Experiencia en pacientes operados de roncopatía y apnea obstructiva del sueño / Clinical experience in patients with surgery of rhonchopathy and obstructive sleep apnea syndrome

RESUMEN Introducción: La uvulopalatofaringoplastía (UPPP) es un procedimiento ampliamente difundido en el tratamiento del ronquido y el síndrome de apnea e hipopnea obstructiva del sueño (SAHOS), ya que permite aumentar el área de sección transversal de la vía aérea superior y eliminar tejidos obstructivos. Conocer el grado de satisfacción de los pacientes con la cirugía es importante para nuestro desempeño. Objetivo: Evaluar la satisfacción de los pacientes con el procedimiento UPPP con cirugía nasal con datos subjetivos mediante la aplicación de una encuesta para ser respondida de forma anónima. Material y método: Estudio observacional, descriptivo. Se envió vía email una encuesta de 4 preguntas cerradas creada en la plataforma online MonkeySurvey a los pacientes que fueron sometidos a UPPP (faringoplastía de relocalización) con cirugía nasal entre 2015 y 2016. Resultados: 27 pacientes respondieron la encuesta. Sesenta y seis coma seis por ciento tenían ronquido primario y/o SAHOS leve, 33,3% SAHOS severo. La edad media al momento de la cirugía fue 41 años. El tiempo de seguimiento medio fue 10 meses (324 meses). Noventa y dos coma cinco por ciento de los pacientes están satisfechos con la cirugía UPPP; 81,4% refieren que recomendarían la cirugía a otra persona. Noventa y dos coma cinco por ciento refieren mejoría en los ronquidos. Noventa y cinco coma seis por ciento de los pacientes con somnolencia diurna refiere mejoría. Conclusión: La cirugía UPPP con técnica faringoplastía de relocalización combinada con cirugía nasal en pacientes con ronquido primario y SAHOS ha demostrado una alta tasa de satisfacción según la percepción de los pacientes en el seguimiento desde los 3 meses hasta los 2 años posoperatorios.

ABSTRACT Introduction: Uvulopalatopharyngoplasty (UPPP) is a widely used surgical procedure for snoring and obstructive sleep apnea syndrome (OSAS), since it allows to increase of the cross-sectional area of the upper airway and elimination of obstructive tissues. Knowing the degree of satisfaction of patients with surgery is important for our performance. Aim: To evaluate patient satisfaction with UPPP procedure (relocation pharyngoplasty) with nasal surgery with subjective data through the application of a survey to be answered anonymously. Material and method: Observational, descriptive study. A survey of 4 closed questions created in the MonkeySurvey online platform was sent to patients who underwent UPPP with nasal surgery between 2015 and 2016 via email. Results: 27 patients answered the survey. 66.6% had primary snoring and/or mild OSAS, 33.3% severe OSAS. The average age at the time of surgery was 41 years. The mean follow-up time was 10 months (3-24 months). 92.5% of patients are satisfied with UPPP surgery; 81.4% reported that they would recommend surgery to another person. 92.5% reported improvement in snoring. 95.6% of patients with daytime somnolence reported improvement. Conclusion: UPPP surgery with relocation pharyngoplasty technique combined with nasal surgery in patients with primary snoring and OSAS has shown a high satisfaction rate according to the perception of patients at follow-up from 3 months to 2 years postoperative.

Effect of classic uvulopalatopharyngoplasty and laser-assisted uvulopalatopharyngoplasty on voice acoustics and speech nasalance

Uvulopalatopharyngoplasty [UPPP] is a commonly used surgical technique for oropharyngeal reconstruction in patients with obstructive sleep apnea [OSA]. This procedure can be done either through the classic or the laser-assisted uvulopalatopharyngoplasty [LAUP] technique. The purpose of this study was to evaluate the effect of classic UPPP and LAUP on acoustics of voice and speech nasalance, and to compare the effect of each operation on these two domains. The study included 27 patients with a mean age of 46 years. All patients were diagnosed with OSA based on polysomnographic examination. Patients were divided into two groups according to the type of surgical procedure. Fifteen patients underwent classic UPPP, whereas 12 patients were subjected to LAUP. A full assessment was done for all patients preoperatively and postoperatively, including auditory perceptual assessment [APA] of voice and speech, objective assessment using acoustic voice analysis and nasometry. Auditory perceptual assessment of speech and voice, acoustic analysis of voice and nasometric analysis of speech did not show statistically significant differences between the preoperative and postoperative evaluations in either group [P>.05]. The results of this study demonstrated that in patients with OSA, the surgical technique, whether classic UPPP or LAUP, does not have significant effects on the patients' voice quality or their speech outcomes

