Pharyngocutaneous Fistula Following Total Laryngectomy: a High-Volume Tertiary Centre Series

Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding risk factors for fistula development. A standard score for fistula prediction is lacking. Study population included all patients submitted to total laryngectomy (with or without pharyngectomy) due to laryngeal or hypopharyngeal tumours, occurring between January 1st, 2012, and December 31st, 2016. Patient demographics were recorded as well as disease and treatment variables. Statistical analysis was performed using the IBM SPSS Statistics 25®. A previously described predictive model for fistula occurrence was applied. A total of 212 patients were included, the vast majority with advanced local disease (97.5%). Only 10% were submitted to rescue surgery. Fistula incidence was 39.9%. Our rates of locally advanced tumours, with extensive hypopharyngeal involvement, were higher than in most series. Age, tumour location, diabetes, previous chemoradiotherapy, advanced local and regional disease, extensive pharyngectomy, flap reconstruction, manual suture and low post-operative albumin level were associated to fistula occurrence on univariate analysis. Only salvage surgery and advanced local disease remained significant on multivariate analysis. An adapted Cecatto score correlated with fistula occurrence but has not achieved statistical significance. Predictive models for fistula occurrence are lacking. Cecatto score showed promising results in our population but large multicentric studies are necessary for cut-off adjustments.

Risk Factors for Pharyngocutaneous Fistula Following Total Laryngectomy

Pharyngocutaneous fistula is the leading complication following total laryngectomy. It delays complementary treatments, speech rehabilitation and oral feeding. Despite evolving medical care, fistula incidence remains high. There is no consensus regarding which patients are at higher risk for fistula development. This article comprised a literature review about risk factors for fistula development. All articles published on an on-line database (PUBMED™) using MESH terms "larynx cancer" and "fistula" in a 5-year period (January 1st, 2014 to January 27th, 2019) were included. Further articles were selected due to expert suggestion by one of the senior surgeons. Only articles written in Portuguese or English were included. Animal studies were excluded. 151 articles were selected and abstracts analysed. 82 articles were selected for full text revision. 32 were later excluded because they described single clinical cases, experimental surgical technics, irrelevant data or poor methodology. Final selection comprised 50 studies: 9 systematic reviews, one non-systematic review, 34 unicentric and 4 multicentric retrospective analysis and two prospective studies. There is no consensus regarding risk factors for fistula development. Patients submitted to salvage surgery for advanced disease seem to be at greater risk. Bad nutritional status is a logical contributor, but the ideal surrogate marker is still missing. Several variables are inconsistently pointed as risk factors and should be abandoned unless proved otherwise. There are no standard scores for fistula occurrence despite being a common complication following surgery.

Adult-onset obstructive sleep apnea and pediatric pharyngoplasty in 22q11.2 deletion syndrome

OBJECTIVE/BACKGROUND

We aimed to evaluate adult-onset obstructive sleep apnea (OSA) and related risk factors, including history of pediatric palatal/pharyngeal surgery to remediate velopharyngeal dysfunction, in 22q11.2 deletion syndrome (22q11.2DS).

PATIENTS/METHODS

Using a retrospective cohort design and standard sleep study-based criteria, we determined presence of adult-onset OSA (age ≥16 years) and relevant variables through comprehensive chart review in a well-characterized cohort of 387 adults with typical 22q11.2 microdeletions (51.4% female, median age 32.3, interquartile range 25.0-42.5, years). We used multivariate logistic regression to identify independent risk factors for OSA.

RESULTS

Of the 73 adults with sleep study data, 39 (53.4%) met criteria for OSA at median age 33.6 (interquartile range 24.0-40.7) years, indicating a minimum OSA prevalence of 10.1% in this 22q11.2DS cohort. History of pediatric pharyngoplasty (odds ratio 2.56, 95% confidence interval 1.15-5.70) was a significant independent predictor of adult-onset OSA, while accounting for other significant independent predictors (asthma, higher body mass index, older age), and for male sex. An estimated 65.5% of those prescribed continuous positive airway pressure therapy were reported as adherent.

