One-stage laser-assisted uvulopalatoplasty.

OBJECTIVE: To assess the efficacy of an author-modified LAUP technique using the principles of UPPP surgery. This new one-stage method of LAUP is described in detail. DESIGN: A retrospective review of all one-stage LAUPs performed. SETTING: The Division of Otolaryngology, University of British Columbia, Vancouver, BC. METHOD: This one-stage LAUP was performed on all patients. MAIN OUTCOME MEASURES: Improvement of snoring, postoperative pain, polysomnography, home oximetry, the Respiratory Disturbance Index, and the need for a second treatment. RESULTS: Two hundred twenty patients have undergone this more aggressive excisional approach, and only 10 needed a second treatment. A 75 to 100% improvement in snoring was noted by 83% of cases. In patients with some residual noise, 78% described only heavy breathing when lying on their back. Postoperative pain was mild (7 days) to moderate (7-10 days) in 79% of cases. Eighty-three percent of patients missed no work after treatment. Documented sleep-apnea was present in 74 people (33%), and 96% of these reported a more restful sleep with less daytime fatigue postoperatively. Ten of 14 patients (71%) with postoperative sleep studies had apneas eliminated or reduced by more than 50%. Overall patient satisfaction was 97%. A low-level laser from Europe (LLLT) has been introduced as an adjunct to help control postoperative pain. A clinical trial on its use in UPPP surgery is also described.

Long-term results of uvulopalatopharyngoplasty for snoring.

Snoring is a disease of listeners and one which can cause significant disruption in an otherwise peaceful household. Uvulopalatopharyngoplasty (UPPP) was initially described in 1981 for the treatment of obstructive sleep apnea, and since that time only one large series has evaluated it as a treatment for snoring. Various therapeutic strategies have been described for the treatment of snoring, but UPPP seems to hold the most promise. A retrospective review was undertaken of over 100 patients undergoing UPPP since 1984 to evaluate the efficacy of the procedure in controlling the symptom of snoring. The group of patients who will benefit most from this procedure is identified.

Upper airway measurements predict response to uvulopalatopharyngoplasty in obstructive sleep apnea.

Although uvulopalatopharyngoplasty relieves obstructive sleep apnea in the majority of patients, the factors that determine a successful response are not well defined. To determine whether preoperative awake upper airway measurements predict the response to uvulopalatopharyngoplasty, presurgical lateral cephalometric radiographs were evaluated on 60 consecutive patients with symptomatic obstructive sleep apnea. Patients underwent overnight polysomnograms before uvulopalatopharyngoplasty and 3 months afterwards. Forty-eight (80%) patients had a good response as defined by a postoperative apnea index of less than or equal to 4 apneas/hour or a reduction in apnea index of greater than or equal to 60%. Responders had a significantly narrower inferior airway space (P less than .0005) and a smaller ratio of inferior airway space to tongue length (P less than .001). Improvement in apnea severity following uvulopalatopharyngoplasty was related to the degree of airway narrowing (r = 0.36; P less than .01). This study shows that upper airway measurements help predict response to uvulopalatopharyngoplasty in patients with obstructive sleep apnea. Patients with a narrow airway, particularly relative to tongue size, have good responses to uvulopalatopharyngoplasty.

Treatment of obstructive sleep apnea by uvulopalatopharyngoplasty.

Although uvulopalatopharyngoplasty has been proposed as a treatment for obstructive sleep apnea, there is limited objective data concerning its efficacy. We have examined 40 patients with moderate to severe obstructive sleep apnea before and 3 months following uvulopalatopharyngoplasty. A standardized questionnaire and detailed overnight sleep study were performed before and after surgery. In addition, 15 patients were retested 1 year postoperatively. Uvulopalatopharyngoplasty resulted in a statistically significant reduction in symptoms, blood pressure, apnea index, and total apneic time. There was no significant change in patient weight or sleep gas exchange. Seventy-seven percent had a reduction in apnea index of greater than 50%, which is better than other reported series using a more conservative approach. Our more aggressive surgical method will be shown in detail. The 1-year follow-up studies revealed the results were maintained or slightly improved over time.

Cancer of the nasopharynx in British Columbia.

The Chinese population in British Columbia has been increasing in recent years due to the migration of the Chinese from Southern China, which has tripled during the last decade. From 1939 to 1980, 296 cases of nasopharyngeal carcinoma (NPC) were seen at the Cancer Control Agency of British Columbia (CCABC). Of these, 167 (56%) were Chinese and 119 (40%) were Caucasians. The incidence of cancer of the nasopharynx in the Chinese born in China was 115 times greater than Caucasians before 1970 and 107 times greater in the 1970s. The incidence of NPC in the Caucasian population remained unchanged as did that of the North American-born Chinese (six times greater than that of the Caucasians) for the last 2 decades. The overall survival for all cases was 39% at 5 years and 28% at 10 years. The survival of cases was better in patients treated after 1970 (48% at 5 years and 36% at 10 years) than in patients treated before 1970 (34% at 5 years and 20% at 10 years). The survival was 50% at 5 years for all N0 cases but it was only 27% in patients with nodal metastasis. The survival of NPC was related essentially to initial staging, type and dose of irradiation, and pre-irradiation biopsy of neck metastasis. The survival was not significantly related to birth place, race, or histological grade.

