The long-term results of modified maxillomandibular advancement in Asian OSA patients.

OBJECTIVE: Maxillomandibular advancement (MMA) surgery is considered a highly successful treatment for obstructive sleep apnea (OSA). Various modifications to the technique have been described. We aim to study the long-term results in Asian patients who underwent a modified MMA procedure intended to avoid bimaxillary protrusion and which involved four-quadrant bicuspid extractions with posterior maxillary alveolar setback. METHOD: A review of operative logs from 2000 to 2003 was conducted to identify Asian patients who underwent modified MMA during that period, for treatment of moderate and severe OSA. Sleep indices and psychometric performances were prospectively analyzed. RESULTS: Eight Asian patients were included. The mean length of follow-up was 14.4 years (range: 13.0-16.5). Mean preoperative apnea-hypopnea index (AHI) was 48.9 (range: 19.0 to 84.8). Mean post-operative AHI was 31.6 (range: 6.2 to 79.5). This reduction was statistically significant (p<0.05). Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire (FOSQ) revealed that majority of the patients (75%) did not have excessive daytime somnolence and all patients had high FOSQ totalled scores (mean 17.7, range 11.8 to 20), indicating good functional performance. CONCLUSION: This series is the longest follow-up of an Asian cohort who underwent modified MMA. With a mean follow-up of 14.4 years, improvement in AHI is still observed but not at a degree as large as prior studies with shorter lengths of follow-up. The purported efficacy of MMA for Caucasian patients may not be reproducible in Asian patients and long-term sustainability of this treatment's efficacy requires rigorous evaluation.

Genioglossus Advancement and Hyoid Surgery.

The structure and dimensions of the mandible, tongue, and hyoid complex are important variables in the pathophysiology of obstructive sleep apnea at the hypopharyngeal level. Genioglossus advancement is based on mandibular osteotomy, which brings the genioglossus muscle (GGM) forward and prevents posterior collapse during sleep. The genioglossus advancement technique has recently undergone several modifications; each has attempted to minimize surgical morbidity while improving the incorporation and advancement of the GGM. The hyoid bone has been of interest in sleep apnea and apnea-related surgical procedures because of its integral relationship with the tongue base and hypopharynx. Hyothyroidopexy is illustrated.

Advances in Box Surgery for Obstructive Sleep Apnea: Genioglossus Advancement, Hyoid Suspension, and Maxillomandibular Advancement.

Box surgery for obstructive sleep apnea (OSA) patients consists of mandibular surgery, including genioglossus advancement, hyoid suspension, and maxillomandibular advancement, as an airway reconstruction. This surgery was developed in the early 1980s. Thereafter, techniques were modified in each surgery for the enhancement of outcome and prevention of complications. However, the indication for surgery remains poorly defined due to the dynamicity of the upper airway, variability of the phenotype in OSA patients, and absence of a representative method for the obstruction site in the upper airway. As a result, box surgery is performed restrictively. On the development of an evaluation method including radiologic and endoscopic examination during sleep, the indications and surgical outcomes of each box surgery should be standardized and reevaluated. In this review, the development and limitations of box surgery will be discussed for the positive future of this surgery.

Evaluation of recurrent nodal disease after definitive radiation therapy for nasopharyngeal carcinoma: diagnostic value of fine-needle aspiration cytology and CT scan.

BACKGROUND: Recurrent nodal disease in patients with nasopharyngeal carcinoma (NPC) after definitive radiotherapy presents a difficult clinical problem. This cohort of patients poses a diagnostic challenge to the head and neck surgeon because evaluation of the post-irradiated neck, both clinically and radiologically, is known to be difficult, and it is not uncommon for neck dissection specimen in suspected recurrent nodal disease to contain no viable tumor cells. Currently, there is no well-accepted method for the preoperative determination of the presence of malignancy in these nodal diseases. METHODS: Over a 7-year period in a tertiary hospital, we systematically reviewed the clinical charts of 42 patients with NPC who were diagnosed with suspected recurrent nodal disease, after radical definitive radiotherapy. Fine-needle aspiration cytology (FNAC) was performed on clinically palpable nodes and results were correlated with final histopathologic results. Findings on CT scan were also correlated with final histopathologic specimens. RESULTS: The specificity and sensitivity of FNAC was 75.0% and 75.0%, respectively. The positive and negative predictive value of FNAC was 93.8% and 37.5%, respectively. CT scan had a positive predictive value of 78.6%. The negative predictive value for multilevel involvement on CT scan was 20%. CONCLUSION: Radiological imaging and FNAC are useful diagnostic modalities in assessing recurrent nodal disease in the post-irradiated neck in patients with NPC. Although routine CT scan criteria for pathologic lymphadenopathy cannot be accurately applied in the post-irradiated neck, it is a useful surveillance tool in the routine follow-up of patients with post-irradiated neck with NPC. Clinicians, however, must understand their limitations when assessing these patients. The possibility of negative neck dissection must be conveyed to the patients.