Tratamiento quirúrgico del ronquido y la apnea obstructiva del sueño / Snoring and sleep apnea syndrome: surgical treatment

La roncopatía y la apnea obstructiva del sueño son problemas muy comunes en la población general. Su causa es un colapso de la vía aérea superior en cualquiera de sus niveles, nasal, orofaringeo y/o hipofaringeo (base de lengua). La roncopatía es un problema fundamentalmente social. Por otro lado la apnea obstructiva del sueño constituye un problema de riesgo médico por la mayor tasa de accidentes de tráfico, accidentes cardiovasculares, etc. Si bien es cierto ambas entidades son de resolución médica mediante el uso de CPAP, se han descrito un sinnúmero de técnicas quirúrgicas desde 1981 con el fin de ayudar a aquellos pacientes que no desean o no toleran el uso de CPAP.

Snoring and Sleep Apnea Syndrom are common disorders among general population. Both entities are produced by collapse of the Upper airway usually at multiples levels, nose, oropharinx and /or hypopharinx (base of tongue). Whereas snoring is social problem, sleep apnea syndrome is a medical entity because of the higher rates of traffic accidents and cardiovascular diseases. The current mainstay for treating these disorders is the CPAP, however many surgical procedures have been described since 1981 in order to help a group of patients who cannot or will not accept CPAP as a permanent form of management.

Carótida interna retrofaríngea: relato de caso / Retropharyngeal internal carotid artery: case report

Introdução: Anomalias no trajeto das artérias carótidas podem gerar protrusões faríngeas, para as quais o otorrinolaringologista deve estar sempre atento. Objetivo: Descrever um caso de abaulamento orofaríngeo causado por anomalia vascular no trajeto da carótida interna, com revisão da literatura. Relato do Caso: Paciente de 73 anos, sexo feminino, apresentou-se com queixas de bolo cervical e disfonia intermitente. Ao exame, foi evidenciado abaulamento pulsátil em orofaringe à direita, associado aos sinais laringoscópicos de refluxo faringo-laríngeo. Solicitada tomografia computadorizada de faringe, que mostrou carótida interna tortuosa em espaço retrofaríngeo. A paciente foi encaminhada ao cirurgião vascular que, após Doppler de carótidas, que não revelou obstrução significativa, optou por conduta expectante. Os sintomas faríngeos cederam com o tratamento anti-refluxo. Comentários Finais: Anomalias vasculares da carótida interna devem ser sempre lembradas no diagnóstico diferencial de abaulamentos da parede faríngea.

Introduction: Variations to the course of carotid arteries may lead to abnormal pharyngeal protrusions, to which the otorhinolaryngologist should always attentive. Objective: To report a case of abnormal pharyngeal protrusion due to vascular anomaly in the course of the internal carotid artery, with literature review. Case Report: A 73- year-old woman complained of globus pharyngeus and intermittent dysphonia. A pulsating convexity was observed at the right part of the oropharynx, associated to laryngoscopic signals of pharyngo-laryngeal reflux. The pharyngeal computed tomography scan showed an abnormal tortuous internal carotid in the retropharyngeal space. The patient was sent to the vascular surgeon, who, after a normal blood flow finding at the Doppler, opted for an expectation conduct. The pharyngeal symptoms improved with the antireflux treatment. Final Comments: Internal carotid vascular anomalies must always be recalled in the pharyngeal wall convexity differential diagnosis.

Avaliação da sobrevida livre de doença de pacientes com recidiva loco-regional de carcinoma epidermóide de cavidade bucal e orofaringe submetidos a tratamento de resgate / Assessment of disease-free survival in patients with loco-regional recurrence of squamous cell carcinoma of the oral cavity and oropharynx submitted to salvage treatment

