Positional awake nasoendoscopic pattern-based surgical decision for correction of retropalatal obstruction in OSA.

PURPOSE: To evaluate differential surgical interventions for obstructive sleep apnea (OSA) patients with single-level retropalatal based on the preoperative topographical diagnosis using nasoendoscopy with Müller's maneuver during supine position (MM-P). SUBJECTS AND METHODS: This case series included adult patients with OSA who showed a predominant single-level retropalatal collapse on MM-P. An anteroposterior pattern of collapse was managed by an anterior advancement procedure, while a transverse pattern of collapse was managed by lateral/anterolateral advancement procedures (double suspension sutures). A combined procedure was provided to the concentric type of collapse. All patients underwent evaluation of the polysomnography, Epworth Sleepiness Scale (ESS) values and snoring scores both preoperatively and 6-8 months after surgery. RESULTS: Among 102 patients, the most commonly reported pattern of collapse at the retropalatal level was the concentric pattern (48.04%) followed by the transverse pattern (27.45%). The AP-pattern of collapse was reported in 24.51%. In the postoperative follow-up visits, no early or late complications were reported. All included groups showed significant improvement in polysomnographic data (mean AHI and lowest O2 saturation level). Significant improvement of VAS of snoring was reported. The overall success rate was ˃90%. CONCLUSION: Preoperative differential diagnosis of OSA with MM-P allows for tailored surgical management. Tailored procedures could yield good surgical outcomes when patients are properly selected and the technique is chosen according to preoperative topographical diagnostic assessment. This study might provide an available less-costly and effective preoperative planning for OSA intervention. LEVEL OF EVIDENCE: 4.

Nasalance Changes Following Various Endonasal Surgeries

Abstract Introduction There is change in nasalance post endonasal surgery which is not permanent. Objectives The objective of this study is to evaluate the long-term nasalance changes following different types of endonasal surgeries. Methods We included in this study patients who underwent sinonasal surgery at the Otorhinolaryngology Department in Zagazig University Hospitals from February 2015 until March 2016. We divided the patients into two groups according to the surgeries they underwent: Group (A) was the FESS group and group (B), the septoturbinoplasty group.We checked nasalance using a nasometer before and after the sinonasal surgery. Results Nasalance increased at one month after the operation in both groups. However, it returned to nearly original levels within three months postoperatively. Conclusion FESS, septoplasty, and turbinate surgery may lead to hypernasal speech. This hypernasal speech can be a result of change in the shape and diameter of the resonating vocal tract. Hypernasal speech in these circumstances may be a temporary finding that can decrease with time. Surgeons should inform their patients about the possibility of hypernasality after such types of surgery, especially if they are professional voice users.

Nasalance Changes Following Various Endonasal Surgeries.

Introduction There is change in nasalance post endonasal surgery which is not permanent. Objectives The objective of this study is to evaluate the long-term nasalance changes following different types of endonasal surgeries. Methods We included in this study patients who underwent sinonasal surgery at the Otorhinolaryngology Department in Zagazig University Hospitals from February 2015 until March 2016. We divided the patients into two groups according to the surgeries they underwent: Group (A) was the FESS group and group (B), the septoturbinoplasty group. We checked nasalance using a nasometer before and after the sinonasal surgery. Results Nasalance increased at one month after the operation in both groups. However, it returned to nearly original levels within three months postoperatively. Conclusion FESS, septoplasty, and turbinate surgery may lead to hypernasal speech. This hypernasal speech can be a result of change in the shape and diameter of the resonating vocal tract. Hypernasal speech in these circumstances may be a temporary finding that can decrease with time. Surgeons should inform their patients about the possibility of hypernasality after such types of surgery, especially if they are professional voice users.

Use of autologous platelet-rich plasma in complete cleft palate repair.

OBJECTIVES/HYPOTHESIS: Evaluate the effect of topical application of autologous platelet-rich plasma (PRP) in primary repair of complete cleft palate and then compare the result with another group of patients using the same surgical technique, without application of PRP with regard to the incidence of oronasal fistula, velopharyngeal closure, and grade of nasality. STUDY DESIGN: Case control study. METHODS: This study was carried on 44 children with complete cleft palate with age range from 12 to 23 months. The children were divided into two age- and gender-matched groups: All children were subjected to the same technique of V-Y pushback repair of the complete cleft palate. In group A (22 children), the PRP prepared from the patient was topically applied between the nasal and oral mucosa layer during palatoplasty, whereas in group B (22 children) the PRP was not applied. RESULTS: All cases were recovered smoothly without problems. In group A, no oronasal fistula was reported, whereas in group B three patients (13.6%) had postoperative fistulae and two patients (9.1%) needed revision palatoplasty. At 6 months postoperative assessment, group A (with PRP application) showed significantly better grade of nasality (P = 0.024) and better endoscopic velopharyngeal closure (P = 0.016) than group B. CONCLUSION: Usage of autologous PRP in complete cleft palate repair is simple; effective; can decrease the incidence of oronasal fistula; and also significantly improves the grade of nasality and velopharyngeal closure, which decreases the need of further surgical intervention in cleft palate patients. LEVEL OF EVIDENCE: 3b. Laryngoscope, 126:1524-1528, 2016.

Voice Changes after Late Recurrent Laryngeal Nerve Identification Thyroidectomy.

