Radiofrequency Ablation Turbinoplasty versus Microdebrider-Assisted Turbinoplasty: A Systematic Review and Meta-analysis.

OBJECTIVE: To critically review published literature for treatment-related outcomes for bilateral inferior turbinate reduction (IFTR) via either microdebrider-assisted turbinoplasty (MAT) or radiofrequency turbinoplasty. The primary outcomes were relief of nasal obstruction according to visual analog scale and nasal airflow, volume, and resistance measures based on acoustic rhinomanometry. DATA SOURCES: MEDLINE, EMBASE, The Cochrane Catalog, and CINAHL. REVIEW METHODS: The databases were searched with the terms "turbinoplasty" and "turbinate reduction." Inclusion criteria were English language, human subjects, and studies specifically relating to IFTR with radiofrequency turbinoplasty or MAT. Exclusion criteria were pediatric patients and concurrent nasal procedures. Results were tabulated, and the data were analyzed per random effects modeling. Subgroup analysis and quality assessment were also performed. RESULTS: A total of 976 articles were initially identified, with 26 meeting the inclusion/exclusion criteria. Random effects modeling demonstrated a significant improvement after IFTR, as measured with the visual analog scale (4.26-point improvement, 95% confidence interval [95% CI] = 3.32-5.20, P < .001, k = 21 studies, I(2) = 99%) and with acoustic rhinomanometry measurements of volume (2.43-cm(3) improvement, 95% CI = 0.48-4.38, P = .015, k = 6 studies, I(2) = 99%), flow (203-mL/s improvement, 95% CI = 131-276, P < .001, k = 4 studies, I(2) = 99%), and resistance change (2.78-Pa/cm(3) improvement, 95% CI = 0.433-5.13, P = .020, k = 5 studies, I(2) = 99%). There was no difference in outcome by technique, allergic rhinitis, or quality score. The 2 highest-quality papers favored MAT. The median follow-up was 6 months. CONCLUSIONS: IFTR produces a significant subjective and objective improvement in nasal airflow in the short term. This change does not appear to be related to the technique used for IFTR.

The effect of tonsillectomy alone in adult obstructive sleep apnea.

OBJECTIVE: The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). STUDY DESIGN: Prospective multi-institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. SETTING: Tertiary care medical centers within the US Department of Defense. SUBJECTS AND METHODS: Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea-hypopnea index (AHI), and lowest saturation of oxygen. RESULTS: A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate--with subjects achieving at least a 50% reduction of AHI to a value <15--was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. CONCLUSIONS: Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.

Maxillomandibular advancement and tracheostomy for morbidly obese obstructive sleep apnea: a systematic review and meta-analysis.

OBJECTIVE: The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m(2)) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes. DATA SOURCES: MEDLINE, Scopus, Web of Science, and the Cochrane Library. REVIEW METHODS: A search was performed from inception through April 8, 2014, in each database. RESULTS: Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m(2)) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m(2)) reported individual patient data. The pre- and post-MMA means ± SDs for apnea-hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h (P < .00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% (P < .00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre- and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h (P = .0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h (P = .22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% (P = .011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy (P = .0034). CONCLUSION: Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.

Inferior turbinate classification system, grades 1 to 4: development and validation study.

OBJECTIVES/HYPOTHESIS: To develop a validated inferior turbinate grading scale. STUDY DESIGN: Development and validation study. METHODS: Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales (>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive clinic patients (n = 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two independent raters, and grading was repeated by each of the same two raters, two separate times for each patient. RESULTS: In the development phase, 25% (grades 1-4) and 33% (grades 1-4) were the most useful systems. In the validation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to grade; the photo grading demonstrated a Cohen's kappa (κ) = 0.4671 ± 0.0082 (moderate inter-rater agreement). Live-patient grading with the 25% classification system demonstrated an overall inter-rater reliability of 71.5% (95% confidence interval [CI]: 64.8-77.3), with overall substantial agreement (κ = 0.704 ± 0.028). Intrarater reliability was 91.5% (95% CI: 88.7-94.3). Distribution for the 200 inferior turbinates was as follows: 25% quartile = grade 1, 50% quartile (median) = grade 2, 75% quartile = grade 3, and 90% quartile = grade 4. Mean turbinate size was 2.22 (95% CI: 2.07-2.34; standard deviation 1.02). Categorical κ was as follows: grade 1, 0.8541 ± 0.0289; grade 2, 0.7310 ± 0.0289; grade 3, 0.6997 ± 0.0289, and grade 4, 0.7760 ± 0.0289. CONCLUSIONS: The 25% (grades 1-4) inferior turbinate classification system is a validated grading scale with high intrarater and inter-rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior turbinates. LEVEL OF EVIDENCE: 2c.

Systematic review of complications of tonsillotomy versus tonsillectomy.

OBJECTIVE: Intracapsular tonsillotomy continues to gain acceptance as an alternative to traditional tonsillectomy. Despite large clinical studies, there is a lack of consensus as to which technique offers lower complication rates. This study seeks to analyze the available data and surmise the complication rates of partial tonsillectomy as compared with traditional tonsillectomy. Data Sources. MEDLINE was searched using multiple search terms. REVIEW METHODS: After the MEDLINE search, the following inclusion criteria were applied: English language, human subjects, and related to partial tonsillectomy. Multiple tonsillotomy techniques were included. The results of these studies were summated and the results analyzed. Subgroup analysis was then performed. RESULTS: Thirty-three studies met inclusion criteria. Tonsillotomy had a lower postoperative bleeding rate, lower postoperative dehydration rate requiring medical care, reduced days of analgesic use, and reduced days to return to normal diet compared with tonsillectomy. When separated into higher versus lower quality studies, the differences in bleeding and dehydration were negligible, while differences in return to diet and days of analgesic use persisted. Mean intraoperative blood loss was similar for both techniques. Insufficient data were available to assess tonsil regrowth rates. CONCLUSIONS: Tonsillotomy appears to be a safe technique that may offer some advantages over tonsillectomy in terms of postoperative morbidity, but differences in hemorrhage and dehydration were not evident in high-quality studies. Data regarding tonsil regrowth rates and efficacy in treating sleep-disordered breathing are not yet sufficient for formal analysis, which may preclude widespread acceptance of this technique.

