Is image interpretation in drug-induced sleep endoscopy that reliable?

PURPOSE: Previous studies have assessed drug-induced sleep endoscopy (DISE) as an interobserver reliable exam, with a learning curve effect. The objective was to check its assumed interobserver agreement and variability of between two groups of experienced and inexperienced French ENT physicians. METHODS: Prospective study. Seventy-six French ENT physicians (69 inexperienced in DISE and seven experienced) observed seven DISE videos. They were asked to determine the level(s), the configuration, and the degree of collapse, according to the VOTE classification. Specific and global agreements using the Fleiss' Kappa coefficient (k) were calculated. RESULTS: The interobserver agreement varied from poor to good in determining the level; the best agreement being found for the oropharynx (global agreement = 0.82 and k = 0.6 in the experienced group, global agreement = 0.87 and k = 0.7 in the inexperienced group), followed by the soft palate and the larynx; the worst agreement being found for the tongue base (k = 0.29 in the experienced group and k = 0.38 in the inexperienced group). The agreement for the configuration and the degree of collapse was moderate except for the tongue base where the concordance was poor. In both groups, agreement was at best good without any statistically significant difference between the two levels of experience groups. CONCLUSION: Even in a French ENT Sleep Experts group, DISE appears to be a technique with a limited interobserver agreement in the detection of obstructive sites, without any learning curve effect. In its current state, DISE interpretation may not be totally reliable.

Adult sleep apnea and tonsil hypertrophy: should pharyngoplasty be associated with tonsillectomy?

PURPOSE: Velopharyngoplasty and palatine tonsillectomy are at the very heart of the surgical treatment of obstructive sleep apnea syndrome (OSAS) care. In cases of major tonsil hypertrophy, we evaluated the relevance of associating soft palate surgery with palatine tonsillectomy, independent of the soft palate length. METHODS: We conducted a retrospective single-center study in OSAS patients with grade III or IV tonsils treated with tonsillectomy. Preoperative assessment included an upper airway examination performed while the patient was awake, a polysomnography and a drug-induced sedation endoscopy (DISE). Surgical efficacy was assessed on postoperative polysomnography. Success was considered when the postoperative apnea-hypopnea index (AHI) was less than 20 events/h with a 50% reduction. We compared palatine tonsillectomy efficacy alone (group A) and associated with soft palate surgery (group B). RESULTS: We analyzed 33 patients who had undergone surgery between December 2006 and May 2018. Their preoperative mean BMI and mean AHI were 27.3 ± 7.5 kg/m2 and 38.6 ± 21.4 events/h, respectively. The two groups (A, n = 18 and B, n = 15) were clinically comparable. The success rate was 72.2% in group A and 60% in group B. There was no statistically significant difference between the two groups (p > 0.1). CONCLUSIONS: According to this study, in our institution, in cases of major tonsillar hypertrophy, simultaneous soft palate surgery had no significant impact on the success rate, regardless of soft palate length. Associating soft palate surgery with palatine tonsillectomy does not seem mandatory to increase the success rate. LEVEL OF EVIDENCE: III. Retrospective comparative study.

Positive Impact of Genetic Test on the Management and Outcome of Patients With Paraganglioma and/or Pheochromocytoma.

CONTEXT: Pheochromocytomas and paragangliomas (PPGLs) are characterized by a strong genetic component, with up to 40% of patients carrying a germline mutation in a PPGL susceptibility gene. International guidelines recommend that genetic screening be proposed to all patients with PPGL. OBJECTIVE: Our objective was to evaluate how a positive genetic test impacts the management and outcome of patients with SDHx or VHL-related PPGL. DESIGN: We performed a multicentric retrospective study involving 221 propositi carrying an SDHB, SDHD, SDHC, or VHL germline mutation. Patients were divided into two groups: genetic patients, who were informed of their genetic status within the year following the first PPGL diagnosis, and historic patients, who only benefited from the genetic test several years after initial PPGL diagnosis. RESULTS: Genetic patients had better follow-up than historic patients, with a greater number of examinations and a reduced number of patients lost to follow-up (9.6% vs 72%, respectively). During follow-up, smaller (18.7 vs 27.6 mm; P = 0.0128) new PPGLs and metastases as well as lower metastatic spread were observed in genetic patients. Of note, these differences were reversed in the historic cohort after genetic testing. Genetic patients who developed metachronous metastases had a better 5-year survival rate than historic patients (P = 0.0127). CONCLUSION: Altogether, our data suggest that early knowledge of genetic status had a positive impact on the management and clinical outcome of patients with a germline SDHx or VHL mutation.

