techniques.

Multimedia in the informed consent process for endoscopic sinus surgery: A randomized control trial

OBJECTIVES/HYPOTHESIS

To determine patient recall of specific risks associated with endoscopic sinus surgery and whether an adjunct multimedia education module is an effective patient tool in enhancing the standard informed consent process.

STUDY DESIGN

Prospective, randomized, controlled trial.

METHODS

Fifty consecutive adult patients scheduled for endoscopic sinus surgery at a rhinology clinic of a tertiary care hospital were recruited for this study. Informed consent was studied by comparing the number of risks recalled when patients had a verbal discussion in conjunction with a 6-minute interactive module or the verbal discussion alone. Early recall was measured immediately following the informed consent process, and delayed recall was measured 3 to 4 weeks after patient preference details were also collected.

RESULTS

Early risk recall in the multimedia group was significantly higher than the control group (P = .0036); however, there was no difference between the groups in delayed risk recall. Seventy-six percent of participants expressed interest in viewing the multimedia module if available online between the preoperative and procedural day. Sixty-eight percent of patients preferred having the multimedia module as an adjunct to the informed consent process as opposed to the multimedia consent process alone.

CONCLUSIONS

There is an early improvement in overall risk recall in patients who complete an interactive multimedia module, with a clear patient preference for this method. Here we emphasize the well-known challenges of patient education and demonstrate the effectiveness of integrating technology into clinical practice in order to enhance the informed consent process.

LEVEL OF EVIDENCE

1b Laryngoscope, 126:1273-1278, 2016.

Quantitative evaluation of headache severity before and after endoscopic transsphenoidal surgery for pituitary adenoma

OBJECT The relationship between headaches, pituitary adenomas, and surgical treatment of pituitary adenomas remains unclear. The authors assessed the severity and predictors of self-reported headaches in patients referred for surgery of pituitary adenomas and evaluated the impact of endoscopic transsphenoidal surgery on headache severity and quality of life (QOL). METHODS In this prospective study, 79 patients with pituitary adenomas underwent endoscopic transsphenoidal resection and completed the Headache Impact Test (HIT-6) and the 36-Item Short Form Health Survey (SF-36) QOL questionnaire preoperatively and at 6 weeks and 6 months postoperatively. RESULTS Preoperatively, 49.4% of patients had mild headache severity, 13.9% had moderate severity, 13.9% had substantial severity, and 22.8% had intense severity. Younger age and hormone-producing tumors predisposed greater headache severity, while tumor volume, suprasellar extension, chiasmal compression, and cavernous sinus invasion of the pituitary tumors did not. Preoperative headache severity was found to be significantly associated with reduced scores across all SF-36 QOL dimensions and most significantly associated with mental health. By 6 months postoperatively, headache severity was reduced in a significant proportion of patients. Of the 40 patients with headaches causing an impact on daily living (moderate, substantial, or intense headache), 70% had improvement of at least 1 category on HIT-6 by 6 months postoperatively, while headache worsened in 7.6% of patients. The best predictors of headache response to surgery included younger age, poor preoperative SF-36 mental health score, and hormone-producing microadenoma. CONCLUSIONS The results of this study confirm that surgery can significantly improve headaches in patients with pituitary adenomas by 6 months postoperatively, particularly in younger patients whose preoperative QOL is impacted. A larger multicenter study is underway to evaluate the long-term effect of surgery on headaches in this patient group.

Squeeze bottle versus saline spray after endoscopic sinus surgery for chronic rhinosinusitis: a pilot multicentre trial

BACKGROUND

There is a need for controlled trials to guide the perioperative management of patients undergoing endoscopic sinus surgery (ESS). The authors performed a pilot multicenter trial to compare two types of saline delivery devices in this population.

METHODS

Patients were randomized to high volume saline irrigation with a squeeze bottle and low volume saline spray after ESS in patients with chronic rhinosinusitis (CRS). Surgeons were blinded to treatment, and one-month postoperative scores for sinonasal outcomes [Sinonasal Outcome Test-22 (SNOT-22)] scale, nasal and sinus symptom score (NSS), and perioperative sinus endoscopy (POSE) scale were compared with preoperative scores.