Idiopathic submandibular sialoceles in the neck.

A submandibular sialocele is a subcutaneous cavity containing saliva. The clinical and radiologic features of 3 patients with an idiopathic submandibular sialocele are presented. All 3 patients were males in their twenties. Submandibular sialocele presents as a soft cystic and compressible neck mass, with no history of previous trauma or diseases of the salivary gland. Computed tomography (CT) of the neck revealed a homogenous lesion with enhancing rim. The lesion appeared to be insinuating into the surrounding tissue. Excision of the sialocele, leaving the submandibular gland intact, was performed for the first patient. Recurrence of a neck mass occurred after 4 months. Complete excision of the sialocele with associated submandibular gland was subsequently performed. There was no recurrence after a follow-up period of 3 years. Excision of gland and sialocele was performed for the other 2 patients. There was no recurrence after a follow-up of 2 years and 10 months, respectively.

Pseudocyst of the auricle: a histologic perspective.

OBJECTIVE: The aim of the study is to describe the histologic spectrum in the pseudocyst of the auricle and to identify any consistent histologic features of this condition. STUDY DESIGN: A prospective study was performed in which the tissue specimen from patients with pseudocyst of the auricle treated at the Department of Otolaryngology, Singapore General Hospital during a 1-year period was sent for histology. METHODS: Consecutive patients with pseudocyst of the auricle who were treated had their tissue specimen sent for histology. These specimens were independently reviewed by one consultant pathologist. RESULTS: All 16 specimens revealed an intracartilaginous cyst devoid of epithelial lining. Interestingly, there were consistent perivascular mononuclear infiltrates of lymphocytes evident in the connective tissue layer just superficial to the anterior segment of the cartilage. CONCLUSION: Pseudocyst of the auricle is a benign condition predominantly affecting young Asian males. Histology characteristically reveals an intracartilaginous cyst devoid of epithelial lining, and there are no pathognomonic features. We postulate that an inflammatory response is crucial to the development of this condition on the basis of a consistent perivascular inflammatory response seen in all our specimens.

Modified maxillomandibular advancement for the treatment of obstructive sleep apnea: a preliminary report.

OBJECTIVE: A prospective study to evaluate the modified maxillomandibular advancement (MMA) technique for the treatment of obstructive sleep apnea (OSA). METHODS: Eleven patients underwent modified MMA for the treatment of OSA. All the patients underwent presurgical and postsurgical polysomnography, nasolaryngoscopy, and clinical facial photographic assessment. The results were analyzed after a minimum of 6 months postsurgery (mean, 7.7 months). RESULTS: The preoperative polysomnography results were as follows: apnea index, 55.7 +/- 19.8; apnea-hypopnea index, 70.7 +/- 15.9; lowest oxygen saturation, 58.6 +/- 12.3%; longest apnea/hypopnea, 67.9 +/- 23.7 seconds; and arousal index, 47.1 +/- 18.2. The postoperative polysomnography results were as follows: apnea index, 3.4 +/- 3.4; apnea/hypopnea index, 11.4 +/- 7.4; lowest oxygen saturation, 83.9 +/- 8.8%; longest apnea/hypopnea, 38.2 +/- 24.6 seconds; and arousal index, 15.1 +/- 7.3. The mean postoperative body mass index (BMI) was 27.2 +/- 3.3. The mean BMI change after surgery was 6.5%. CONCLUSION: The preliminary review has demonstrated that the modified MMA technique for the treatment of OSA is highly effective in the treatment of severe OSA without the significant facial profile change commonly associated with the traditional MMA technique.