Parafoveal and optic disc vessel density in patients with obstructive sleep apnea syndrome: an optical coherence tomography angiography study.

AIMS: To compare optic disc perfusion, radial peripapillary capillaries (RPC) and macular vascular density, between normal subjects and subjects with obstructive sleep apnea syndrome (OSAS) using spectral-domain OCT angiography (OCTA). METHODS: Sixteen eyes of patients with mild OSAS, 17 eyes with moderate OSAS, 20 eyes with severe OSAS on polygraphy and 28 controls were evaluated with OCTA RT XR Avanti (AngioVue software, Optovue Inc., Fremont, CA). Optic nerve head (ONH), RPC and macular vessel density were measured. Clinical data, visual field parameters, and Spectral Domain OCT evaluation (retinal nerve fiber layer (RNFL) thickness and ganglion cell complex (GCC) thickness) were recorded for all patients. RESULTS: ONH vascular flow (p = 0,396), RPC vascular density (automatized data "whole" p = 0,913, "peripapillary" p = 0,539, and segmented analysis with a topographic grid) and macular vascular density (foveal p = 0,484, parafoveal p = 0,491) were not significantly different between the four groups. FDT-Matrix™ and Humphrey 24/2 mean deviation were significantly lower in eyes with severe OSAS and were correlated to the apnea-hypopnea index. Retinal nerve fiber layer (RNFL) thickness, Cup/Disc ratio, rim area, and ganglion cell complex (GCC) were not significantly modified. CONCLUSIONS: OCTA did not detect reduced ONH, RPC, neither macular blood vessel density in eyes with OSAS. The precise mechanisms that link OSAS with optic nerve pathologies remain unclear: our study was not able to demonstrate a vascular impact by OCTA examination.

Comparison of negative pressure wound therapy and conventional dressing methods for fibula free flap donor site management in patients with head and neck cancer.

BACKGROUND: Evaluation of the efficacy of negative pressure wound therapy in fibula free flap donor site management in head and neck cancer. METHODS: We conducted a single-center retrospective study from 2007 to 2013 comparing fibula free flap donor site healing time after conventional bolster dressing or negative pressure wound therapy. RESULTS: Thirteen patients were treated by conventional dressing and 16 patients were treated by negative pressure wound therapy. The mean graft loss rate was higher in the bolster group (37%) than in the negative pressure wound therapy group (19%). The mean total healing time was significantly shorter in the negative pressure wound therapy group than in the bolster group (67 days vs 163 days; p = .02). CONCLUSION: The use of negative pressure wound therapy for fibula free flap donor site management facilitates early patient mobilization, ensures better graft acceptance, and significantly decreases the healing time.

Upper Airway Stimulation for Obstructive Sleep Apnea: Durability of the Treatment Effect at 18 Months.

