Patient-Reported Outcome Measures Including Nasal Breathing Improvement After Functional Rhinoplasty Using Endonasal Septal Extension Grafting

Objective: To measure the change perceived by patients after endonasal rhinoplasty using a, septal extension graft (SEG), as measured by patient-reported outcome measures (PROMs). Methods: A retrospective review of patients with nasal obstruction underwent septoplasty, turbinoplasty, and SEG. PROMs were assessed to compare operative outcomes for breathing (Nose Obstruction Symptom Evaluation [NOSE], Sinonasal Outcome Test [SNOT]-22, Standardized Cosmesis and Health Nasal Outcomes Survey [SCHNOS]), and sleep quality (Epworth Sleepiness Scale [ESS]) Results: Of the 34 patients undergoing rhinoplasty with Endonasal SEG, the median patient age was 38.3 years (range 17-58) and mostly male (n = 18, 52.9%). Additional procedures performed on the patients included septoplasty (n = 34, 100%) and turbinate reduction (n = 34, 100%). Average follow-up was 126.6 days (range 28-573) for a majority of PROMs. There were no complications. The average change in NOSE score was 71.5 and -49.4 (standard deviation [SD] = 19.0, p < 0.001). SNOT-22 change was 35.4 and -24.2 (SD = 14.5, p < 0.001), and ESS scores averaged 6.7 and -3.4 (SD = 4.3, p < 0.001). The average SCHNOS total, functional, and cosmetic scores were 40.6, 67.9, and 22.4, respectively, and -28.0 (SD = 19.8), -44.5 (SD = 22.9), and 17.1 (SD = 24.6) (p < 0.001). Conclusion: In this pilot study, patients reported improvement in nasal breathing after correcting a deviated caudal septum and applying an Endonasal SEG.

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.

Skeletal Surgery for Obstructive Sleep Apnea

Multilevel surgery has been established as the mainstay of treatment for the surgical management of obstructive sleep apnea (OSA). Combined with uvulopalatopharyngoplasty, tongue-base surgeries, including the genioglossus advancement (GA), sliding genioplasty, and hyoid myotomy and suspension, have been developed to target hypopharyngeal obstruction. Total airway surgery consisting of maxillomandibular advancement (MMA) with/without GA has shown significant success. Skeletal procedures for OSA with or without a palatal procedure is a proven technique for relieving airway obstruction during sleep. A case study demonstrating the utility of virtual surgical planning for MMA surgery is presented.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study

OBJECTIVE

To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort.

METHODS

Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression.

RESULTS

Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m² . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely).

CONCLUSION

DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique.

LEVEL OF EVIDENCE

2B Laryngoscope, 129:761-770, 2019.

Predicting Surgical Response Using Tensiometry in OSA Patients after Genioglossus Advancement with Uvulopalatopharyngoplasty

Objective

To evaluate the role of tension on the genioglossus muscle in the performance of genioglossus advancement on sleep-disordered breathing in patients undergoing multilevel obstructive sleep apnea (OSA) surgery.

Study Design

Prospective study.

Setting

Academic practice.

Subjects and Methods

Twenty-three subjects underwent genioglossus advancement with uvulopalatopharyngoplasty for OSA. Subjects underwent pre- and postoperative polysomnography, cephalometry, and subjective assessment questionnaires. Eighteen subjects completed the study. The tension force of the mandible and the bicortical width of the genial tubercle were measured and surgical response determined.

Results

Improvement in apnea-hypopnea index (AHI) was seen in 15 of 18 subjects (83.3%). Eleven subjects were classified as responders and 7 as nonresponders (61.1% success), with responders exhibiting a statistically significant reduction in mean delta AHI as compared with nonresponders: 28.3 ± 26.2 versus 2.0 ± 22.0 events per hour (95% confidence interval, 1.8-50.8; P = .037). The Epworth Sleepiness Scale improved from 13.2 ± 4.5 to 7.6 ± 3.4 ( P = .002). There was no significant difference in body mass index, neck circumference, overall tension, or mandibular width between responders and nonresponders. However, there was a significant difference in the tension:width ratio between responders (53.9 ± 6.38 g/mm) and nonresponders (65.4 ± 11.2 g/mm; 95% confidence interval, 0.92-22.1; P = .036).

Conclusion

This article describes a novel approach to determine the force applied to the genioglossus during advancement and its correlation to postoperative outcomes. The tension:width ratio may be an indicator for postoperative success and delta AHI improvement in OSA patients.

Chromosomal aneuploidy precedes morphological changes and supports multifocality in head and neck lesions

OBJECTIVE

To identify chromosome changes associated with the transformation of dysplastic lesions and to verify evidence for multifocality in synchronous premalignant lesions associated with head and neck squamous cell carcinoma (HNSCC).

STUDY DESIGN

Chromosomal aneuploidy was evaluated in sections of formalin-fixed, paraffin-embedded tissues from 16 patients with HNSCC, including sites with normal squamous mucosa, dysplasia (low- and high-grade), and invasive tumor.