CONCLUSIONS

In addition to factors of known importance in the general population, delayed effects of pediatric pharyngoplasty may contribute to risk of adult-onset OSA in individuals with 22q11.2DS. The results support increased index of suspicion for OSA in adults with a 22q11.2 microdeletion. Future research with this and other homogeneous genetic models may help to improve outcomes and to better understand genetic and modifiable risk factors for OSA.

[Oncologic follow-up in head and neck cancer patients]

Despite medical treatment according to evidence-based guidelines, approximately 25-30% of all head and neck tumor patients suffer a disease relapse, depending on tumor stage and entity. The primary goal of systematic follow-up examinations is early detection and treatment of recurrent tumors or metachronous secondary tumors, but it also serves to rule out distant metastasis. Secondary goals are the diagnosis and management of treatment-associated side effects to optimize quality of life. Because of an especially high relapse risk in the first 2 years after treatment, close-knit clinical controls are recommended, e.g., quarterly. Later on, the clinical control interval can be extended to 6 months. Cross-sectional diagnostic imaging of the primary tumor region is performed annually and when screening for possible distant metastases, or upon clinical suspicion of recurrence. After 5 years without tumor recurrence, the structured clinical follow-up is usually completed.

Supine or non-supine apnea; which can be treated better with expansion sphincter pharyngoplasty?

OBJECTIVES

Expansion sphincter pharyngoplasty is a well-known palatal correction surgery applied for obstructive sleep apnea patients. Even though high success rates are reported, in some patients, the desired outcome cannot be achieved. Therefore, patient selection is crucial to avoid undesirable outcomes. In this study we present our results with expansion sphincter pharyngoplasty, and we aim to show the difference between supine and non-supine apnea in terms of their response to the surgery, in order to utilize position dependency for selection of surgical candidates.

METHODS

Pre- and post-operative polysomnography results of patients who underwent expansion sphincter pharyngoplasty were analyzed retrospectively. Total AHI, supine AHI, non-supine AHI, supine/non-supine AHI ratio and surgical success values are compared.

RESULTS

85 patients were included to the study. Mean AHI significantly decreased from 48.7 ± 27.99 to 26.37 ± 21.16 with the surgery. Surgical success rate was found to be 51.8%. Both supine and non-supine apnea decreased significantly with the surgery, but the decrease was significantly higher in non-supine apnea (20.6% to 39.1% respectively, p = 0.016). There was significant negative correlation between pre-operative supine to non-supine AHI ratio and the change in AHI, showing that supine dominant patients had less improvement with the surgery (r = 0.274, p = 0.01).

CONCLUSION

Expansion sphincter pharyngoplasty is an effective surgery which achieves significant improvement in AHI. Non-supine respiratory events respond better to the surgery than supine events.

[Radicality of maxillary sinus surgery and size of the maxillary sinus ostium]

Until the 1990s, radical sinus surgery was considered a standard procedure for maxillary sinus diseases, but it is no longer favored due to the high morbidity. Today, functional endoscopic sinus surgery (FESS) is considered the gold standard in sinus surgery. Modifications of surgical approaches also allow access to regions of the maxillary sinus that were previously difficult to reach. Depending on anatomy and pathology, different methods for widening the maxillary ostium can be selected. In type I sinusotomy, the natural ostium is widened dorsally by a maximum of 1 cm. Sinusotomy type II involves widening the natural ostium up to a maximum diameter of 2 cm. In sinusotomy type III, the natural ostium is widened dorsally to the posterior wall of the maxillary sinus and caudally to the base of the inferior turbinate. Beside the prelacrimal approach, more invasive approaches are the medial maxillectomy, in which the dorsal part of the inferior turbinate and the adjacent medial wall of the maxillary sinus is resected, as well as its modifications "mega antrostomy" and "extended maxillary antrostomy." Correct selection of the size of the maxillary sinus window is prerequisite for successful treatment and long-term postoperative success. Isolated purulent maxillary sinusitis can usually be treated by a type I sinusotomy. Sinusotomy type II addresses nasal polyps with involvement of the mucosa of the ostium, recurrent stenosis after previous surgery, chronic maxillary sinusitis due to cystic fibrosis, and purulent maxillary sinusitis with involvement of other adjacent sinuses. Sinusotomy type III is required for choanal polyps with attachment to the floor of the maxillary sinus, for extensive polyposis and fungal sinusitis, and for inverted papilloma. Particularly for (recurrent) disease and extensive interventions in the maxillary sinus, medial maxillectomy or a modification thereof may be required.