RESULTS

Nine centers provided data for 86 patients. All three outcomes measures improved significantly for both groups. Saline spray: SNOT-22 48.8 versus. 23.7, treatment effect 25.1 (95% confidence interval [CI], 17.9-32.2), POSE 21.1 versus. 8.4, treatment effect 12.7 (95% CI, 9.2-16.1), and NSS 8.2 versus 5.0, treatment effect 3.1 (95% CI, 1.4-4.9) pre- and postoperatively, respectively (all p < 0.0001). Squeeze bottle: SNOT-22 49.5 versus 23.6, treatment effect 25.9 (95% CI, 20.3-31.6), POSE 18.6 versus 9.2, treatment effect 9.3, (95% CI 6.7-12.0), and NSS 9.0 versus 5.7, treatment effect 3.3 (95% CI, 2.3-4.3) pre- and postoperatively, respectively (all p < 0.0001). Analysis of variance did not identify a difference between the two treatment groups. Subgroup analysis based on preoperative disease severity did not change the nonassociation of saline bottle with outcome measures. Post hoc sample size calculation determined that 176 patients is required to detect an 8.9-point difference in SNOT-22 scores.

CONCLUSION

In this pilot multicenter trial examining patients with chronic rhinosinusitis undergoing ESS, both squeeze bottle and saline spray showed significant improvement in SNOT-22, POSE, and NSS scores at one-month postoperatively. Because the study was nonpowered, we cannot rule out a potential difference between the two treatment groups.

Iatrogenic fracture of the superomedial orbital rim during frontal trephine irrigation

Frontal sinus trephination (FST) has numerous applications in the treatment of acute and chronic sinus disease. This procedure involves making an incision at the medial aspect of the supraorbital rim and then drilling the sinus's anterior table. Placement of a frontal trephine allows for irrigation of the frontal recess in order to evacuate the frontal sinus in a minimally invasive manner. Orbital injury is a rare complication of FST. We present a case of previously unreported orbital compartment syndrome secondary to iatrogenic fracture of the superomedial orbital rim as a complication of frontal trephine irrigation. We also review the literature on the applications of FST and its associated complications, and we discuss orbital compartment syndrome as a complication of sinus surgery.

Impact of nasal surgery on speech resonance

OBJECTIVES

The nose and paranasal sinuses contribute to speech resonance and changes to these structures may alter speech nasality. This change may influence one's vocational and social functioning and quality of life. Our investigation explored objective and subjective changes in nasality following nasal surgery in a prospective and longitudinal fashion.

METHODS

Recordings of sustained vowel and sentence stimuli and voice-related quality of life measurements were obtained preoperatively and at 2, 4, 8, and 24 weeks postoperatively from individuals undergoing nasal and/or sinus surgery. Objective measures of fundamental frequency, jitter, shimmer, and harmonic to noise ratio (HNR) were determined. Pre- and postoperative speech samples were assessed by 15 naïve listeners.

RESULTS

In all, 15 subjects completed the study. Neither speakers nor listeners perceived a subjective change in nasality following surgery. No statistically significant change in microacoustic measures were identified. Although nasal sentences did not reveal differences for 3 microacoustic measures, a difference in HNR was identified.

CONCLUSIONS

Patients undergoing nasal surgery did not exhibit subjective changes in resonance postoperatively. Aside from a difference in HNR for the nasal sentence, objective microacoustics remained unchanged. These results demonstrate the stability of oranasal resonance despite nasal surgery and provide valuable data for patient informed decision-making.

The utility of routine polyp histopathology after endoscopic sinus surgery

BACKGROUND

Routine histopathological assessment is standard practice for nasal polyp specimens obtained during endoscopic sinus surgery (ESS) for chronic rhinosinusitis (CRS). Retrospective studies suggest that routine histopathology of nasal polyps shows few unexpected diagnoses that alter patient management. Our objective was to study the use of routine pathological analysis, and its cost to the healthcare system, in a prospective manner.

METHODS

A multicenter prospective assessment was performed from data collected between 2007 and 2013. Only cases of patients undergoing ESS for bilateral CRS were included. We excluded unilateral disease cases, and cases in which diagnoses other than polyps were suspected either preoperatively or intraoperatively. We then compared the preoperative diagnosis with the final histopathology and identified the rate of unexpected pathologies. A cost analysis was performed.