METHODS

A panel of 6 centromeric probes (chromosomes 1, 3, 7, 8, 9, and 17) was analyzed in dual-color fluorescence in situ hybridization assays, using matched hematoxylin-eosin-stained sections for histologic correlation.

RESULTS

Imbalances for most of the targets tested were found in 20 of 24 invasive carcinoma sites, mainly represented by gain in copy number per cell. However, cell populations with chromosome losses and gains in multimodal patterns were concomitantly observed in a number of tumors, indicating a high degree of chromosome instability. The detection of chromosomal aneuploidy precedes the malignant transformation as indicated by findings of monosomy and trisomy in normal squamous mucosa, and in low-grade and high-grade dysplasia sites. Loss of chromosomes 3 and 17 prevailed in low-grade dysplasias, and gain of chromosomes 7 and 8 were prevalent in high-grade dysplasias. Synchronous low-grade and high-grade dysplastic lesions displayed discordant molecular signatures, suggesting a multifocal origin.

CONCLUSIONS

The interphase fluorescence in-situ hybridization (FISH) assay with centromeric may detect early changes in the progression of dyplastic epithelia to invasive carcinoma and supports the field cancerization theory of multifocality.

Identification of individuals at high risk for head and neck carcinogenesis using chromosome aneuploidy detected by fluorescence in situ hybridization

To visualize the accumulation of chromosome abnormalities in head and neck squamous cell carcinomas (HNSCC) and investigate the extension of the abnormal field, we applied the fluorescence in situ hybridization (FISH) technique to tumor cells and cells collected from a large extension of clinically normal buccal mucosa distant from the tumor in 10 patients. DNA probes specific for 14 human chromosomes (1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 15, 17, X, and Y) were used in dual-target, dual-color FISH assays. Control specimens were collected from oral mucosa of 10 healthy non-smokers, in order to define the tolerance limits for abnormalities, and from 10 healthy smokers. Extensive aneuploidy was detected in most of tumor specimens, more frequently represented by chromosome gains than losses. Interestingly, the clinically normal distant oral regions displayed chromosomal aneuploidies in seven out of the 10 patients tested. These findings support the occurrence of field cancerization in HNSCC. In addition, interphase FISH is demonstrated as an effective technique for detecting chromosome aneuploidy associated with malignancy and a potential tool for non-invasive screening of individuals at high-risk for HNSCC.

Hypopharyngeal stenosis and dysphagia complicating toxic epidermal necrolysis

Toxic epidermal necrolysis is a severe dermatologic disorder clinically characterized by the acute onset of erythema and tenderness of the skin. Destruction of the epidermal barrier results in significant morbidity and mortality. Large erosions of mucous membrane, including the mouth and oral mucosa, are typical of toxic epidermal necrolysis. After ingesting naproxen sodium (Aleve) and aspirin, a previously healthy 43-year-old woman developed toxic epidermal necrolysis that resulted in hypopharyngeal stenosis complicated by dysphagia and recurrent aspiration.

Malignancy detection by molecular cytogenetics in clinically normal mucosa adjacent to head and neck tumors

OBJECTIVE

To identify the potential use of chromosome imbalances as biomarkers for tumorigenesis in head and neck squamous cell carcinoma (HNSCC) by fluorescence in situ hybridization (FISH).

DESIGN

In this case-control study, chromosome copy numbers were assessed in dual-target, dual-color FISH assays using DNA probes specific for 14 human chromosomes (1, 2, 3, 6, 7, 8, 9, 10, 11, 12, 15, 17, X, and Y) applied to exfoliated epithelial cells.

SETTING

University medical center.

PATIENTS

We examined 20 cell brushings (from 10 primary tumors and 10 clinically normal margins) collected from 10 patients with HNSCC and compared these with cell brushings from the oral cavity of 10 nonsmoker and 10 smoker control subjects.

INTERVENTION

None.

MAIN OUTCOME MEASURE

Chromosomal aneuploidy.

RESULTS

Specimens from nonsmokers displayed greater than 91% of cells with normal signals, indicating high analytical sensitivity for the probes. Specimens from smokers demonstrated large variability without significant imbalance (P>.05) compared with those from nonsmokers. Tumor specimens from patients with HNSCC displayed significant chromosomal imbalance (P<.05) for all probes except chromosome Y. Similar imbalance, although in lower frequency, was found in all clinically normal adjacent mucosa specimens.

CONCLUSIONS

Interphase FISH demonstrated great applicability in detecting chromosome imbalance associated with malignancy in HNSCC and clinically normal adjacent cells, thereby detecting subclinical tumorigenesis. A panel of chromosome probes (chromosomes 3, 8, 9, and 10) is proposed as an efficient and sensitive additional tool for future routine screening of tumor margins and potential diagnosis of residual disease in HNSCC.