OBJETIVO: A cirurgia de resgate é primeira opção terapêutica, principalmente nas lesões de estadio clínico inicial. O objetivo do estudo é avaliação da sobrevida livre de doença após resgate cirúrgico de tumores de cavidade bucal e orofaringe. MÉTODOS: Estudo retrospectivo de 276 pacientes tratados com cirurgia, sendo que 127 desenvolveram recidiva loco-regional. Noventa e sete pacientes eram de estadiamento clínico inicial e 178 de estadiamento clínico avançado. Vinte e cinco casos de lábio, 173 cavidade bucal e 78 de orofaringe. A radioterapia pós-operatória foi realizada em 121 pacientes com dose média de 60,8 Gy. RESULTADOS: Oitenta e nove pacientes foram submetidos a tratamento de resgate, sendo que 76 destes foram à cirurgia. As recidivas loco-regionais de cavidade bucal foram submetidas ao resgate cirúrgico em 65 por cento casos. A sobrevida livre de doença pós-cirurgia de resgate foi de 13 por cento nas recidivas até seis meses e 48 por cento nas recidivas após 12 meses de seguimento (p=0,0009). O tipo de resgate e o intervalo livre de doença foram fatores independentes de sobrevida na análise multivariada. CONCLUSÃO: A sobrevida livre de doença pós-resgate nos estadios clínicos iniciais (I e II) foi de 70 por cento.

OBJECTIVE: Salvage surgery is the first therapeutic option for recurrent tumors of the mouth and oropharynx, mainly in early stage tumors. This study intends to evaluate the disease free survival interval after salvage treatment for recurrent tumors of the mouth and oropharynx. METHODS: Retrospective analysis of 276 patients with squamous cell carcinoma of the mouth and oropharynx treated with surgery. One hundred and twenty seven patients developed loco-regional recurrence. Ninety-seven were staged as early tumors and 178 as advanced ones. The tumor site was the lip in 25 cases, oral cavity in 173 and oropharynx in 78. Postoperative radiotherapy was indicated in 121 cases with a mean dose of 60.8Gy. RESULTS: Eighty-nine patients underwent salvage treatment (surgery in 76 patients). Loco-regional recurrences were treated with salvage surgery in 65 percent of cases. Disease free survival after salvage surgery was 13 percent in cases with recurrences diagnosed up to 6 months and 48 percent in those who recurred after 12 months of follow-up (p=0.0009). Modality of salvage treatment and the disease free interval were independent variables of survival in the multivariate analysis. CONCLUSION: In cases clinically staged as I and II, the disease free survival in five years after salvage treatment was 70 percent.

Galeal flap based on superficial temporal vessels for oral cavity and pharynx reconstruction: an anatomical study

PURPOSE: Despite the advances in microvascular free tissue transfer for intraoral reconstruction, this surgery is not recommended for all patients. In specific cases, the pedicled temporoparietal galeal flap may be an option for reconstructive procedures in the head and neck regions. The objective of this paper is to present the anatomical aspects of a galeal flap based on the superficial temporal vessels and to test its potential for reconstructing diverse sites of the oral cavity and pharynx. METHODS: We performed 40 dissections on 34 fresh adult cadavers. The flap vascular anatomy was studied by injecting latex into the superficial temporal vessels. A standardized square-shape flap measuring 10 x 10 cm², pedicled on the superficial temporal vessels, was raised. Oral cavity and oropharynx reconstruction simulations were performed after flap transposition into the mouth by passing it under the zygomatic arch. Hypopharyngeal reconstruction was tested by transposing the flap to the neck under the facial nerve. RESULTS: After latex injection, a rich vascular network over the temporoparietal galea was observed directly from the superficial temporal artery, and a well-vascularized flap based on this vessel was raised. In the reconstruction simulations, the flap was shown to be suitable for the coverage of hypothetical defects in most oral cavity and pharyngeal sites, mainly the retromolar trigone, tonsil area, and buccal mucosa. CONCLUSIONS: A galeal flap based on the superficial temporal vessels presents favorable anatomical characteristics for oral cavity and pharyngeal reconstruction.

Endoscopic excision of the antrochoanal polyp

To evaluate the effectiveness of endoscopic excision of the antrochoanal polyp and its role in decreasing the recurrence rate. Retrospective. Medical records of thirty patients with antrochoanal polyp [ACP] diagnosed and treated at King Abdulaziz University Hospital [KAUH] in Riyadh between January 1996 and December 2002 were retrospectively studied. Factors such as gender, age, presenting complaints, findings, pathology, management and recurrence rates were included in this study. Out of thirty patients, 17 were male and their ages ranged from six to 45 years with a mean age of 17.37 years. Nasal obstruction was the most common presenting symptom. Endoscopic transnasal removal of ACP was performed in 25 patients as primary surgery. Revision endoscopic removal was done in three patients and two of those who had failure of revision surgery had combined transcanine and endonasal endoscopic removal. All candidates had follow up from nine to 42 months with mean average time of 24 months. Recurrence was confirmed in five patients [four of them after primary surgery and one patient after revision surgery]. However those who underwent combined approach had no recurrence. Endoscopic approach compared to previous modalities of treatment has the capability to ensure complete removal of the ACP and decrease its rate of recurrence. Its safety in children is considerable in capable hands. Power instrumentation with combined transcanine and middle meatal antrostomy approach is another way to deal with difficult cases and those with recurrence

