Lateral-Expansion Pharyngoplasty: Combined Technique for the Treatment of Obstructive Sleep Apnea Syndrome

Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a multifactorial disease characterized by episodes of partial or complete collapse during sleep of different regions of the upper airway. Surgery for OSAS evolved with the introduction of different techniques, considering new surgical concept of reconstruction of the upper airway. Objective To retrospectively evaluate the effectiveness of a new approach aimed at reducing pharyngeal collapse by combining two surgical techniques: lateral and expansion pharyngoplasty. Methods We reviewed the medical records of 38 patients with OSAS undergoing lateral/expansion pharyngoplasty from January 2012 to December 2016. The following data were collected: patient age, gender, and pre- and postoperative body mass index (BMI), Epworth sleepiness scale (ESS) scores, snoring visual analogue scale (VAS) scores, and polysomnography (PSG) results. Results The PSG results showed a significant reduction in the apnea/hypopnea index (AHI) from 22.4 ± 27.3 events/h preoperatively to 13.6 ± 17.9 events/h postoperatively (p = 0.009), with postoperative AHI reduction greater than 50% in 63.2% of the patients. There was also a significant reduction in the microarousal index (19.5 ± 22.6 vs 11.0 ± 13.4 events/h; p = 0.001) and in the minimum oxygen saturation (82.6 ± 10.3 vs 86.9 ± 11.1; p = 0.007). Conclusions Lateral-expansion pharyngoplasty represents a new surgical strategy for the treatment of OSAS in patients with palatal collapse by combining two different techniques: lateral and expansion pharyngoplasty. The two techniques, performed as a one-stage procedure, led to improvements in excessive daytime sleepiness, snoring, and PSG respiratory parameters by acting on lateral and retropalatal collapse, produc- ing favorable results with good applicability in otolaryngology clinical practice.

The Changes for Strength of Oropharyngeal Muscles in Patients with Dementia and Dysphagia

Although dysphagia is an important health problem and one of the determinants of quality of life in patients with dementia, the neurophysiologic changes of dysphagia in dementia have not been fully uncovered, yet. we investigated the changes of strength of tongue lip and pharyngeal muscles in patients with dementia. This study included 30 subjects with dementia. In all subjects, clinical assessments consisted of the Iowa Oral Performance Instrument (IOPI) for tongue and lip, surface electromyography (sEMG) with Vital stim plus on suprahyoid muscles, the Mini-Mental State Examination, and Clinical Dementia Rating (CDR) scales. All subjects were classified into 3 groups according to severity; CDR 1, 2, and 3. There was no difference between IOPI and sEMG among all 3 groups. The values of tongue and lip IOPI from all 3 dementia groups were significantly lower than values of control. The comparisons for values of tongue and lip IOPI among 3 dementia group were not different from each other. The sEMG of suprahyoid muscles were not different between all 3 dementia groups and control. These findings are supportive of dysphagia therapy for oral phase would be beneficial for the restoration of swallowing function in patients with dementia and dysphagia.

Auto-segmentation of head and neck organs at risk in radiotherapy and its dependence on anatomic similarity

PURPOSE: The aim is to study the dependence of deformable based auto-segmentation of head and neck organs-at-risks (OAR) on anatomy matching for a single atlas based system and generate an acceptable set of contours. METHODS: A sample of ten patients in neutral neck position and three atlas sets consisting of ten patients each in different head and neck positions were utilized to generate three scenarios representing poor, average and perfect anatomy matching respectively and auto-segmentation was carried out for each scenario. Brainstem, larynx, mandible, cervical oesophagus, oral cavity, pharyngeal muscles, parotids, spinal cord, and trachea were the structures selected for the study. Automatic and oncologist reference contours were compared using the dice similarity index (DSI), Hausdroff distance and variation in the centre of mass (COM). RESULTS: The mean DSI scores for brainstem was good irrespective of the anatomy matching scenarios. The scores for mandible, oral cavity, larynx, parotids, spinal cord, and trachea were unacceptable with poor matching but improved with enhanced bony matching whereas cervical oesophagus and pharyngeal muscles had less than acceptable scores for even perfect matching scenario. HD value and variation in COM decreased with better matching for all the structures. CONCLUSION: Improved anatomy matching resulted in better segmentation. At least a similar setup can help generate an acceptable set of automatic contours in systems employing single atlas method. Automatic contours from average matching scenario were acceptable for most structures. Importance should be given to head and neck position during atlas generation for a single atlas based system.