OBJECTIVE: To determine the stability of improvement in polysomnographic measures of sleep disordered breathing, patient reported outcomes, the durability of hypoglossal nerve recruitment and safety at 18 months in the Stimulation Treatment for Apnea Reduction (STAR) trial participants. DESIGN: Prospective multicenter single group trial with participants serving as their own controls. SETTING: Twenty-two community and academic sleep medicine and otolaryngology practices. MEASUREMENTS: Primary outcome measures were the apnea-hypopnea index (AHI) and the 4% oxygen desaturation index (ODI). Secondary outcome measures were the Epworth Sleepiness Scale (ESS), the Functional Outcomes of Sleep Questionnaire (FOSQ), and oxygen saturation percent time < 90% during sleep. Stimulation level for each participant was collected at three predefined thresholds during awake testing. Procedure- and/or device-related adverse events were reviewed and coded by the Clinical Events Committee. RESULTS: The median AHI was reduced by 67.4% from the baseline of 29.3 to 9.7/h at 18 mo. The median ODI was reduced by 67.5% from 25.4 to 8.6/h at 18 mo. The FOSQ and ESS improved significantly at 18 mo compared to baseline values. The functional threshold was unchanged from baseline at 18 mo. Two participants experienced a serious device-related adverse event requiring neurostimulator repositioning and fixation. No tongue weakness reported at 18 mo. CONCLUSION: Upper airway stimulation via the hypoglossal nerve maintained a durable effect of improving airway stability during sleep and improved patient reported outcomes (Epworth Sleepiness Scale and Functional Outcomes of Sleep Questionnaire) without an increase of the stimulation thresholds or tongue injury at 18 mo of follow-up.

Induction therapy with cetuximab plus docetaxel, cisplatin, and 5-fluorouracil (ETPF) in patients with resectable nonmetastatic stage III or IV squamous cell carcinoma of the oropharynx. A GERCOR phase II ECHO-07 study.

Induction TPF regimen is a standard treatment option for squamous cell carcinoma (SCC) of the oropharynx. The efficacy and safety of adding cetuximab to induction TPF (ETPF) therapy was evaluated. Patients with nonmetastatic resectable stage III/IV SCC of the oropharynx were treated with weekly cetuximab followed the same day by docetaxel and cisplatin and by a continuous infusion of 5-fluorouracil on days 1-5 (every 3 weeks, 3 cycles). The primary endpoint was clinical and radiological complete response (crCR) of primary tumor at 3 onths. Secondary endpoints were crCR rates, overall response, pathological CR, progression-free survival, overall survival, and safety. Forty-two patients were enrolled, and 41 received ETPF. The all nine planned cetuximab doses and the full three doses of planned chemotherapy were completed in 31 (76%) and 36 (88%) patients, respectively. Twelve (29%) patients required dose reduction. The crCR of primary tumor at the completion of therapy was observed in nine (22%) patients. ETPF was associated with a tumor objective response rate (ORR) of 58%. The most frequent grade 3-4 toxicities were as follows: nonfebrile neutropenia (39%), febrile neutropenia (19%), diarrhea (10%), and stomatitis (12%). Eighteen (44%) patients experienced acne-like skin reactions of any grade. One toxic death occurred secondary to chemotherapy-induced colitis with colonic perforation. This phase II study reports an interesting response rate for ETPF in patients with moderately advanced SCC of the oropharynx. The schedule of ETPF evaluated in this study cannot be recommended at this dosage.

Are the obstruction sites visualized on drug-induced sleep endoscopy reliable?

PURPOSE: Drug-induced sleep endoscopy (DISE) has been claimed to be a reliable tool, improving surgical results in obstructive sleep apnea syndrome (OSAS). One means of assessing reliability would be to ablate only a part of the sites observed on endoscopy and find only partial success versus ablating all observed sites and finding resolution of apnea. METHODS: A retrospective study included 24 OSAS patients, operated on following awake clinical examination. DISE was performed prior to surgery. Overnight sleep study was performed before and after surgery. Two groups of patients were obtained: success (postoperative apnea-hypopnea index (AHI) <10 and >50 % reduction in preoperative AHI) and failure. Obstruction sites found on DISE and those ablated or left after surgery were compared between the two groups. RESULTS: Mean AHI fell from 30.9 ± 12.4/h to 13.7 ± 14.2/h after surgery. In eight of the 14 patients in the success group, DISE showed an obstruction site not treated by surgery. In six patients out of the ten patients in the failure group, all DISE sites were treated by surgery, which nevertheless was not effective. Four patients had retrovelar concentric obstruction. CONCLUSION: DISE could in some cases explain surgical failure. However, it also seems to show additional obstruction sites which do not need to be treated. Proper knowledge of pharyngeal fluid dynamics and mastery of the DISE technique would probably help us understand better some of the DISE findings.