[The maxillary sinus via a prelacrimal approach as a gateway to the retromaxillary space and orbital floor]

Endonasal surgery has emerged as the standard procedure for the majority of nasal and paranasal sinus pathologies. However, some pathological changes beyond the maxillary sinus seem to be out of the instrumental range and are addressed by open approaches. The prelacrimal approach to the maxillary sinus published by Zhou and coworkers has stimulated a rapid development of various procedures in this field. In the current work, the possibilities of the prelacrimal approach are illustrated by means of three clinical cases. The prelacrimal approach enables isolated fractures of the orbital floor to be reconstructed without the risk of lower eyelid complications. Meningo- or encephaloceles in the far lateral aspects of the sphenoid sinus are comparatively well reached via endonasal, transantral, and transpterygoid approaches. Until recently, tumors beyond the maxillary sinus were the domain of open surgery, particularly when they extended laterally of the maxillary sinus. The technique of choice was either a Caldwell-Luc or a midfacial degloving approach. Many of these operations can now be performed via the endonasal prelacrimal approach, with lower morbidity and more rapid postoperative healing. The approach described herein is equal if not superior to the traditional approaches in terms of overview and accessibility.

[Application of endoscopic resection of benign tumor in infratemporal fossa]

Objective: To explore the application of endoscopy and clinical effect of endoscopic resection of benign tumor in infratemporal fossa. Methods: The clinical data of 11 patients with benign tumors in infratemporal fossa admitted to the Department of Otorhinolaryngology Head and Neck Surgery and Skull Base Surgery of the Affiliated Hospital of Qingdao University from January 2016 to September 2018 were retrospectively analyzed. There were 6 males and 5 females, with the age ranging from 11 to 63 years old. The main clinical manifestations were pharyngeal foreign body sensation, submaxillary pain, maxillofacial numbness and tongue numbness. Imaging examination showed that the tumor was round and had a clear boundary with the surrounding tissue. All the patients underwent endoscopic surgery. Appropriate surgical approach was selected according to the location of the tumor and its relationship with the internal carotid artery. The endoscopic surgical approaches included trans-oropharyngeal approach in 7 cases, trans-lateral pterygomandibular raphe approach in 1 case and trans-medial pterygomandibular raphe approach in 3 cases. The pathological results, prognosis, complications and relapse of patients were summarized through descriptive statistics. Results: The tumors were completely resected under endoscope in all patients, and there was no significant complication occurred after surgery. The average pain VAS score was 3.1 after surgery and average hospital stay was 5.9 d. The postoperative pathological diagnoses consisted of 6 cases of pleomorphic adenoma, 4 cases of neurilemmoma and 1 case of basal cell adenoma. All patients were followed up regularly from 6 to 39 months without recurrence of tumor. Conclusion: Endoscopic resection of benign tumors in infratemporal fossa has the advantages of minimal damage, rapid recovery, few complications, and definite curative effect, which can be used as an important alternative for surgical treatment of benign tumors.

[Application of mucosal flap technique in Draf type Ⅱb/Ⅲ frontal sinus surgery]

Draf type Ⅱb/Ⅲ frontal sinus surgery has been widely used in clinical practice. They can obtain a wide operating space and sufficient drainage pathways. However, the mucosa around the frontal sinus ostium was removed during the surgery, resulting in bone exposure, and sinus ostium stenosis or atresia may occur after the operation. In recent years, rhinologists at home and abroad have applied various mucosal flaps to cover the exposed bone around the frontal sinus orifice after Draf Ⅱb/Ⅲ frontal sinus surgery, in order to reduce scar formation and bone hyperplasia along with the incidence of frontal sinus ostium stenosis or atresia after surgery. Satisfactory results have been achieved. The article reviews the application of mucosal flap technique in Draf Ⅱb/Ⅲ frontal sinus surgery, in order to promote the clinical research and technical development of this technique in China.