Pleomorphic adenoma of the nasal cavity: a case report.

Pleomorphic adenomas of the nasal cavity are rare. We describe the case of a middle-aged white man who presented to our clinic with a long history of unilateral nasal obstruction. Preoperative imaging was performed, and the patient was taken to the operating room for endoscopic excision of the lesion. Surgical margins were negative. The patient's nasal obstruction resolved, and he was doing well at his first postoperative visit. The pathologic diagnosis was a pleomorphic adenoma. We discuss the features and management of this entity.

Airway management in pediatric epiglottitis: a national perspective.

OBJECTIVES: The purpose of this study was to describe current demographics and resource utilization in the treatment of pediatric epiglottitis. STUDY DESIGN: Case series from a national database. SUBJECTS AND METHODS: The Kids' Inpatient Database was systematically searched to extract patients under 19 years old admitted with a diagnosis of epiglottitis and undergoing an airway intervention. RESULTS: Three hundred forty-two sampled admissions were for epiglottitis; 40 of these patients were under the age of 19 and had an airway intervention (intubation or tracheotomy). On average, patients were 4.3 years old (SD = 6.0 years). The average length of stay was 15.6 days (SD = 33.9 and range = 0-199) with average total charges of $74,931 (SD = $163,387, range = $3342-$938,512). Multivariate analysis revealed that admission to a children's facility, admission other than via the emergency room, and nonemergent admission were associated with increased total charges. Twenty-two states reported an admission for pediatric epiglottitis that required airway intervention. CONCLUSIONS: In our sample, only 40 patients were identified who were under the age of 19 years and required an airway intervention for the treatment of epiglottitis. Epiglottitis is a rare, expensive, and protracted disease to treat in the postvaccine era. The unique nature of this disease has implications for training future surgeons on proper management of this potentially fatal disease.

Existence of important variations in the United States in the treatment of pediatric mastoiditis.

OBJECTIVE: To determine national variations in resource utilization in the treatment of pediatric mastoiditis. DESIGN: Retrospective review. SETTING: National pediatric inpatient database. PATIENTS: The Kids' Inpatient Database for 2003 was used to extract data for admissions for mastoiditis. RESULTS: A total of 1049 patients (57% were male, and the mean age was 6.3 years) were identified. Median total charges for an admission were $9600; total charges were less than $28,604 in 90% of admissions. The mean length of stay (LOS) was 4.3 days (range, 0-87 days). A total of 792 procedures were performed; 50.0% of patients underwent tympanostomy tube placement and/or myringocentesis, and 21.6% underwent mastoidectomy. The LOS for nonsurgical patients was 3.7 days. The LOS for children undergoing tube placement was 4.6 days, with mean total charges of $15,713; for mastoidectomy, the LOS was 5.5 days, with mean total charges of $23,185. The primary payer was private insurance in 51.5% and Medicaid in 39.4%. Predictors of increased charges were treatment at teaching hospitals (P = .005), treatment at children's hospitals (P < .001), LOS (P < .001), the number of procedures (P < .001), and hospital region (P = .003). Wide geographic variation was noted with respect to the mean total charges per admission, which ranged from $5016 to $35,898. CONCLUSIONS: In 2003, the median charge for a pediatric mastoiditis admission was $9600; 50% of patients underwent tympanostomy tube placement, and about 21.6% underwent a mastoidectomy. There was wide variation in total charges for admissions. Resource utilization was higher in teaching hospitals and in children's' hospitals.

Nonsurgical therapies for lymphangiomas: a systematic review.

OBJECTIVE: Systematically review the published literature regarding the efficacy of nonsurgical therapies in the treatment of head and neck (H&N) lymphatic malformations (LM) in children. DATA SOURCE: MEDLINE. REVIEW METHODS: MEDLINE was searched for literature relating to nonsurgical treatments for H&N LM. RESULTS: The initial search returned 1876 articles, with 22 meeting criteria. The majority (20) were case series. All therapies were percutaneous, with OK-432 or bleomycin sclerotherapy being most common. Random-effects modeling revealed 43% (CI = 28.9%-57%) of patients undergoing OK-432 for LM achieved a complete/excellent response, 23.5% (CI = 5.8%-41.3%) achieved a good response, 16.9% (CI = 10.3%-23.4%) achieved a fair/poor response, and 15.4% (CI = 8.6%-22.2%) observed no response. In the bleomycin group, the results were: 35.2% (CI = 15.7%-54.6%) excellent, 37.1% (CI = 22%-52.3%) good, 18.4% (CI = 2.7%-34.2%) fair/poor, and 11.6% (CI = 3.5%-19.6%) no response. Seven major complications were noted out of the 289 patients in the series, including two mortalities. CONCLUSIONS: The literature indicates that sclerotherapy for H&N LM achieves excellent/good clinical response in a majority of patients, with few complications, and anecdotally does not complicate future surgery.