The physiologic impact of sleep apnea on wakefulness.

The physiologic impact of sleep apnea on wakefulness is believed to be mediated by sleep fragmentation secondary to airway obstruction. Although there has been much study on the association between sleep apnea and daytime sleepiness, little is known about the effects of sleep apnea on non-sleepiness-related manifestations of impaired wakefulness, such as fatigue and depression. Present studies suggest that impaired wakefulness secondary to sleep apnea probably plays a contributory role in traffic and industrial accidents.

Parotid gland surgery: 4-year review of 118 cases in an Asian population.

BACKGROUND: To determine the presentation and management of parotid lesions requiring excision in a largely Chinese Asian population. METHODS: Retrospective study of 118 consecutive parotidectomies. RESULTS: Thirty-seven percent were Warthin's tumor (WT), 33% pleomorphic adenoma (PA), 21% other benign disease (OBD), and 9% malignant tumor (MT). Mean age was significantly different between benign (51 years) and malignant (40 years) lesions. MT decreased above 50 years, but increased five times with pain and two times with a noninferior pole lesion. Sensitivity of fine-needle aspiration (FNA) for differentiating benign from MT = 78%, for WT =5 8%, for PA =82%, for OBD = 28%, and for MT = 38%. CT scans did not alter WT management. Facial nerve (FN) paresis was not associated with histology, tumor size, site, or parotidectomy type. CONCLUSIONS: This is the first report documenting that most benign parotid tumors are WT and not PA. MT risk is greater in those less than 50 with pain and a noninferior pole lesion. Cystic lesions such as WT require great care in the evaluation of FNA findings.

Endovascular treatment of epistaxis in patients irradiated for nasopharyngeal carcinoma.

Posterior epistaxis commonly occurs after radiotherapy for nasopharyngeal carcinoma and is difficult to treat. Endovascular treatment was carried out on 11 previously irradiated patients who presented with intractable epistaxis over 4 years. We review their outcomes. All had significant angiographic abnormalities. Ten patients underwent intra-arterial embolization and, in one patient, balloon occlusion of an arterial pseudo-aneurysm was performed. Two patients (18%) suffered permanent neurological deficits. Two (18%) required further embolization in the first 2 days and one (9%) after the first month. One patient (9%) is still alive 4 years later. Only three (27%) died from haemorrhage. The mean survival duration after treatment was 225 days. Post-radiation anatomical changes often make conventional treatment of epistaxis difficult. Endovascular treatment maps out aberrant vascular anatomy and identifies the offending vessel. Our results show that the survival benefit of this treatment outweighs the risks, as such haemorrhage is often fatal.

Cribriform-morular variant of papillary carcinoma: the sporadic counterpart of familial adenomatous polyposis-associated thyroid carcinoma. A case report with clinical and molecular genetic correlation.

The increased incidence of thyroid carcinomas in familial adenomatous polyposis (FAP) patients is well recognised. These thyroid neoplasms display distinctive clinicopathological features and generally show good prognostic outcome. Recently, unusual sporadic tumours that share the morphological features of FAP-associated thyroid carcinomas have also been described. In this report, we document a case of a thyroid tumour in a previously well, 46-year-old female. Histology revealed a circumscribed neoplasm composed of tubular, papillary, cribriform and solid areas. The pseudostratified columnar tumour cells showed occasional nuclear grooves and rare nuclear inclusions. Immunohistochemistry showed positive staining with antibodies to cytokeratin AE1/AE3, oestrogen and progesterone receptor proteins. Focal immunoreactivity was also noted with antibodies to thyroglobulin, epithelial membrane antigen, 34betaE12 and cytokeratin CK7. The absence of polyps on colonoscopy and germline mutation in the adenomatous polyposis coli (APC) gene provides evidence that this tumour represents the sporadic counterpart of FAP-associated thyroid carcinoma. The patient is well with no evidence of disease 7 months following resection of the tumour. The differential diagnoses and molecular genetics of this unusual tumour are discussed.