[The effect of genioglossus activity to velopharyngeal surgery in patient with obstructive sleep apnea hypopnea syndrome]

Objective: To investigate the effect of genioglossus (GG) activation at sleep onset on the outcome of velopharyngeal surgery in obstructive sleep apnea hypopnea syndrome (OSAHS) patients. Methods: Thirty-five patients between April 2014 and February 2015 in Beijing Tongren Hospital with OSAHS underwent overnight polysomnography with synchronous genioglossus electromyography (GGEMG) using intraoral electrodes. The upper airway (UA) anatomy was evaluated by three-dimensional computer tomography (3D-CT) in OSAHS patients. Then, all of the patients received velopharyngeal surgery, including revised uvulopalatopharyngoplasty (UPPP) with uvula preservation or UPPP combined transpalatal advancement pharyngoplasty. All patients were followed-up using polysomnography 3-6 months after surgery. T-test or Wilcoxon test were used to compare the variables between groups, and Spearman correlation analysis was used to test the correlation between parameters. Results: Thirty-five patients received velopharyngeal surgery. Twenty-two patients (62.86%) were responders, and 13 patients (37.14%) were non-responders. Responders had a higher mean GGEMG during sleep onset (15.31±3.74 vs. 9.92±2.93, t=4.504, P=0.001). The decreased AHI was significantly positively related to the sleep onset mean GGEMG (r=0.541, P=0.004) and the change in GGEMG (r=0.422, P=0.028). The decreased AHI was significantly negatively related to the minimal cross sectional airway area (mCSA,ρ=0.629,P=0.000) and the minimal lateral airway dimension (mLAT, ρ=0.484, P=0.009) at velopharynx. Conclusions: The outcome of velopharyngeal surgery was affected by the mean GGEMG during sleep onset. We speculated that the patient with higher GGEMG at sleep onset and narrower velopharynx were more suitable candidates for velopharyngeal surgery.

[Misdiagnosic analysis and treatment of pyriform sinus fistula in children]

Objective: To discuss the misdiagnosis of pyriform sinus fistula and to better understand this kind of illness. Methods: The analysis was based on twenty-eight patients with congenital pyriform sinus fistula aged from 11 months to 14 years, with the median age of 5 years, and who were surgically treated from January 2013 to January 2017 in Kunming Children's Hospital.Twenty patients were misdiagnosed in other hospital.After the routine examination of neck ultrasound and enhanced CT, internal fistula was found by self-retaining laryngoscope, traced by methylene blue, and excised by high ligation. Results: Twenty patients were misdiagnosed.The misdiagnosis time ranged from 6 months to 3 years.Under self-retaining laryngoscope, piriform fossa fistula were found in all patients.Nineteen fistula were found in the left and 1 in the right.The fistula in patients was unilateral.Seven cases were misdiagnosed as suppurative lymphadensitis, undergone abscess incisional drainage many times.Three cases were misdiagnosed as thyroglossal duct cyst and performed excision of thyroglossal duct cyst.One case was treated by extended Sistruck operation again because the doctor considered that excision of middle segment of hyoid bone was not enough and the fistula was not ligated completely.One case was misdiagnosed as second branchial cleft fistula on the right side of the neck.Nine cases were misdiagnosed as hyroid-associated diseases including 2 cases suppurative thyroiditis, 2 cases subacute thyroiditis and 5 cases thyroid neoplasms.Among them, 2 cases underwent partial thyroidectomy.All the patients were treated with high ligation of fistula under general anesthesia.The operation was smooth, and no hoarseness, bucking and pharyngeal fistula occurred after the operation.Postoperative follow-up time ranged from 12 months to 4 years and the median follow-up was 18 months without recurrence.The diagnosis was confirmed pathologically. Conclusions: Pyriform sinus fistula in children was uncommon and easily misdiagnosed in clinic.The majority of physician including some otolaryngologists were lack of understanding of the disease.It should be regarded as one of the important differential diagnosis of neck mass in children.Children with recurrent left neck infection and/or abscess should be highly suspected.Self-retaining laryngoscopic examination can make a definite diagnosis and high ligation of the fistula through the external neck approach can achieve good therapeutic effect.