The Role of Modified Expansion Sphincter Pharyngoplasty in Multilevel Obstructive Sleep Apnea Syndrome Surgery

Abstract Introduction Obstructive sleep apnea syndrome (OSAS) is a sleep disorder caused by an excessive narrowing of the pharyngeal airway that also collapses during inspiration, with an important role played by the lateral pharyngeal wall in the development of the obstruction. Objective To describe our surgical experience with modified expansion sphincter pharyngoplasty (MESP) in the management of lateral collapse in upper airway multilevel surgery. Methods A total of 20 patients with moderate to severe OSAS were recruited in the Ear, Nose and Throat (ENT) Department of the University of Palermo, Italy. All of the enrolled patients refused the ventilatory therapy. The subjects were evaluated for snoring, and daytime sleepiness had a clinical evaluation including collection of anthropometric data and ENT examination and rhinofibroscopy with Müller maneuver. The patients undergoing upper airway multilevel surgery and we selected for MESP the patients with an oropharyngeal transverse pattern of collapse at Müller maneuver. Results In the postoperative assessment, all of the patients reported a reduction in snoring scores and daytime sleepiness. We observed a reduction in the mean apnea-hypopnea index (AHI) of 57.5% of the sample, which decreased from a mean value of 41.7 ( ± 21.5) to 17.4 ( ± 8.9) (p< 0.05), with a success rate, according to the Sher criteria, of 65%. We observed very few postoperative complications. Conclusion Modified expansion sphincter pharyngoplasty in multilevel surgical therapy preceded by a careful selection of patients has proven to be effective in treating patients with moderate to severe syndromes.

Killian-Jamieson diverticulum lined with two epithelia in a Korean cadaver / 대한해부학회지

Killian-Jamieson diverticulum is a permanent protrusion of anterolateral proximal esophagus through anatomically weak muscular gap, known as Killian-Jamieson area, into adjacent area. During a routine educational dissection, we found a well-defined lateral diverticulum just inferior to the transverse fibers of the cricopharyngeus muscle in a Korean male cadaver. It had a dimension of 1.8×1.4×1.0 cm with two types of epithelial cells, stratified squamous and simple cuboidal to low-columnar epithelium, and attenuated and haphazardly arranged muscle fibers. No epithelial dysplasia or malignant transformation was identified except ulcerative changes. Although Killian-Jamieson diverticulum is a very rare disease, clinicopathological aspects should be considered.

Characteristics of Cricopharyngeal Dysphagia After Ischemic Stroke

OBJECTIVE: To evaluate the characteristics of cricopharyngeal dysfunction (CPD), the frequency, and correlation with a brain lesion in patients with first-ever ischemic stroke, and to provide basic data for developing a therapeutic protocol for dysphagia management. METHODS: We retrospectively reviewed the medical records of a series of subjects post-stroke who underwent a videofluoroscopic swallowing study (VFSS) from January 2009 to December 2015. VFSS images were recorded on videotape and analyzed. CPD was defined as the retention of more than 25% of residue in the pyriform sinus after swallowing. The location of the brain lesion was assessed using magnetic resonance imaging. RESULTS: Among the 262 dysphagic patients with first-ever ischemic stroke, 15 (5.7%) showed CPD on the VFSS. Patients with an infratentorial lesion had a significantly higher proportion of CPD than those with a supratentorial lesion (p=0.003), and lateral medullary infarction was identified as the single independent predictor of CPD (multivariable analysis: odds ratio=19.417; confidence interval, 5.560–67.804; p < 0.0001). Compared to patients without CPD, those with CPD had a significantly prolonged pharyngeal transit time, lower laryngeal elevation, and a higher pharyngeal constriction ratio and functional dysphagia scale score. CONCLUSION: Overall, the results support the notion that an impaired upper esopharyngeal opening is likely related to the specific locations of brain lesions. The association of CPD with lateral medullary infarction can be explained based on the regulation of the pharyngolaryngeal motor system by the motor neurons present in the dorsal nucleus ambiguus. Overall, the results reveal the relation between CPD and the problems in the pharyngeal phase as well as the severity of dysphagia.

