Radiofrequency tongue reduction through a cervical approach: a pilot study.

OBJECTIVE/HYPOTHESIS: The objective of this prospective cohort study was to determine the feasibility, safety, and efficacy of radiofrequency tongue base reduction through a cervical approach in patients with obstructive sleep apnea syndrome (OSAS). METHODS: Patients with moderate to severe OSAS and predominant tongue base obstruction by physical examination were included at our institution from 1999 to 2003. A sonogram was obtained to identify the lingual arteries, and an electrode was inserted through the neck and into the tongue under fluoroscopic guidance. Adverse events were recorded as well as efficacy on snoring (visual analog scale), daytime sleepiness (Epworth score), and polysomnography. RESULTS: The 10 patients received a mean of 14,288 +/- 3,251 J per session. No cases of tongue palsy or infection occurred. During the first 7 days, mean pain score (0-10 scale) was 1.3 +/- 1.5. Snoring volume (0-10 scale) decreased from 6.2 +/- 2.3 to 3.9 +/- 2.6 (P = .017) and sleepiness (0-24 scale) from 8.7 +/- 5.6 to 4.7 +/- 3.3 (P = .011). The respiratory disturbance index (events/hour) decreased from 52.0 +/- 19.6 to 33.6 +/- 24.4 (P = .016). Mean minimal oxygen saturation (%) increased from 64.2 +/- 13.0 to 75.8 +/- 10.3 (P = .003). Sleep architecture improved although not significantly. CONCLUSION: Radiofrequency tongue base reduction through a cervical approach proved feasible and safe despite the large energy doses used. Fluoroscopic guidance enables to place the electrode at the desired site of treatment. Although OSAS improved in nine of 10 patients, greater efficacy might be achieved in patients with less severe OSAS at baseline. Studies are needed to correlate objective clinical efficacy with the dose per lesion site and the number of lesion sites per session.

Radiofrequency in the treatment of craniofacial plexiform neurofibromatosis: a pilot study.

BACKGROUND: Neurofibromatosis type 1 manifests itself by the development of plexiform neurofibromas, with craniofacial deformities caused by bone alterations and soft-tissue infiltration. The medical treatment of this disease is disappointing, and the surgical management of these deformities calls for aggressive procedures. There is a strong risk of recurrence. METHODS: A pilot study was performed to test radiofrequency as a minimally invasive method with which to diminish the size of craniofacial neurofibromas either as an adjunct to craniofacial surgery (in cranio-orbital neurofibromas) or to avoid a visible scar in young patients (in infraorbital neurofibromas). Five patients ranging in age from 6 to 18 years were treated by three procedures 2 months apart using radiofrequency performed under local anesthesia or under sedation for the youngest patients. RESULTS: The tolerance of the treatment was excellent, with no major side effects and no pain in the postoperative course. A diminution of the size of the lesion was noted clinically in four patients and on computed tomography in two patients. A biopsy performed in one case illustrated the effect of the treatment. CONCLUSIONS: A partial diminution or stabilization of plexiform neurofibromas may be obtained using radiofrequency. This treatment is well tolerated. The best effect can be observed in the early stages of the disease. The optimal dose and frequency of the procedure require further study.

Orbital morphology in exophthalmos and exorbitism.

BACKGROUND: Exophthalmos is a protrusion of the eyeball due to an increase in orbital contents in a normal bony orbit. Exorbitism is a protrusion of the eyeball due to a decrease in capacity of the orbital container, with a normal orbital content volume such as seen in a congenital form termed nonsyndromic exorbitism. High myopia can enhance proptosis. The purpose of this study was to provide values for orbital measurements from computed tomography and to suggest computed tomography criteria for nonsyndromic exorbitism. METHODS: Seventy-three computed tomography scans were collected (57 of Graves' ophthalmopathy and 16 of nonsyndromic exorbitism). Thirty-two scans from nonproptotic patients constituted a control series. Nine measurements and two indexes, performed on a reference axial computed tomography slice transecting the neuro-ocular plane, were obtained from each scan. RESULTS: The angle between the sagittal axis and the lateral orbital wall, as well as the width of the ethmoid bone (midinterorbital distance), was found to be more open in the nonsyndromic exorbitism population. A lateral orbital wall angle greater than or equal to 42 degrees and a midinterorbital distance greater than 30 mm were chosen as cutpoints. The association of these two criteria allowed the authors to obtain a sensitivity of 62 percent, a specificity of 78 percent, a positive predictive value of 80 percent, and a negative predictive value of 86 percent for nonsyndromic exorbitism. CONCLUSIONS: The different mechanisms of globe protrusion have to be taken into account before an orbital expansion/decompression procedure is planned. Only a preoperative morphological analysis of the orbital shape permits a precise analysis of the relative position of the ocular globe and orbital structures, in addition to clinical examination.

Surgical strategy in the treatment of globe protrusion depending on its mechanism (Graves' disease, nonsyndromic exorbitism, or high myopia).

BACKGROUND: Graves' ophthalmopathy affects orbital contents and eyelids. Protrusion of the globe can also be the result of myopia and/or an abnormal orbit shape, which is responsible for nonsyndromic exorbitism. It is necessary to recognize these components of protrusion to treat patients adequately. The authors present a surgical strategy for treatment of the orbit and lids. METHODS: Files of 84 patients treated from 1984 to 2003 were retrospectively reviewed. Sixty-eight patients were operated on for Graves' ophthalmopathy and 16 for nonsyndromic exorbitism with or without myopia. The surgical strategy was adapted to the degree of emergency, the age of the patient, and the shape of the orbit measured using computed tomography. The accepted standard of treatment was a coronal approach with a two-wall expansion, with or without bone grafts, especially in cases of associated nonsyndromic exorbitism, with or without complementary ablation of the external part of the orbital floor. Lid surgery was performed at a second stage. RESULTS: Nonsyndromic exorbitism patients were successfully treated in one step. No diplopia was present either preoperatively or postoperatively. In contrast, the treatment of the Graves' ophthalmopathy patients justified one to three orbital expansion procedures per patient and/or one to seven procedures for levator palpebrae lengthening or reinsertion. Forty-three percent of preexisting diplopias were improved by the surgery. The overall postoperative incidence of de novo diplopia was 19 percent. In the Graves' ophthalmopathy series, three patients (5 percent) finally underwent strabismus surgery. No major complication occurred. CONCLUSIONS: The treatment of Graves' ophthalmopathy is challenging. A graded approach is justified. Patients have to be informed that several procedures may be necessary and, in cases of nonsyndromic exorbitism or myopia, that facial modifications might occur.