[The impact of resection of skull base tumor via an endoscopic endonasal approach on the visual function of vision impaired patients and the analysis of factors affecting their visual recovery]

Objective: To evaluate the visual outcomes of patients with visual impairment after resecting skull base tumor via an endoscopic endonasal approach, and to analyze the factors affecting visual recovery. Methods: One hundred and fifty-three patients with skull base tumor who suffered from preoperative visual impairment from Skull Base Surgery Center of Xuanwu Hospital were operated through an endoscopic endonasal approach. Both preoperative and postoperative visual function outcomes as well as factors that might have affected their visual recovery were analyzed retrospectively by Chi square test and Logistic regression analysis. Results: Complete resection was achieved in 85.6% of the patients using this technique. The rate of postoperative visual recovery in the female group (86.1%) was higher than that in the male group (73.9%), the benign group (90.2%) higher than the malignant group (20.0%), the group without optic atrophy (97.1%) higher than the one with (51.2%), and the acute group (96.6%) higher than the chronic group (80.0%). Significant differences were found between the abovementioned groups (χ(2) value was 5.849, 87.860, 79.757, 4.745, respectively, all P<0.05). The degree of optic atrophy and the property of tumors were significantly associated with visual improvement after treatment (Wold χ(2) value was 18.597 and 35.623, all P<0.001). Conclusions: Our results indicate that endoscopic endonasal surgery shows its ability both to resect skull base tumors and to improve visual function in the majority of patients. The timing of treatment for patients suffered from preoperative visual impairment should be selected in early stage before optic atrophy occurs.

[Control study of H-uvulopalatopharyngoplasty combined with tongue base radiofrequency for the treatment of obstructive sleep apnea hypopnea syndrome]

Objective: To investigate the effect of H-uvulopalatopharyngoplasty(H-UPPP) combined with tongue base radiofrequency ablation in the treatment of obstructive sleep apnea hypopnea syndrome(OSAHS). Methods: Sixty-two patients with moderate or severe OSAHS, whose obstructive plane located in the oropharynx and tongue base were divided into two groups two groups according to the patient's independent choice under the condition of fully informed before the operation. The control group of 30 cases underwent H-UPPP, while the experimental group of 32 patients underwent improved H-UPPP and tongue base radiofrequency. The clinical efficacy between the two groups was compared. Results: There was no significant difference between the two groups before operation. After the operation, the total effective rate of the experimental group was 71.9%, significantly higher than that of the control group (46.7%, χ(2)=4.09, P<0.05), the difference was statistically significant. After operation, in the control group, AHI was (19.4±8.1)/h, LSaO(2) was 0.767±0.052. In the experimental group, AHI was (17.8±7.8)/h, LSaO(2) was 0.790±0.059. There was significant difference in both groups before and after surgery (P<0.001), with statistical significance. In the experimental group, after operation, the minimum diameter of oropharyngeal cavity was (10.6±2.4) mm, there was obvious increase compared with the diameter of oropharyngeal cavity (9.9±2.2) mm before operation, the difference was statistically significant (t=2.64, P<0.05). In the control group, after operation, the minimum diameter of oropharyngeal cavity was(10.0±2.4) mm, there was no obvious increase compared with the diameter of oropharyngeal cavity (9.9±2.5) mm before operation, the difference was not statistically significant (P>0.05). Compared between control group and experimental group, the differences of AHI, LSaO(2), the minimum anteroposterior diameter of oropharyngeal cavity before and after operation were not statistically significant (P>0.05). Conclusion: The effect of same time H-UPPP and radiofrequency ablation surgery is definitive.