Long-term results of surgical treatment of vocal fold nodules.

OBJECTIVES/HYPOTHESIS: To evaluate the long-term outcome of patients with vocal fold nodules treated by surgery alone, or by a combination of surgery and voice therapy and to identify factors associated with long-term recurrent dysphonia. STUDY DESIGN: Retrospective study. METHODS: All patients who had undergone surgery for vocal fold nodules in a tertiary care hospital between 1996 and 2006 were contacted. After giving their consent, they were evaluated by videostroboscopic examination of vocal fold nodules and by a subjective questionnaire including the Voice Handicap Index (VHI). RESULTS: Sixty-two out of 90 patients (69%) (60 women, 2 men with a mean age of 33 years) answered the questionnaire at a mean interval of 9.5 years after surgery. Recurrent dysphonia was observed in 19 patients (30%) at a mean interval of 5.2 years after surgery and new benign vocal fold lesions (nodules or Reinke's edema) were observed in 11 patients (18%). Absence of postoperative voice therapy was significantly associated with a higher recurrence rate (P = 0.02) (56% of recurrent dysphonia without voice therapy versus 22% with voice therapy). CONCLUSIONS: Postoperative voice therapy decreases the risk of recurrence. Vocal fold nodules can recur over a period of 5 years, consequently requiring follow-up for at least 5 years in clinical practice and in future prospective studies.

Snoring intensity after a first session of soft palate radiofrequency: predictive value of the final result.

OBJECTIVES/HYPOTHESIS: To determine whether snoring sound intensity measured after a first soft palate radiofrequency (RF) session for simple snoring helps predict the final result of the treatment. STUDY DESIGN: Observational retrospective study. METHODS: We conducted a retrospective review of 105 subjects presenting with simple snoring or mild sleep apnea. All patients underwent two to three sessions of RF-assisted stiffening of the soft palate. In addition, uvulectomy was performed in case of a long uvula, and two paramedian trenches were created in the presence of palatal webbing. Snoring sound intensity was evaluated by the bed partner after each session. RESULTS: Eighty-six men and 19 women were included in the study. Mean age was 51.7 ± 9.8 years, and mean body mass index was 24.7 ± 4.4 kg/m(2) . The mean apnea/hypopnea index was 6.6 ± 4.2/h. The mean snoring sound intensity, as evaluated on a 10-cm visual analog scale (VAS), decreased from 8.2 ± 1.5 to 3.5 ± 2.2 after all sessions (P < .0001). A score of 3 was determined as being a score that satisfied the bed partner. Two groups were formed according to the final snoring sound intensity, using 3 as a threshold. Both groups had similar preoperative characteristics, but the snoring sound intensity was significantly lower after the first session in the group with final score <3 (P = .01). Similarly, a VAS score >7 after the first session was associated with a final score <3 in 30% of the cases. CONCLUSIONS: Snoring sound intensity after the first RF session helps predict the final outcome of RF-assisted stiffening of the soft palate for simple snoring.

Imaging work-up for screening of paraganglioma and pheochromocytoma in SDHx mutation carriers: a multicenter prospective study from the PGL.EVA Investigators.