The Effect of Balloon Dilatation and/or Botulinum Toxin Injection on the Severe Dysphagic Patients with Cricopharyngeal Dysfunction: Case Series / 대한연하장애학회지

OBJECTIVE: To investigate changes of swallowing function after ballooning dilatation (BD) and the Botox injection (BI) into the cricopharyngeus muscle in patients with severe dysphagia. METHOD: Nine severe dysphagic patients with cricopharyngeal dysfunction (CPD) who underwent BD and/or BI into the cricopharyngeal muscle were retrospectively reviewd. Patients who had severe dysphagia (Functional Oral Intake Scale (FOIS)≤2) after at least 3 months of the conventional swallowing therapy were included by a thorough review of medical records with videofluoroscopic swallowing study (VFSS). Before and after several interventions (BD and/or BI), swallowing function was evaluated using VFSS. RESULT: Among 9 patients, 5 underwent both BD and BI, and the other 4 patients underwent only BD. Four among 9 cases showed that interventions were effective. Of the 5 cases with both BD and BI, 2 cases were effective for treatment of CPD. In all the effective 4 cases, pyriform sinus residue seemed to be related with FOIS. Of those cases, one case had long-term effect (more than 4 months) and the other 3 case had short term effect (less than 4 months). CONCLUSION: Interventions were effective in 4 among 9 cases with severe CPD and the therapeutic effect was sustained for more than 4 months. The results suggest that in CPD patients, the BD or BI into UES could be considered in selected patients.

Cell-to-cell Transmission of Polyglutamine Aggregates in C. elegans

Huntington disease (HD) is an inherited neurodegenerative disorder characterized by motor and cognitive dysfunction caused by expansion of polyglutamine (polyQ) repeat in exon 1 of huntingtin (HTT). In patients, the number of glutamine residues in polyQ tracts are over 35, and it is correlated with age of onset, severity, and disease progression. Expansion of polyQ increases the propensity for HTT protein aggregation, process known to be implicated in neurodegeneration. These pathological aggregates can be transmitted from neuron to another neuron, and this process may explain the pathological spreading of polyQ aggregates. Here, we developed an in vivo model for studying transmission of polyQ aggregates in a highly quantitative manner in real time. HTT exon 1 with expanded polyQ was fused with either N-terminal or C-terminal fragments of Venus fluorescence protein and expressed in pharyngeal muscles and associated neurons, respectively, of C. elegans. Transmission of polyQ proteins was detected using bimolecular fluorescence complementation (BiFC). Mutant polyQ (Q97) was transmitted much more efficiently than wild type polyQ (Q25) and forms numerous inclusion bodies as well. The transmission of Q97 was gradually increased with aging of animal. The animals with polyQ transmission exhibited degenerative phenotypes, such as nerve degeneration, impaired pharyngeal pumping behavior, and reduced life span. The C. elegans model presented here would be a useful in vivo model system for the study of polyQ aggregate propagation and might be applied to the screening of genetic and chemical modifiers of the propagation.

Uso del láser CO2 en la cirugía de la disfagia cricofaríngea: caso clínico / CO2 Laser use in the surgery of the cricopharyngeal muscle dysfunction: case report

La miotomía cricofaríngea es una técnica quirúrgica introducida hace años para el tratamiento de la disfagia asociada a disfunción del músculo cricofaríngeo con o sin divertículo de Zenker, mostrando resultados exitosos que revierten la sintomatologta y mejoran la calidad de vida del paciente. Con los avances científicos surge la cirugía láser endoscópica que permite ser una alternativa quirúrgica segura, viable y efectiva respecto a la miotomía clásica abierta, según diferentes series publicadas, mostrando disminuir los tiempos de anestesia, quirúrgico y de recuperación. En este artículo describimos un caso clínico, la técnica quirúrgica utilizada y los resultados en un paciente con disfagia por disfunción cricofaríngea con buen resultado posoperatorio.

Cricopharyngeal myotomy is a surgical technique introduced years ago for the treatment of dysphagia associated with cricopharyngeal muscle dysfunction with or without Zenker’s diverticulum, showing successful results that reverse the symptoms and improve the quality of life of patients. With scientific advances endoscopic laser surgery allows to be an open safe, feasible and effective for classical surgical myotomy alternative, according to various published series showing decreasing times anesthesia, surgical and recovery emerges. In this article we describe a case, the surgical technique used and results in a patient with dysphagia by cricopharyngeal dysfunction with good postoperative outcome.