[Long-term efficacy of supracricoid partial laryngectomy for 298 patients with laryngeal carcinoma]

Objective: To evaluate the oncologic and functional outcomes of supracricoid partial laryngectomy (SCPL) in the treatment of laryngeal carcinoma. Methods: A total of 298 laryngeal carcinoma patients who underwent SCPL treatment from January 2005 to December 2013 were reviewed retrospectively. Clinical data of demographic and clinical characteristics, postoperative complications, rehabilitation information, recurrence and metastasis were analysed. Survival and local control were used to evaluate the clinical outcome.Data were analyzed by SPSS 23.0 software. Results: Thirty-one patients with supraglottic carcinoma underwent cricohyoidoepiglottopexy (CHEP)and 267 with glottic carcinoma underwent cricohyoidopexy (CHP) were enrolled in this study. The mean duration of followed up was 74 months, ranging from 12 to 146 months. Fifty-four cases died at last follow-up. With respect to 31 patients with supraglottic carcinoma, 5- and 10-year overall survival rates and disease specific survival rates all were 78.1%; 5- and 10-year disease free survival rates were 72.1% and 63.7% respectively; and 5- and 10-year local control rates were both 84.2%. In 267 patients with glottic carcinoma, 5- and 10-year overall survival rates were 85.8% and 77.1% respectively; 5- and 10-year disease specific survival rates were 86.6% and 78.4% respectively; 5- and 10-year disease free survival rates were 80.6% and 74.2% respectively; and 5- and 10-year local control rates were 90.0% and 89.4% respectively. The survival rate of patients with glottic carcinoma at stage T1 was higher than that at stage T2 or T3, and the disease free survival rate of patients with early stage was superior than that of patients with advance stage. Cox regression analysis showed that tumor stage T2, and T3, tumor recurrence, and tumor metastasis were independent risk factors for survival. Furthermore, nasogastric feeding tube removal rate was 100% and the decannulation rates of SCPL were 96% in the patients with SCPL. Conclusions: SCPL is a safe procedure with tumor resection for laryngeal carcinoma, with preserving of swallowing, respiration, and phonation functions, and has excellent survival and local control rates. This procedure could be considered as a standard function-sparing treatment for selected patients with laryngeal carcinoma of stages T1b-T3.

[Endoscopic salvage treatment for optic neuropathy caused by sinonasal fibro-osseous lesions]

Objective: To summarize the surgical techniques, benefits and limitations of transnasal endoscopic resection and optic nerve decompression for patients with optic neuropathy caused by fibro-osseous lesions. Methods: Eight patients with optic neuropathy caused by fibro-osseous lesions who accepted endoscopic surgery of either resection of the lesion or decompression of optic nerve in Otorhinolaryngology Hospital, First Affiliated Hospital of Sun Yat-sen University from 2007 to 2016 were retrospectively reviewed and followed until April, 2017. Analyses were performed on the pathology type, disease extent and disease duration, especially on the visual acuity and visual field changes before and after surgery. Results: Eight patients (5 male and 3 female) were included in this study, with a median age of 12 years old (8-19 years old). The median disease duration was 12 months (1-72 months). The visual acuity (VA) of five patients (40 cm/FC, 0.2, 0.1, 0.2, 10 cm/FC, respectively) improved after surgery (0.1, 0.3, 1.2, 0.1, 0.6, respectively), and one patient had no change of VA after the surgery. Two patients (0.02, hand movement, before surgery) became deprived of light perception (VA=0) immediately after surgery. One patient complicated with intra orbital hemorrhage because of anterior artery injury. No complications of cerebral spinal fluid leak, intra-ocular muscle injury, intra-cranial hemorrhage or brain tissue injury occurred. Conclusion: For the treatment of optic neuropathy caused by fibro-osseous lesions, transnasal endoscopic surgery might have a good outcome.

[Modern modifications of uvulopalatopharyngoplasty]

Uvulopalatopharyngoplasty (UPPP) was first described in 1964 with regard to surgical treatment of snoring and in 1981 with regard to treatment of obstructive sleep apnea (OSA). The initial surgical techniques for OSA were very invasive, frequently leading to significant morbidity and complications. Wolfgang Pirsig et al. were the first in Germany to recognize that a radical surgical technique increased only the complications, not the efficacy of UPPP. The less invasive surgical technique developed based on these findings is still established in Germany. A meta-analysis from 1996 described a success rate of UPPP of about 50%. High-quality randomized trials demonstrate significant superiority of UPPP plus tonsillectomy compared to untreated controls. However, the objective outcome measures of classic UPPP could not be improved even with additional patient selection criteria, and the effects of UPPP often deteriorate over time. To overcome these limitations, various modifications of UPPP have been developed. Due to limited data, evaluation of these new techniques and their comparison with conventional UPPP is difficult at present. In studies comparing a modification of UPPP with the standard approach, the tested modification was demonstrated to be superior. A relevant limitation of the available data results from the small number of institutions (usually not more than two) that investigated the respective modification and the follow-up periods of usually only 6 months. Data are also too sparse to reliably assess complication rates. For conventional UPPP there are considerably more data, wider experience with long-term outcome, and more robust studies examining treatment effects beyond basic respiratory parameters. At present, modifications of UPPP should be principally employed in clinical trials.