RESULTS

Only 4 of 866 pathological specimens were identified as having a clinically significant unexpected diagnosis. All unexpected pathologies in this series were benign. These 4 cases account for 0.46% of all specimens reviewed. This translates to a number needed to screen of 217 cases of bilateral CRS to discover 1 unexpected pathology. The associated cost for making an unexpected diagnosis was $19,192.73.

CONCLUSION

Routine histopathology of nasal polyps in ESS for bilateral CRS with polyps yields few unexpected and management-altering diagnoses. It carries a significant cost to the healthcare system. In cases of bilateral CRS with no other concerning clinical features, clinicians should exercise judgment in submitting polyp specimens for pathology rather than routinely sending polyps for histopathologic analysis.

Emergencies in otolaryngology-head and neck surgery bootcamp: a novel Canadian experience

OBJECTIVES/HYPOTHESIS

A 1-day intensive course (bootcamp) was developed, to teach junior otolaryngology-head and neck surgery (OTO-HNS) residents emergency procedural skills, clinical reasoning, and communication skills. This learning paradigm utilized a number of novel task trainers, panel discussions, and emergency simulations. The study objective was to assess the educational value of this bootcamp.

STUDY DESIGN

Prospective cohort survey.

METHODS

Residents were recruited from regional teaching centers within a 2000-km radius of the simulation center. Preceptors fluent in English and in French were in attendance. Pre-bootcamp outcome measures included the Kolb Learning Style Inventory and a self-administered survey measuring confidence levels in performing specific OTO-HNS tasks. Post-bootcamp outcome measures included a survey evaluating the bootcamp experience and a structured follow-up telephone interview.

RESULTS

Twenty-eight residents participated in the bootcamp from across the United States and Canada. When asked if they felt that "overall, the educational day was an effective learning process," the average score was 4.75/5.0. The vast majority of participants (92.9%) felt they would recommend the bootcamp to a future junior resident. Kolb learning styles that prefer active experimentation (acting, initiating, and deciding) were more common than those that utilize reflective observation (imagining, analyzing, reflecting), which favors a hands-on model of learning.

CONCLUSION

This first Canadian OTO-HNS bootcamp demonstrated the feasibility and effectiveness of conducting a centralized bootcamp for regional training centers spanning multiple states/provinces and languages. Future bootcamps will be held annually and will ideally continue the natural evolution of surgical, hands-on training.

Redefining the timing of surgery for obstructive sleep apnea in anatomically favorable patients

OBJECTIVES/HYPOTHESIS

Healthcare remunerating agencies in North America require patients with obstructive sleep apnea (OSA) to undergo a continuous positive airway pressure (CPAP) trial before funding surgical therapy. The adherence rate of CPAP is problematic. This study's objective was to determine the proportion of surgically favorable patients who failed CPAP who subsequently benefitted from surgical therapy, and to explore consideration of surgical therapy as first-line treatment in this specific OSA subpopulation.

STUDY DESIGN

This was a prospective cohort study.

METHODS

Patients with moderate-severe OSA who had failed a minimum 6-month trial of CPAP were recruited. All had optimal anatomy for surgery and underwent tonsillectomy with palatoplasty ± septoplasty. Outcome measures included apnea-hypopnea index (AHI), Epworth Sleepiness Scale (ESS), and Sleep Apnea Quality of Life Index (SAQLI-E), and blood pressure. Patients were followed for 1 year.

RESULTS

By AHI measurement, 85.7% of patients in the entire cohort were successfully treated by surgery. ESS while on CPAP was 13.7 ± 2.9, improving to 4.1 ± 2.5 after surgery. SAQLI-E scores on CPAP were 25.7 ± 5.8, improving to 10.2 ± 3.2 after surgery. Blood pressure remained elevated during CPAP but normalized after surgery. All changes were significant at P < .001.

CONCLUSIONS

Surgical intervention improved OSA severity as measured by the ESS, SAQLI-E, and blood pressure. These measures had not improved on CPAP. AHI improved as well. Our results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence and with only minor surgical risk.

LEVEL OF EVIDENCE

2 Laryngoscope 124:S1-S9, 2014.