The use of self-expanding metal stents in the cervical esophagus

A case series was conducted at our institution on the the use of self-expanding metal stents (SEMS) in the cervical esophagus and their tolerability. Departmental records identified 20 consecutive stents placed in the cervical esophagus of 12 patients at our institution. There were 6 men and 6 women, mean age 67.2 years (range, 47.6-91.6 years). Ten patients had either primary or recurrent malignant disease and two had benign disease; a recalcitrant stricture at the oesophago-gastric anastomosis following oesophagectomy and a tracheo-oesophageal fistula secondary to tracheomalacia. Three patients received multiple stents on separate occasions requiring 2, 3, and 6 stents. Nineteen stents were placed radiologically with fluoroscopic guidance via a per-oral route under conscious sedation, and one was placed under direct endoscopic visualisation. Patients were followed up until death or to date. All stents were successfully deployed across the strictures. There was no foreign body sensation (FBS) reported after 16 of the procedures (80%). One patient reported transient FBS. Three stents were removed without complication because of symptoms; the endoscopically placed stent which was within 5 mm of cricopharyngeus and two which were inadvertently deployed across cricopharyngeus. There were no other significant complications related to the stent or procedure. All patients reported significant improvement in dysphagia with dysphagia scores improving from a mean of 3.1/4 to 0.9/4 (Wilcoxon matched-pairs signed-ranks test, P = 0.0158). One stent migrated in a patient with malignant disease; however, all 6 stents placed across the benign stricture migrated. Hence our case series concludes that SEMS can be safely and effectively deployed in the cervical esophagus.

Combined use of a double-lumen tube and Fogarty catheter to prevent the endobronchial spread of infection: a case report / 대한마취과학회지

Huntington's disease is a neurodegenerative disorder with an autosomal dominant inheritance pattern. Patients with Huntington's disease show an increased risk of aspiration pneumonia when the pharyngeal muscle is invaded. We report a case of advanced-stage Huntington's disease in which the patient received right middle lobectomy for a lung abscess caused by repeated aspiration. The best lung isolation technique has not yet been established in these patients. We successfully performed selective lobar isolation of the right lower and middle lobes using a double lumen tube and a Fogarty embolectomy catheter.

ASSESSMENT OF MECHANICAL AND MANUAL SUTURE IN THE SURGICAL TREATMENT OF THE PHARYNGOESOPHAGEAL DIVERTICULUM / AVALIAÇÃO DA SUTURA MECÂNICA E MANUAL NO TRATAMENTO CIRÚRGICO DO DIVERTÍCULO FARINGOESOFÁGICO

Background: The occurrence of the pharyngoesophageal, or Zenker diverticulum is not frequent in the national scenario, and the technique of the diverticulectomy with cricomyotomy in medium and great dimension diverticula is still the most indicated. Because the resection of the diverticulum requires the suture of the pharynx, dehiscence can occur, thereafter delaying swallowing. Hence, the idea is to accomplish this surgical procedure, comparing the manual and mechanical suture, in order to evaluate the real benefit of the mechanical technique. Aim: To evaluate the results of the pharyngoesophageal diverticulectomy with cricomyotomy using manual and mechanical suture with regard to local and systemic complications. Method: Fifty-seven patients with pharyngoesophageal diverticula diagnosed through high digestive endoscopy and pharyngeal esophagogram were studied. The applied surgical technique was diverticulectomy with myotomy of the cricopharyngeal muscle, done in 24 patients (42.2%) the mechanical suture (group A) with the mechanical linear suture device and in 33 (57.8%) a manual closure of the pharynx (group B). Results: In the postoperative period, one patient of group A (4.1%) presented fistula caused by dehiscence of the pharyngeal suture, and three of group B (15.1%) presented the same complication, with a good outcome using a conservative treatment. In the same group, three patients (9.0%) presented stenosis of the suture of the pharynx, with good outcome and with endoscopic dilatations, and no patient from group A presented such complication. Lung infection was present in five patients, being two (8.3%) of group A and three (9.0%) on B, having good outcomes after specific treatment. In the late review, done with 43 patients (94.4%) of group A and 22 (88.0%) on B, the patients declared to be pleased with the surgical procedure, because they were able to regain normal swallowing. Conclusion: The diverticulectomy with myotomy and pharyngeal closure using mechanical suture was proven appropriate, for having restored regular swallowing in most of the patients, and the mechanical closure of the pharynx proved to be more effective in comparison to the manual one, because it provided a lower index of local post-surgical complications.

