Pharyngeal suspension suture with repose bone screw for obstructive sleep apnea.

OBJECTIVE: Multilevel surgery for obstructive sleep apnea syndrome (OSA) may improve success. This study's goal is to prospectively evaluate the feasibility and short-term subjective effectiveness of a new tongue-suspension technique. METHODS: A multicenter nonrandomized open enrollment trial used the Repose device to treat tongue obstruction in 39 snoring and OSA patients. Outcomes include 1- and 2-month subjective reports of general health, snoring, and sleep. RESULTS: Twenty-three patients completed 1 month and 19 completed 2 months of follow-up. In OSA patients, activity level, energy/fatigue, and sleepiness improved. Two-month outcomes were less (activity level, energy/fatigue, and sleepiness). Fewer changes were observed in snorers than in OSA patients. There were 6 complications (18%), including sialadenitis (4), gastrointestinal bleeding (1), and dehydration (1) after the procedure. CONCLUSION: A pharyngeal suspension suture changes subjective outcomes. Improvement is incomplete. The procedure is nonexcisional, but significant complications may occur. Further evaluation is required to demonstrate effectiveness.

Clinical photographs as teaching aids: how reliable are they?

A study to investigate the value and reliability of clinical photographs as teaching aids was undertaken. Twenty colour photographs were taken using the StarMed video-otoscopic system. The pictures, which were a mixture of normal and abnormal ears, were shown to 21 experienced otolaryngologists from the UK and Canada. These clinicians were asked to identify the abnormality if any. The median score for correctly identified pictures was 15 (range 12-18). This score was identical for both the UK and Canadian subgroups. Although the abnormalities were consistently well recognized with an average correct identification rate of 90 per cent (range 67-100 per cent), the 'normals' were recognized significantly less well at only 41 per cent (range 5-71 per cent) (chi-squared = 110.6; 1 df; p < 0.001). This result is probably due to failure of the camera to capture the huge variation and subtleties in the range of normal, and the clinicians' natural inclination to identify pathology, when in doubt. We would conclude that as long as this failing is recognized, clinical photographs, and specifically those from the video-otoscope, represent a useful and reliable teaching tool.

Ulcerated atherosclerotic plaques in the thoracic aorta are associated with cryptogenic stroke: a multiplane transesophageal echocardiographic study.

Atherosclerotic plaque ulcers > or = 2 mm in depth and width in the thoracic aorta have been implicated by autopsy study as a cause of unexplained or cryptogenic ischemic strokes. Transesophageal echocardiography (TEE) allows visualization of complex atherosclerotic lesions of the thoracic aorta. We compared the prevalence of thoracic aorta ulcerated plaques (ulcers > or = 2 mm in both depth and width) in three age-matched groups undergoing multiplane TEE: group 1, 23 patients with cryptogenic ischemic stroke; group 2, 26 patients with known-cause strokes; and group 3, 57 control patients without strokes. TEEs were interpreted in a blinded fashion. Ulcerated plaques were found in 9 (39%) group 1 patients but in only 2 (8%) group 2 patients and in only 4 (7%) group 3 patients (p < 0.001). There was an association between advancing age and the presence of ulcerated plaques (p < 0.02). We conclude that ulcerated atherosclerotic plaques in the thoracic aorta are associated with cryptogenic ischemic stroke and should be considered a potential source of cerebral emboli.

Diagnostic imaging of fungal sinusitis: eleven new cases and literature review.

Fungal sinusitis should always be considered in the differential diagnosis of chronic or recurring sinusitis resistant to adequate medical treatment. A high index of suspicion is necessary for the diagnosis, and the clinical examination is rarely conclusive. The definitive diagnosis depends on the pathologist in most cases. We reviewed retrospectively the imaging findings, specifically computed tomography (CT) and magnetic resonance (MR), in a series of fungal sinusitis patients. Non-enhanced CT scan is more sensitive than conventional X-ray in detecting the classical focal areas of hyper-attenuation and calcification seen in soft-tissue masses of fungal sinusitis. MR findings of hypo-intense signals on T1-weighted sequences which progress to signal-void area on T2-weighted sequences, are characteristic features of fungal sinusitis; however, it is reserved for cases where intracranial invasion is suspected or CT findings are inconclusive.