CONTEXT: Recommendations have not been established concerning imaging to screen SDHx mutation carriers for paraganglioma and pheochromocytoma. OBJECTIVE: Our objective was to compare the performance of gadolinium-enhanced magnetic resonance angiography, contrast-enhanced computed tomography, and [(123)I]metaiodo-benzylguanidine and somatostatin receptor scintigraphies for detecting head and neck and thoracic-abdominal-pelvic paragangliomas in SDHx mutation carriers. DESIGN AND SETTING: We conducted a prospective, multicenter study from June 2005 to December 2009 at 23 French medical centers. PATIENTS: A total of 238 index cases or relatives carrying mutations in SDHD, SDHB, or SDHC genes were included. INTERVENTION: Images obtained by each technique were analyzed blind, without knowledge of results from other tests, first in each local center and then centrally. MAIN OUTCOME MEASURES: We evaluated sensitivity, specificity, and likelihood ratios for individual and combinations of tests, the gold standard being the consensus of an expert committee. RESULTS: Two hundred two tumors were diagnosed in 96 subjects. At local assessment, the sensitivity of anatomical imaging for detecting all tumors was higher (85.7%) than that of both scintigraphic techniques (42.7% for [(123)I]metaiodo-benzylguanidine and 69.5% for somatostatin receptor scintigraphy), except for thoracic localizations where somatostatin receptor scintigraphy was more sensitive (61.5 vs. 46.2% for anatomical imaging and 30.8% for [(123)I]metaiodo-benzylguanidine scintigraphy). The best diagnostic performance during local assessment was obtained by combining anatomical imaging tests and somatostatin receptor scintigraphy (sensitivity 91.7%). Central assessment significantly increased the sensitivity (98.6%) of tests in combination. CONCLUSIONS: In routine practice, the imaging work-up for screening SDHx mutation carriers should include thoraco-abdomino-pelvic computed tomography, head and neck magnetic angiography, and somatostatin receptor scintigraphy. Expert centralized image assessment is recommended.

Early detection of hypocalcemia after total/completion thyroidectomy: routinely usable algorithm based on serum calcium level.

BACKGROUND: The purpose of this prospective bicentric study was to investigate the course of serum calcium (Ca) and phosphorus (Phph) after total/completion thyroidectomy to establish a reliable and cost-effective strategic algorithm to detect patients at risk for postoperative hypocalcemia. METHODS: This observational study included 136 patients. Serum Ca and Phph levels were preoperatively and postoperatively recorded 6, 12, 20, and 48 h (H) after skin closure. Criteria for hypocalcemia were postoperative Ca levels ≤1.9 mmol/L at any time point and/or patients experiencing symptoms of hypocalcemia. Postoperative Ca supplementation was never given before H20 assay. Ca levels and their differences between time points were compared. RESULTS: Twenty-four percent of patients experienced hypocalcemia. At H12 and H20, the rates of patients with Ca levels ≤1.9 mmol/L were similar and larger than at H6 (p < 0.001). The H20-preoperative difference had the best area under the ROC curves (value = 0.87), and a difference ≤-0.3 was significantly more frequent in case of hypocalcemia (p = 0.001). The H20 assay and the difference H20-preop were consequently selected to design a new algorithm for hypocalcemia detection. Adding H48 assay in some specific cases (12.5 % of all included patients) enabled 100 % detection. Phosphorus assays were not informative in detecting hypocalcemia. CONCLUSIONS: This new algorithm enables, with 100 % sensitivity and 88.4 % specificity, early detection of severe hypocalcemia after total/completion thyroidectomy. It may become a useful and cost-effective tool for safe and early patient discharge, especially if PTH assays cannot be routinely used because of their availability or cost.

Sleep-disordered breathing: choosing the right cephalometric analysis.

PURPOSE: Cephalometry can be helpful for choosing the optimal treatment of sleep apnea. The presence or absence of maxillomandibular retrusion can contribute to the choice of treatment with an oral appliance or a skeleton-based or soft tissue surgery. To measure the position of the maxillomandibular complex, the analysis of Tweed has been cited most often. It uses dental landmarks. The analysis of Delaire relies on deeper skeletal points. The present study compared these 2 analyses for the diagnosis of maxillomandibular retrusion in a context of sleep-disordered breathing by determining the correlation between retrusion and the apnea-hypopnea index (AHI) for both methods. MATERIALS AND METHODS: A retrospective cohort study was conducted in a tertiary care university hospital. The population consisted of patients diagnosed with sleep-disordered breathing for whom polysomnographic and cephalometric data were available. Tweed and Delaire cephalometric analyses were performed for each case. The main outcome was the correlation between the degree of maxillomandibular retrusion and the AHI, as determined by Pearson coefficients. RESULTS: A total of 243 patients (42 females and 201 males) were included. For maxillary retrusion, the correlation coefficient with the AHI was -0.109 (P = .089) for Tweed and -0.160 (P = .012) for Delaire. For mandibular retrusion, the coefficient was -0.090 (P = .16) for Tweed and -0.201 (P = .002) for Delaire. Statistical significance was found only for the analysis of Delaire. CONCLUSION: The correlation between maxillomandibular retrusion and the AHI was better using the analysis of Delaire. If cephalometry is to be included in the workup of sleep-disordered breathing, the analysis of Delaire might be preferable.