Racional: A ocorrência do divertículo faringoesofágico, ou de Zenker, é pouco frequente no cenário nacional, sendo que a técnica da diverticulectomia com cricomiotomia em divertículos de média e grandes dimensões ainda é a mais indicada. Devido à ressecção do divertículo necessitar de sutura da faringe ocorre possibilidade de deiscência, o que retarda o retorno da deglutição. Daí a ideia de realizar este procedimento cirúrgico, comparando a sutura manual com a mecânica, para avaliar o real benefício da técnica mecânica. Objetivo: Avaliar os resultados da diverticulectomia faringoesofágica com cricomiotomia utilizando à sutura manual e mecânica em relação às complicações locais e sistêmicas. Métodos: Foram estudados 57 pacientes com divertículos faringoesofágicos diagnosticados através da endoscopia digestiva alta e faringoesofagograma. A técnica cirúrgica empreendida foi a diverticulectomia com miotomia do músculo cricofaríngeo, sendo a sutura mecânica realizada em 24 pacientes (42,2%, grupo A) com o aparelho linear e em 33 (57,8%, grupo B) a manual para o fechamento da faringe. Resultados: Na avaliação do pós-operatório precoce, um paciente do grupo A (4,1%) apresentou fístula consequente à deiscência da sutura da faringe e três do grupo B (15,1%) ambos com boa evolução com tratamento conservador. Neste mesmo grupo, três pacientes (9,0%) apresentaram estenose da sutura da faringe, com boa evolução com dilatações endoscópicas sendo que nenhum do grupo A apresentou esta complicação. A infecção pulmonar esteve presente em cinco pacientes, dois (8,3%) do grupo A e três (9,0%) do grupo B, com boa evolução com tratamento específico. Na avaliação tardia, realizada em 43 pacientes, 17(94,4%) do grupo A e 22 (88,0%) do grupo B, os pacientes referiram estarem satisfeitos com o procedimento cirúrgico, pois conseguiram resgatar a deglutição normal. Conclusões: A diverticulectomia com a miotomia do cricofaríngeo demonstrou ser procedimento cirúrgico ...

Effectiveness of Rehabilitative Balloon Swallowing Treatment on Upper Esophageal Sphincter Relaxation and Pharyngeal Motility for Neurogenic Dysphagia

OBJECTIVE: To investigate the relationship between dysphagia severity and opening of the upper esophageal sphincter (UES), and to assess the effect of balloon size on functional improvement after rehabilitative balloon swallowing treatment in patients with severe dysphagia with cricopharyngeus muscle dysfunction (CPD). METHODS: We reviewed videofluoroscopic swallowing studies (VFSS) conducted in the Department of Physical Medicine and Rehabilitation, Myongji Hospital from January through December in 2012. All subjects diagnosed with CPD by VFSS further swallowed a 16-Fr Foley catheter filled with barium sulfate suspension for three to five minutes. We measured the maximum diameter of the balloon that a patient could swallow into the esophagus and subsequently conducted a second VFSS. Then, we applied a statistical technique to correlate the balloon diameter with functional improvement after the balloon treatment. RESULTS: Among 283 inpatients who received VFSS, 21 subjects were diagnosed with CPD. It was observed that the degree of UES opening evaluated by swallowing a catheter balloon had inverse linear correlations with pharyngeal transit time and post-swallow pharyngeal remnant. Videofluoroscopy guided iterative balloon swallowing treatment for three to five minutes, significantly improved the swallowing ability in terms of pharyngeal transit time and pharyngeal remnant (p<0.005 and p<0.001, respectively). Correlation was seen between balloon size and reduction in pharyngeal remnants after balloon treatment (Pearson correlation coefficient R=-0.729, p<0.001), whereas there was no definite relationship between balloon size and improvement in pharyngeal transit time (R=-0.078, p=0.738). CONCLUSION: The maximum size of the balloon that a patient with CPD can swallow possibly indicates the maximum UES opening. The iterative balloon swallowing treatment is safe without the risk of aspiration, and it can be an effective technique to improve both pharyngeal motility and UES relaxation.