[Effect of the obstructive sleep apnea hypopnea syndrome treatment on blood pressure in patients with resistant hypertension]

Objective: To investigate the effect of the treatments for obstructive sleep apnea hypopnea syndrome (OSAHS) on the resistant hypertension (RH) of patients. Methods: Eighty patients with OSAHS and RH (blood pressure could not be controlled under 140/90 mmHg (1 mmHg=0.133 kPa) even with more than three kinds of antihypertensive drugs including diuretics) received surgery or continuous positive airway pressure (CPAP) treatment. The results of polysomnography monitoring, ambulatory blood pressure monitoring, and the dosage of antihypertensive medication were recorded before and six months after the treatment. Results: Apnea hypopnea index (AHI) decreased from (32.9±10.8) before treatment to (9.4±6.5) after treatment, while the lowest oxygen saturation (SaO(2)) increased from (0.682±0.062) to (0.884±0.056), with significant differences (t value was 18.863 and 26.614, respectively; both P<0.001). Twenty-four hours systolic blood pressure (SBP)/diastolic blood pressure (DBP) decreased respectively from ((150.5±9.8)/(97.8±7.3)) mmHg to ((140.7±6.8)/(88.6±6.3)) mmHg, daytime SBP/DBP decreased from ((154.3±8.9)/(100.6±7.4)) mmHg to ((144.8±5.8)/(91.3±5.5)) mmHg, and nighttime SBP/DBP decreased from ((145.5±8.8)/(93.8±6.4)) mmHg to ((135.8±5.7)/(84.6±5.9)) mmHg, with significant differences (t value was 7.832, 6.903, 7.005, 6.848, 8.025, 7.554, respectively; all P<0.001). The reduction of nighttime SBP /DBP was ((11.5±2.2)/(10.2±3.1)) mmHg, and the reduction of daytime SBP/DBP was ((9.0±2.8)/(7.9±3.5)) mmHg. The reduction of nighttime SBP/DBP was more obvious than daytime SBP/DBP, with significant differences (t value was 9.732 and 6.936, respectively; both P<0.001). Before treatment, nighttime blood pressure decrease rate below 10% was showed in 75 percent of patients, and after treatment, this rate only in 37.5 percent of patients (χ(2)=22.857, P<0.01). The numbers of required antihypertensive drugs decreased in 45 (56.3%) cases, the average numbers of antihypertensive drugs decreased from (3.2±0.4) before treatment to (2.6±0.5) after treatment, with a significant difference (t=9.276, P<0.01). Conclusions: After treatment of OSAHS, the blood pressure of the patients with OSAHS and RH dropped significantly, the circadian rhythm of blood pressure condition was better, the varieties of antihypertensive drugs taken in these patients were reduced significantly.

[Imaging for surgical planning : Tumor surgery including reconstructive procedures]

Alongside clinical investigation, imaging is an important diagnostic modality for guiding treatment decisions and particularly for surgical planning in head and neck cancer. The significance and type of imaging depends on localization of the primary tumor. Beside the primary tumor, each imaging procedure must also include the lymph nodes, in order to develop an overall concept of surgical treatment. In addition to the superficial growth of a tumor, it is of utmost importance that its infiltration also be detected by imaging, in order to define the extent of tumor resection and identify potentially necessary reconstructive procedures. The type of imaging needed to understand tumor localization and size, e.g., CT or MRI, depends on the region. In some cases the methods are complementary.