Continuous intrathoracic pressure monitoring with a new esophageal microchip catheter in sleep-related upper airway obstructions.

A new small-diameter microchip catheter, especially developed for continuous intrathoracic pressure monitoring to assess the degree of respiratory obstruction and effort in patients with sleep-related upper airway obstructions, was investigated. The technical performance and clinical applicability of the catheter was tested in a simplified screening study comprising 122 sleep recordings in patients with varying complaints of snoring and daytime tiredness. In six obese snorers, sensitivity of the catheter to apneas, hypopneas, and nonapneic snoring was compared to the traditional assessment of respiratory events by conventional polysomnography. The catheter was found to be easy to handle and introduce, with technical qualities meeting the demands for overnight recordings of intrathoracic pressure variations. Patient tolerance was high (93%), and sensitivity to apneas and hypopneas was equivalent to that of traditional polysomnography. Periods with upper airway obstruction and increased respiratory effort on the borderline between asymptomatic obstructions and obstructions resulting in significant blood-gas changes could be detected primarily with intrathoracic pressure monitoring. Monitoring the intrathoracic pressure variations in the esophagus has been shown previously to reflect respiratory effort. Increased respiratory effort might be one of the explanations for the fragmented sleep patterns and sleep related daytime symptoms sometimes seen in patients without a pathologic respiratory index. In addition to being applicable for the detection of apneas and hypopneas, continuous nocturnal monitoring of the intrathoracic pressure variations also detects small increases in respiratory effort and thus may constitute a valuable tool for the understanding and diagnosis of upper airway resistance syndrome and obstructive sleep apnea syndrome.

The influence of angiographically demonstrated coronary collaterals on the results of stress echocardiography.

Previous studies using thallium-201 scintigraphy have suggested that angiographic coronary collaterals can protect against the development of stress-induced perfusion abnormalities, but the effect of collaterals on stress echocardiography (SECHO) has not been determined. In this study, 21 consecutive patients referred for cardiac catheterization underwent SECHO and coronary angiography. Of the 21 study patients, there was a total of 16 significantly obstructed coronary arteries (> or = 70% stenosis) in 14 patients. SECHO revealed stress-induced wall motion abnormalities in the distribution of seven of nine obstructed coronary vessels without angiographic collaterals, but in only one of seven vessels with collaterals (p < 0.05). Six of eight obstructed vessels not associated with a stress-induced wall motion abnormality had collaterals, whereas only one of eight obstructed vessels associated with a stress-induced wall motion abnormality had collaterals. We conclude that (1) angiographically demonstrated coronary collaterals can protect against the development of stress-induced wall motion abnormalities despite the presence of a high-grade coronary artery obstruction, and (2) the lack of a stress-induced wall motion abnormality on SECHO in the perfusion territory of an obstructed vessel may suggest the presence of adequate collateral perfusion.

Continuing medical education interests of Canadian otolaryngologists.

A questionnaire was sent to Canadian otolaryngologists to assess their continuing medical education interests. One hundred and eighty-seven completed questionnaires were returned, a response rate of 28.5%. The categories of highest interest were nose/sinus, otology/vestibular, and general otolaryngology. Lower overall ratings were found for head and neck surgery and facial plastic/reconstructive surgery topics.

The early development of sino-nasal mucosa.

The development of human nasal mucosa was studied in 20 fetal heads between 8 and 24 weeks of gestation. Initially the nasal cavity is lined by a single layer of flattened cells, which produces two to three layers of undifferentiated spherical cells. Olfactory epithelium lines the cranial portion of the human fetal nasal cavity at 8 weeks of gestation. Pseudostratified ciliated cuboidal or columnar epithelium appears at 9 weeks of gestation in the nasal cavity and between 14 and 16 weeks of gestation in the primitive ethmoid sinuses and maxillary sinus infundibulum. Goblet cells and glandular acini appear between 12 and 14 weeks of gestation. Initially these goblet cells/glands are found predominantly in the anterior nasal cavity but are more evenly distributed at 24 weeks of gestation. The epithelial development of the nasal septum generally precedes that of the lateral nasal wall. This study documents nasal mucosal maturation and associated anatomic development in the human fetus.

The uncinate process: a histological and morphological study.