Treatments with Balloon Catheter Dilatation and Botulium Toxin Injection in a Patient with Pharyngeal Dysphagia Secondary to Cricopharyngeal Dysfunction / 대한소화기학회지

No abstract available.

The clinical investigation of the potential complications of H-UPPP surgery in removing the partial pharyngeal muscle / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#In order to improve the postoperative effect of modified UPPP, removing the partial pharyngeal muscle in surgery, we investigate the postoperative effect, the characteristics of pharyngeal cavity and the potential complications in OSAHS patients.@*METHOD@#To choose 82 OSAHS patients with obstructive oropharyngeal plane diagnosed by Apneagraphy (AG), Fibre nasopharyngoscope combined with Müller examination and nasopharyngeal 3D-CT, which had completed clinical data inpatients in the anesthesia underwent of the partial pharyngeal muscles in the postoperative, divided into a control group of 26 cases, operating the H-UPPP surgery which did not remove partial pharyngeal muscle; The experimental group of 56 cases did a H-UPPP surgical which removed partial pharyngeal muscle of possible concurrent symptoms such as nasal regurgitation, Eustachian tube dysfunction and other follow-up study in six months after the monthly telephone follow-up or outpatient exams to understand the disease. Patients were evaluated the sleepiness by ESS(Epworth sleepiness scale) in 6 months after the surgery, compared with the preoperative ESS scores, do a t test for statistical analysis. AG can be used to evaluate effects of the UPPP after 6 months. By measuring uvula length (L1), extent from free edge of soft palate to postpharyngeal (L2) and stenosis of nasopharynx width (L3) mean, we investigate the characteristics of pharyngeal cavity using the multiple linear regression to do the hypothesis test and evaluate the association between measuring mean and effect. Using SPSS19.0 software do the preoperative contrast analysis.@*RESULT@#After 6 months in surgery, 56 cases in the experimental group, effect in 50 cases (89.29%), effective in 6 cases (10.71%); ESS score: Preoperative 11.74 +/- 2.48, after the first 6 months 3.84 +/- 2.05. Twenty-six cases in control group,effect in 19 cases (73.08%), effective in 7 cases (26.92%); ESS score: Preoperative 11.91 +/- 2.40, after the first 6 months 6.92 +/- 2.47, t-test P value of less than 0.05 between the experimental group and the control group; There are no ear fullness, hearing loss, increase their own sound which reflect eustachian tube dysfunction and other complications in two groups; The function of pharyngeal cavity could be recovered normal lever after 6 months; After 6 months of the operation, in the experimental group and the control group L1 mean was respectively (5.91 +/- 3.38) mm and (6.20 +/- 3.76) mm (P>0.05); L2 mean was respectively (15.70 +/- 3.29)mm and (15.35 +/- 1.44) mm (P> 0.05); L3 mean was respectively (20.54 +/- 3.33) mm and (16.43 +/- 2.21) mm (P<0.05). Nasal fauces pitch mean was significantly widened. By the multiple linear regression analysis, the postoperative effect has the linear correlation between L2 and 1,3 residual mean with the negative correlation. Due to the standardized coefficient, L3 residual mean has the most influence on the postoperative effect.@*CONCLUSION@#Modified UPPP surgery removing the partial pharyngeal muscle is in favor of upgrading the postoperative effect with significantly increasing the width of postoperative nasal pharyngeal isthmus area, then there are not occur the eustachian tube dysfunction, the soft palate function, swallowing and articulation function disabled.