[Therapeutic effectiveness of the soft palate fold surgery in patients with obstructive sleep apnea hypopnea syndrome]

Objective: To evaluate the relationships between anatomical changes and treatment outcomes after modified velopharyngeal surgery in obstructive sleep apnea hypopnea syndrome (OSAHS) patients with the soft palate drooping. Methods: From November 2011 to November 2015, 44 OSHS patients (AHI 5-30 times/h) with the soft palate drooping determined by Muller test and drug-induced sleep endoscopy (DISE) were randomly selected. Treatment group included 23 patients who underwent modified velopharyngeal surgery, in which uvula was preserved and soft palate was shortened and advanced. Control group included 21 patients who received conventional UPPP surgery.Compared the differences in preoperative and postoperative Epworth Sleepiness Scale (ESS), Numeric Rating Scale (NRS), lowest arterial blood oxygen saturation (LSaO(2)), and apnea hypoventilation index (AHI) between the two groups. Each data rows normality test. The two groups' preoperative and postoperative data row intra-group comparison and matching t test. Used the independent sample t test after homogeneity of variance test to compare the two groups. The difference was statistically significant when P<0.05. Results: There were statistically significant differences in AHI , LSaO(2) and ESS score between before and after surgery in individual groups. There were not significant differences in preoperative AHI and LSaO(2) between the two groups, but with a higher ESS in treatment group compared to control group. There were no statistically significant differences in postoperative AHI, LSaO(2) or ESS between the two groups. Compared with control group, treatment group had a lower postoperative pain scale score (4.3±1.3 vs 6.3±0.8, P=0.000) and a shorter time to resume normal eating ((6.7±1.6) d vs (15.5±3.5) d, P=0.000). Conclusion: OSAHS patients (AHI 5-30 times/h) with the soft palate drooping are more likely to have favorable anatomical changes after revised velopharyngeal surgery.

Preparation and placement of cartilage island graft in tympanoplasty

INTRODUCTION

Cartilage graft tympanoplasty has a better success rate in the treatment of chronic otitis media if regularly prepared and placed.

OBJECTIVE

To prepare cartilage island material and evaluate its effect on the success rate of tympanoplasty.

METHODS

The medical records of 87 patients (48 males and 39 females; mean age, 27.3±11.2 years; range, 14-43 years) with chronic otitis media without cholesteatoma who underwent intact canal-wall-up tympanoplasty and revision surgery between December of 2007 and October of 2011 were retrospectively evaluated. Surgery was performed under general anesthesia via a retroauricular approach.

RESULTS

The overall success rate of this technique was 93% in terms of perforation closure. No graft lateralization or displacement into the middle ear occurred. The overall average preoperative air bone gap was 37.27±12.35 dB, and the postoperative air bone gap was 27.58±9.84 dB. The mean postoperative follow-up period was 15.3 months (range: 7-21 months).

CONCLUSION

If cartilage graft is properly prepared and placed, cartilage graft tympanoplasty appears to provide better success rates and hearing results.

[Impact of early elective tracheotomy in critically ill patients]

INTRODUCTION

Tracheotomy is one of the most frequent surgical procedures performed in critically ill patients hospitalized at intensive care units. The ideal timing for a tracheotomy is still controversial, despite decades of experience.

OBJECTIVE

To determine the impact of performing early tracheotomies in critically ill patients on duration of mechanical ventilation, intensive care unit stay, overall hospital stay, morbidity, and mortality.

METHODS

Retrospective and observational study of cases subjected to elective tracheotomy at one of the intensive care units of this hospital during five consecutive years. The patients were stratified into two groups: early tracheotomy group (tracheotomy performed from day one up to and including day seven of mechanical ventilation) and late tracheotomy group (tracheotomy performed after day seven). The outcomes of the groups were compared.

RESULTS

In the early tracheotomy group, there was a statistically significant reduction in duration of mechanical ventilation (6 days vs. 19 days; p<0.001), duration of intensive care unit stay (10 days vs. 28 days; p=0.001), and incidence of ventilator-associated pneumonia (1 case vs. 44 cases; p=0.001).

CONCLUSION

Early tracheotomy has a significant positive impact on critically ill patients hospitalized at this intensive care unit. These results support the tendency to balance the risk-benefit analysis in favor of early tracheotomy.