Retalho galeal baseado nos vasos temporais superficiais para reconstrução dos defeitos da cavidade oral, orofaringe e hipofaringe: estudo anatômico em cadáver / Galeal flap based on superficial temporal vessels for oral cavity, oropharynx and hypopharynx reconstruction: a cadaveric anatomic study

O trabalho tem por objetivo estudar a viabilidade anatômica do retalho constituído pela gálea da região têmporo-parietal que, baseado nos vasos temporais superficiais, seria utilizado para reconstrução dos defeitos pós-excisionais da cavidade oral, orofaringe e hipofaringe. Foram realizadas 40 dissecções em cadáveres nas quais, após infusão de resina nos vasos temporais superficiais, confeccionou-se um retalho galeal pediculado nestes vasos e testou-se a possibilidade deste retalho reconstruir diversos sítios da cavidade oral e faringe. O retalho apresentou bom alcance e cobertura para a maioria das regiões analisadas, além de características favoráveis para as reconstruções propostas.The aim of this paper is to study the anatomic viability of a flap that, based on superficial temporal vessels and constituted by the galea of temporoparietal region, would be used for oral cavity, oropharynx, and hypopharynx reconstruction after tumor ablation. Forty cadaveric dissections were performed with latex injection into the superficial temporal vessels. A galeal flap was harvested pedicled on these vessels and simulations of oral cavity and pharynx reconstruction were realized. The flap showed success to reach and cover the majority of analyzed sites as well as favorable characteristics for the proposed reconstructions...

Standardization of Flap Design for Oropharyngeal Reconstruction after Cancer Ablation Surgery

A variety of residual defects containing many sulci and fossae in the oropharyngeal cavity make it extremely difficult to achieve an adequate flap design as well as the functional reconstruction of the complex defects after ablation surgery for oropharyngeal tumors. This study attempted to standardize flap design for the different types of defects in order to produce a better functional reconstruction of intra-oral defects. The oropharyngeal defects were classified into 6 Zones. When the defect involves only the mouth floor, it was classified as Zone 1. A hemi tongue was classified as Zone 2. A defect involving the mouth floor and a part of the tongue was classified as Zone 3. A defect involving the mouth floor, a part of the tongue and the tonsil was classified as Zone 4. A defect involving the mouth floor, a part of the tongue, tonsil and soft palate was classified as Zone 5. A defect involving the pharyngeal wall was classified as Zone 6. The following four types of forearm free flap designs were applied to each defective Zone accordingly: Type I flap design - an unilobed design for reconstructing Zone 1, 2 and 6 defects, Type II design - bilobed design for reconstructing Zone 3 defects, Type III design - trilobed design for reconstructing Zone 4 defects and Type IV design for reconstructing Zone 5 defects. During 1999 to 2002, 91 patients with oropharyngeal defects underwent a reconstruction using these standardized forearm free flap designs. The Type I design was used in 41 cases, the Type II design in 18 cases, the Type III design in 10 cases and the Type IV design in 22 cases. In all patients, the decannulation was successful, and the swallowing and deglutination functions were within the normal parameters. There was less nasal escape of the voice and the regurgitation of food than that observed using the conventional flap design method. Effective and functional reconstructions with minimal morbidities are possible with the application of the standardized forearm free flap design in oropharyngeal defects.