Pathologic changes of the palatopharyngeal muscles in adult patients with obstructive sleep apnea hypopnea syndrome / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To investigate the pathology of palatopharyngeal muscle obtained from patients with obstructive sleep apnea hypopnea syndrome (OSAHS).</p><p><b>METHODS</b>The samples from both groups were studied under HE, nicotinamide adenine dinucleotide-tetrazolium reductase (NADH- TR), modified Gomori trichrome (MGT) and adenosine triphosphatase (ATPase) staining. There were 36 cases of OSAHS who received uvulopalatopharyngoplasty in the experimental group (including 6 mild, 6 moderate and 24 severe cases). There were 6 patients with chronic tonsillitis but without OSAHS as matched control group. Both groups were diagnosed by PSG.</p><p><b>RESULTS</b>Centralized located nuclei and obvious variability of the size of fiber types were observed in both groups. The occurrence rate of the former were 1/6 in control group and 52.8% (19/36) in OSAHS, while the rate of the latter were 4/6 and 58.3% (21/36)respectively. A large number of fibers in both groups (control group 5/6, OSAHS group 28/36) presented an irregularly distributed staining for oxidative activity reaction in NADH stain.Endomysium connective tissue proliferation, a lobular or motheaten appearance, target-like fibers, ragged red fiber (RRF) and muscle necrosis were only observed in OSAHS group.While it was more common in serious OSAHS patients. Dominance of type 1 fibers were observed in matched control group in ATPase stain. Clusters of type 2 fibers or clusters of both type fibers were observed in OSAHS, especially more common in serious OSAHS. There was a predominance of the type 2 fibers in some OSAHS patients.</p><p><b>CONCLUSIONS</b>The observation of HE and special muscular stain identified that palatopharyngeal muscle of OSAHS patients had pathological lesion. The pathological changes included muscular lesion and abnormal distribution of different fiber types, the rate of type 1 fiber which maintained the opening of upper air way decreased.</p>

Treatment of dysphagia in patients with brain disorders

Dysphagia is caused by various pathologic conditions of which brain disorders are the major etiology. If food materials enter an airway, aspiration pneumonia or serious asphyxia can develop, which necessitates early detection and proper management of dysphagia. Diagnosis of dysphagia includes history taking, physical examination, bedside screening tests, videofluoroscopic swallowing study (VFSS), and fiberoptic endoscopic examination of swallowing (FEES). Dysphagia management or rehabilitation consists of direct and indirect training methods. The direct one consists of modification of the texture and viscosity (using fluid thickener) of the diet, and diverse compensatory techniques for posture change (chin tuck, head rotation, and head tilt), airway protection (supraglottic swallowing and super-supraglottic swallowing) and improvement of bolus passage (effortful swallowing, multiple swallowing, Mendelsohn maneuver). Indirect training methods without using food are made up of thermal tactile stimulation, electrical stimulation of suprahyoid or infrahyoid muscles, repetitive transcranial magnetic stimulation, and strengthening of the tongue or pharyngeal muscles involved in swallowing (Shaker's exercise and vocal cord adduction exercise). Oral hygiene, adequate hydration, and nutritional support are also crucial. Although the prognosis of dysphagia is favorable with proper rehabilitation, enteral feeding through percutaneous endoscopic gastrostomy or an oroesophageal tube would be helpful to patients who have unresolved dysphagia for some time. Further large-scale clinical studies will be needed to establish evidence on various training methods for dysphagia management.

Anesthetic management of a patient with Huntington's chorea: A case report / 대한마취과학회지

Huntington's chorea is a rare hereditary disorder of the nervous system. It is inherited as an autosomal dominant disorder and is characterized by progressive chorea, dementia and psychiatric disturbances. The best anesthetic technique is yet to be established for these patients with increased risk of aspiration due to involvement of pharyngeal muscles and an exaggerated response to sodium thiopental and succinylcholine. The primary goal in general anesthesia for these patients is to provide airway protection and a rapid and safe recovery. We report the anesthetic management of a 51-year-old patient with Huntington's chorea admitted for an emergency operation.

Diagnosis With Manometry and Treatment With Repetitive Transcranial Magnetic Stimulation in Dysphagia

Videofluoroscopic swallowing study (VFSS) used for the diagnosis of dysphagia has limitations in objectively assessing the contractility of the pharyngeal muscle or the degree of the upper esophageal sphincter relaxation. With a manometer, however, it is possible to objectively assess the pressure changes in the pharynx caused by pharyngeal muscle contraction during swallowing or upper esophageal sphincter relaxation, hence remedying the limitations of VFSS. The following case report describes a patient diagnosed with lateral medullar infarction presenting a 52-year-old male who had dysphagia. We suggested that the manometer could be used to assess the specific site of dysfunction in patients with dysphagia complementing the limitations of VFSS. We also found that repetitive transcranial magnetic stimulation was effective in treating patients refractory to traditional dysphagia rehabilitation.