Adult pharyngoplasty for velopharyngeal insufficiency.

Nine adults underwent superiorly based pharyngeal flaps for the treatment of severe velopharyngeal insufficiency (VPI). The etiology of the VPI was failed pediatric cleft palate repair in eight and myasthenia gravis in the ninth. All patients were evaluated by a speech therapist pre-operatively. There were no significant early or late postsurgical complications. After extensive speech therapy all patients were noted subjectively and objectively to have a marked reduction in hypernasality and nasal air escape and improved speech intelligibility. The healed fibrotic flaps appeared to be adynamic and acted more as a viable midline obturator. Lateral pharyngeal wall contraction was necessary to close the lateral ports during phonation. The patient with myasthenia gravis had the least improvement presumably due to poor lateral wall mobility.

Nasopharyngeal carcinoma: an evaluation of 134 patients treated between 1971-1980.

An analysis is made of 134 patients with nasopharyngeal carcinoma treated from 1971-1980 at the Cancer Control Agency of British Columbia. Incidence rate for Chinese born in the Orient was 20.5 per 100,000 per year compared to 1.32 per 100,000 for Canadian born Chinese. The Caucasian rate was .19 per 100,000 per year. These figures confirm a 15 times greater incidence of the disease in Chinese born in the Orient over those born in North America. The 86 Chinese patients were noted to have a 10% poorer survival than the 48 Caucasian patients on long-term follow-up. The main factor affecting survival was initial staging. Overall survival rates were 46.3% three year, no evidence of disease (NED) and 38.3% five year NED survival, but when disease was limited to the nasopharynx (T1, T2, N0) they were 73.9% three year NED and 66.6% five year NED survival. One-third of the patients ultimately developed distant metastases below the clavicle. Although lower T and N stage cases had fewer of these, the overall correlation with staging was poor. Female patients showed statistically significant better survival which was not related to better initial staging. They did, however, have 11% fewer eventual distant metastases.

Fatal myocarditis associated with peritonsillar abscess.

A case report of a patient with tonsillitis and peritonsillar abscess, who subsequently developed fatal myocarditis, is presented. The clinical course and pathological findings are outlined. The rare association of tonsillitis and pharyngitis with non-rheumatic, non-diphtheritic, non-fatal myocarditis was recognized and reported in the pre and early antibiotic era. The present reported case is only the second recent description of fatal myocarditis associated with tonsillitis, and the first ever reported in the English Otolaryngologic literature.

Nasopharyngeal carcinoma: an evaluation of 209 patients.

A unique racially balanced North American series of 209 patients with nasopharyngeal carcinoma will be presented. The patients were 49% Chinese and 51% non-Chinese (predominantly caucasian). Whereas Chinese born in China had a 117.9 times greater incidence of the disease, North American born Chinese showed only a 7.3 times greater incidence than Caucasians. Five year absolute (NED) survival was 25.6% for Chinese and 32% for non-Chinese. Other racial differences are also discussed. Two four-year-old patients with definite nasopharyngeal carcinoma, the youngest in the literature, are included in the study. Survival and prognosis of nasopharyngeal carcinoma depends on tumor histology, initial stage of disease, dose of radiation and pre-irradiation node biopsy. Five year absolute survivals for different histologies were; lymphoepithelioma 52.4%, non-keratinizing squamous cell 31.5% and keratinizing squamous cell 16.3%. The overall 5 year absolute survival for the series was 29%. When initial primary disease was localized to the nasopharynx (T0, T1, T2) with or without mobile nodes (N0, N1, N2) the survival rose to 41%. Cases treated with 6000 rads or more primarily had the best survival results. Pre-irradiation node biopsy consistently resulted in poorer survival. When the nodes were mobile (N1, N2) the survival rate was 46.9% 5 year NED in the non-biopsied group and 25% 5 year NED when nodes were excised prior to primary irradiation therapy.

Malignant squamous papillomatosis of the mastoid.

Benign squamous papilloma of the external ear is rarely reported in the literature. This paper describes the occurrence of an extensive benign squamous papillomatosis of the mastoid that showed an apparent malignant transformation with fatal results to the patient.

The pathogenesis, differential diagnosis, and treatment of malignant otitis externa.

Three cases of malignant external otitis with varied clinical causes are presented. It is most important to suspect the condition in any diabetic who has external otitis refractory to the usual treatment. Once the diagnosis is made, aggressive medical management is imperative to prevent progression of the disease.