Resultados da vulvopalatofaringoplastia para tratamento do ronco e da apnéia do sono / Results of uvulopalatopharyngoplasty for snoring and sleep apnea syndrome

No período de 1988 à 1993, no Serviço de Otorrinolaringologia do Hospital Pellegrin Bordeaux-França, 54 pacientes foram submetidos à uvulopalatofaringoplastia (UPP) para tratamento de ronco habitual. Quarenta e nove pacientes apresentaram eliminaçäo completa ou melhora significativa do ronco. Complicaçäo importante ocorreu em um caso

Emprego de retalho livre radial do antebraço para a reconstruçäo orofaríngea / Radial forearm free flap for reconstruction of oropharyngeal defects

Avaliaçäo de 15 doentes submetidos a reconstruçäo intra-oral com retalho livre proveniente de antebraço. O período de acompanhamento pós-operatório variou de três a 36 meses (média 14). A idade variou de 15 a 58 anos (média 41). Os defeitos tratados eram conseqüência de ressecçäo neoplásica (11 casos), seqüela de tratamento convencional de deformidade congênita (três casos) e ferimento por arma de fogo com lesäo de palato e lábio superior (um caso). O retalho funcionou muito bem na grande maioria dos casos. Após a operaçäo, houve necrose total de um retalho, e um doente foi re-operado, no primeiro dia, para revisäo das anastomoses. Os resultados permitem indicar este tipo de retalho como primeira opçäo na reconstruçäo de defeitos extensos de orofaringe

Laser in the management of stenosing oropharyngeal scleroma.

We present here our experience of laser for the management of stenosed oropharyngeal scleroma. The diagnosis of scleroma was made 14 years ago and the patient underwent repeated procedures like dilatation, diathermy excision of adhesions and cryosurgery during this period. He attended our out-patient department with complaints of dysphagia and difficulty in breathing, progressing to stridor. On examination, severe oropharyngeal stenosis due to cicatrization extending between the base of the tongue and the post-pharyngeal wall was seen. Using CO2 laser, cicatrix was released by making radial cuts and the oropharyngeal opening was widened. No tracheostomy was needed; no blood loss occurred and the patient was discharged on the next day.

Posibilidades del autotrasplante de yeyuno para la reconstrucción orofaringoesofágica / Possibilities of jejunal autotransplantation for oropharyngoesophagic reconstruction

El autotrasplante de yeyuno con técnica microquirúrgica fue efectuada en 7 pacientes para reconstruir el defecto creado luego de resecciones orofaringoesofágicas por carcinomas localmente avanzadas. Este procedimiento reemplaza con mayor eficacia a los colgados miocutáneos pediculados, especialmente para las reconstrucciones tubulares. En esta situación (5 casos) se recomienda la anastomosis faringoyeyunal en forma terminoterminal. En los otros el yeyuno se usó abierto como parche orofaríngeo. La técnica detallada es relativamente sencilla, pero la viabilidad del ansa depende tanto de las correctas microanastomosis como de la adecuada elección de los vasos receptores.Los usados preferentemente fueron la vena yugular externa y la arteria tiroidea superior. Es imprescindible el monitoreo inicial y permanente del ansa trasplantada para detectar precozmente la necrosis. Esta ocurrió en 2 enfermos, falleciendo 1 de ellos como consecuencia del procedimiento. El otro sobrevivió reemplazando el parche de yeyuno por colgajo pectoral. Un enfermo falleció por severa celulitis cervical y el otro por recurrencia precoz, pero ambos con el injerto viable. Los 3 enfermos con seguimiento alejado tuvieron deglución normal, no hubo ninguna complicación abdominal. Se destaca la ventaja de esta técnica para las reconstrucciones tubulares faringoesofásicas sobre los procedimientos hasta ahora utilizados.

Acompanhamento polissonográfico das apnéias do sono após uvulopalatofaringoplastia / Polysomnographic follow-up of sleep apneas after uvulopalatopharyngoplasty

Uvulopalatofaringoplastia (UPFP) foi realizada em 12 pacientes com apnéia do sono tipo obstrutiva. Comparamos aqui dados clínicos e traçados polissonográficos pré-operatórios aos realizados de um a três meses após a cirurgia. Sonolência excessiva diurna foi realizada parcialmente em 4 casos e totalmente em 8. Tempo total de sono, eficiência do sono, número de despertares e latência do sono mantiveram-se constantes. A latência REM foi acentuadamente maior após a cirurgia. A distribuiçäo dos estágios de sono foi semelhante nas duas avaliaçöes exceto pela ausência de estágio 4 verificada em menor número de casos no pós-operatório. Houve melhora da SaO2, encontrando-se valores abaixo de 80% em 10 pacientes no pré e em 4 no pós-operatório. Os índices de apnéia reduziram-se em todos os casos, mas apenas 4 atingiram valores normais