OBJECTIVES: To assess voice changes in patients after thyroidectomy where the recurrent laryngeal nerve (RLN) was found late in the thyroid dissection and where the RLN was not injured (late RLN identification technique). METHODS: This study was conducted on 64 patients who underwent thyroidectomy by late RLN identification technique. Voice was assessed preoperatively, 1 week, 3 months, and 6 months after surgery using the voice assessment protocol and Voice Problem Self-Assessment Scale. The study group was divided into two subgroups (hemithyroidectomy: N = 13 and total thyroidectomy: N = 51). Voice assessments of both subgroups were then compared with a control group (N = 20) of patients who recently underwent extracervical surgeries. RESULTS: All voice analysis differences between the control group and the individual study subgroup were nonsignificant. Dysphonia in the study group was significantly worse at 1 week and 3 months postoperatively but became nonsignificant at 6 months postoperatively. The deviations from the preoperative acoustic analysis were significant only in the first week postoperative comparison for fundamental frequency, noise-to-harmonic ratio, and maximal phonation time and thereafter became nonsignificant. Significant Voice Problem Self-Assessment Scale mean score increase (worsening) was also detected only at first week postoperatively. CONCLUSION: Minimal voice changes were reported early after late RLN identification thyroidectomy in absence of RLN injury and disappeared gradually in a few months. Those changes are comparable with that of other extracervical surgeries, making thyroidectomy with late RLN identification a relatively safe technique as regard voice.

Laryngeal Compensation for Voice Production After CO2 Laser Cordectomy.

OBJECTIVES: Carbon dioxide (CO2) laser cordectomy is considered one of the modalities of choice for treatment of early glottic carcinoma. In addition to its comparable oncological results with radiotherapy and open surgical procedures, it preserves of laryngeal functions including voice production. The aim of this study was to detect how the larynx compensates for voice production after different types of CO2 laser cordectomy for early glottic carcinoma together with assessment of the vocal outcome in each compensation mechanism. METHODS: One hundred twelve patients treated with CO2 laser cordectomy were classified according to their main postoperative phonatory site. Perceptual analysis of voice samples using GRBAS (grade, roughness, breathiness, asthenia, and strain) scale was done for 88 patients after exclusion of the voice samples of all female patients to make the study population homogenous and the samples of 18 male patients due to bad quality (4 patients) or unavailability (14 patients) of their voice samples and the results were compared with those obtained from control group that included 25 age-matched euphonic male subjects. RESULTS: Five types of laryngeal compensation were defined including: vocal fold to vocal fold, vocal fold to vocal neofold, vocal fold to vestibular fold, vestibular fold, to vestibular fold, and arytenoids hyper adduction. Characters changes of voice produced by each compensation type were found to be statistically significant except for breathiness, asthenia and strain changes in vocal fold to vocal fold compensation type. CONCLUSION: The larynx can compensate for voice production after CO2 laser cordectomy by five different compensation mechanisms with none of them producing voice quality comparable with that of controls.

Comparison between laser- and diathermy-assisted posterior cordotomy for bilateral vocal cord abductor paralysis.

IMPORTANCE: A reliable procedure is needed to solve the problem of difficult airway in patients with bilateral vocal cord paralysis without adversely affecting patient "voice quality." OBJECTIVES: To compare the results of laser-assisted posterior cordotomy with diathermy-assisted posterior cordotomy for bilateral vocal cord paralysis in regard to dyspnea severity, voice quality, and aspiration. DESIGN: Prospective randomized clinical trial at a university medical center. SETTING: Zagazig University Hospitals, Zagazig, Egypt. PARTICIPANTS: Twenty patients randomly categorized into 2 groups; group A was treated with laser-assisted posterior cordotomy and group B was treated with diathermy-assisted posterior cordotomy. INTERVENTION: Laser-assisted posterior cordotomy for group A and diathermy-assisted posterior cordotomy for group B. MAIN OUTCOME AND MEASURE: Dyspnea severity, voice quality, and aspiration. RESULTS: A significant difference (P < .05) was found between group A and group B at all postoperative comparisons in dyspnea, whereas no significant difference (P ≥ .05) was detected at all postoperative comparisons in voice quality. CONCLUSIONS AND RELEVANCE: Laser-assisted posterior cordotomy can be considered as a reliable and superior procedure compared with diathermy-assisted posterior cordotomy in the treatment of bilateral vocal cord abductor paralysis. TRIAL REGISTRATION: clinicaltrials.gov Identifier: ISRCTN08093874.

Posterior pharyngeal flap for velopharyngeal insufficiency patients: a new technique for flap inset.

OBJECTIVES/HYPOTHESIS: To describe a modification of the originally described superiorly based pharyngeal flap as a secondary operation to correct velopharyngeal insufficiency (VPI) in patients with nonsyndromic repaired cleft palate. STUDY DESIGN: Prospective clinical trial at university medical center. METHODS: Twenty-six patients with VPI after cleft palate repair underwent a modified posterior pharyngeal flap procedure. Patients with submucous cleft palate or associated with syndromic VPI or Pierre Robin sequence were excluded from the study. Flap was harvested high up in the nasopharynx and inserted into the soft palate through a transverse full-thickness palatal incision. Lateral pharyngeal ports were determined by 45-degree nasoendoscopy. Speech assessment was done preoperatively and 3 months postoperatively. The flap integrity and lateral pharyngeal ports were evaluated with postoperative nasoendoscopy. RESULTS: Postoperative speech assessment showed significant improvement in the overall velopharyngeal function, nasal emission, resonance, and articulation defects. The pattern of velopharyngeal closure was circular in 15 patients, coronal in six patients, and sagittal in five patients. Eighteen patients received medium to wide flap, five patients had narrow flap, and three patients had near obstructing flap. Velopharyngeal function was normal or borderline insufficiency in 24 patients (92%). Partial flap dehiscence was seen in two patients and was considered as failure despite the significant improvement in their preoperative VPI. CONCLUSIONS: The minimal complication and ease of flap design with precise flap inset make this modified superior flap technique easily applicable with a high success rate for patients with VPI after cleft palate repair.