The uncinate process (UP) has become a familiar anatomical landmark to otolaryngologists due to the increasing popularity of functional endoscopic sinus surgery (FESS) in recent years. This study examines the histological and morphological features of UPs removed from a group of patients undergoing FESS operations for chronic sinusitis. The structure of the UP by light microscopy (LM) is reported. A relatively high proportion of goblet cells and seromucous glands was noted. Scanning electron microscopy (SEM) identified four surface cell types on the UP. Furthermore, four categories of surface morphology were noted. The most common appearance was of predominantly ciliated cells. A nonciliated surface ultrastructure is associated with a longer history of sinonasal symptoms and a higher incidence of surgical intervention.

Computer generated three-dimensional reconstruction of the bony labyrinth in Mondini's dysplasia.

The bony labyrinth obtained at necropsy in four cases was studied by a new computer-generated three-dimensional (3-D) system. One case was normal (control) and the other three were histopathologically confirmed cases of Mondini's dysplasia. In case 1, the cochlea had only 2 turns and the lateral semicircular canal did not make a circle but appeared as a spherical mass projecting from the utricle even though the posterior semicircular canal made a normal circle. In case 2, there were no turns in the cochlea even though the semicircular canals and the vestibule appeared normal. In case 3, the cochlea showed 1 to 1 and 1/2 turns and the semicircular canals were premature showing only bud-like projections. This 3-D imaging system, which utilizes the toggling method, provides a way of obtaining satisfactory images without markers, and the time required to obtain these 3-D images was reduced by using a video camera instead of a digitizer. One of the problems associated with the use of 3-D imaging is the long processing time. We resolved this by inputting the section images with a video camera and by picking up structures using density segmentation instead of tracing with a digitizer.

Maxillary sinus hypoplasia, embryology, and radiology.

Maxillary sinus hypoplasia has been observed in up to 10% of radiological studies of the face or head. Although this may be a coincidental finding, it has been associated with chronic sinusitis and facial pain. Associated abnormalities of the lateral nasal wall, orbit, and ostiomeatal complex are common. The importance of this condition is, first, in the differential diagnosis of an "opaque" maxillary sinus and, second, as a potential hazard to the orbit of such patients, should they undergo functional endoscopic sinus surgery.

Abnormal Valsalva blood pressure response in dilated cardiomyopathy: association with "pseudonormalization" of echocardiographic Doppler transmitral filling velocity pattern.

In patients with dilated cardiomyopathies, the presence of an abnormal blood pressure response to the Valsalva maneuver has been shown to correlate well with increased left-sided filling pressures. The presence of a "pseudonormalized" early peak to late peak velocity (E/A) ratio on echocardiographic Doppler transmitral filling pattern has also been correlated with increased left ventricular end-diastolic pressures in these patients. Since both abnormal blood pressure response to the Valsalva maneuver and a "pseudonormalized" Doppler transmitral E/A ratio probably represent elevated left ventricular filling pressure, we postulated that there would be a positive correlation between the two in a group of patients with dilated cardiomyopathy and abnormal systolic function. Twenty-five consecutive male patients with New York Heart Association (NYHA) class II to IV heart failure and dilated cardiomyopathy were included. Patients with abnormal blood pressure responses to Valsalva had significantly larger peak early (E) velocities, smaller peak late (A) velocities, and larger E/A ratios compared with patients with normal responses. E/A ratio < 1.0 was present in eight (100%) of the eight patients with a normal blood pressure response to the Valsalva maneuver and E/A ratio > 1.0 was present in 12 (71%) of 17 patients with an abnormal response (p < 0.01). This correlation supports the hypotheses of the physiologic mechanisms of these phenomena and also provides two noninvasive methods of evaluating left-sided filling pressures useful in the diagnosis and treatment of congestive heart failure caused by dilated cardiomyopathy.

The spectrum of thromboembolization in the central circulation.

The right heart and great veins can be the harbinger of septic and aseptic thromboemboli, which can result in a spectrum of clinical syndromes. This report presents five distinct clinical scenarios of thromboembolization, the occurrence of which in the central circulation resulted in life-threatening sepsis and hemodynamic and pulmonary insufficiency. Recommendations for therapeutic intervention and a review of the literature also are presented.