Is snoring intensity responsible for the sleep partner's poor quality of sleep?

PURPOSE: This study aimed to determine if the intensity of breathing noise (including snoring) and/or the presence of abnormal breathing events (ABE) are factors that trigger arousal/awakening of a snorer's bed partner. METHODS: We conducted a prospective multicenter study investigating couples where the male had a chronic disturbing snoring. We simultaneously recorded the male's respiration and snoring and the female' sleep. We counted the number of arousals and awakenings during N2 sleep and randomly took nine of each. Then, for periods before, during, and after each arousal and awakening, we observed on the respiratory tracings what was happening in terms of breathing noise intensity and presence/absence of snoring and/or ABE. RESULTS: Thirteen couples were analyzed. The intensity of breathing noise and the presence/absence of snoring and/or ABE were comparable before and at initiation of arousal/awakening and between arousal and awakening. However, breathing volume intensity was lower and the presence of snoring and/or ABE was less frequent when the bed partner returned back to sleep from awakening compared to the other periods (p always <0.001). CONCLUSIONS: The intensity of breathing noise or the presence of ABE does not seem to be essential to trigger an arousal or an awakening. However, the persistence of noise or events may prolong the duration of wakefulness during the sleep period and could be one factor that explains the bothersome snoring.

Does propulsion mechanism influence the long-term side effects of oral appliances in the treatment of sleep-disordered breathing?

BACKGROUND: Mandibular advancement appliances (MAAs) can be used to treat sleep-disordered breathing, and differences in their designs have been thought to influence the occurrence of secondary effects. With bibloc devices, the lateral attachments producing mandibular propulsion can be inserted to generate traction or compression. We evaluated the clinical impact of this difference by comparing the long-term secondary effects and compliance of two devices. METHODS: One hundred sixty-two records of patients fitted with a traction-based or compression-based MAA before January 2008 were reviewed retrospectively for physical examination findings and cephalometry. Patients were sent a postal survey and contacted by phone 2 weeks later. They were offered a follow-up medical visit with repeat cephalometry. Main outcomes were long-term (> 2 years) secondary effects, compliance, or satisfaction. RESULTS: Of the patients who attended the follow-up visit, 48 had worn the MAA for > 2 years (16 traction based and 32 compression based), and nine for < 6 months (used as control subjects). Mean follow-up times for the traction and compression groups were 3.7 ± 1.2 years and 3.6 ± 1.2 years, respectively. No difference was found between the MAAs for subjective and objective side effects, except for greater early pain to the masticatory muscles (P = .02) and residual tongue pain (P = .04) in the compression group. However, pain intensity was low and clinical relevance was uncertain. No difference was found for compliance, satisfaction, and objective or subjective efficacy. CONCLUSIONS: This study suggests that traction-based appliances are similar to compression-based devices with regard to secondary effects and compliance.

[Obstructive sleep apnea syndrome]. / Syndrome d'apnées obstructives du sommeil.

Obstructive sleep apnea syndrome is a common disorder associated with potentially severe complications. Polysomnography is the gold standard diagnostic tool, while CPAP ventilation is recognized as the most efficient therapy. The numerous symptoms, even though little specific, should be rapidly detected to screen for the syndrome and transfer the patient to an adequate healthcare facility. The severity of the condition depends on the complications it causes.

The tongue-retaining device: efficacy and side effects in obstructive sleep apnea syndrome.

STUDY OBJECTIVES: The tongue-retaining device is a customized monobloc oral appliance used in the treatment of obstructive sleep apnea syndrome (OSAS). This study evaluated tongue-retaining device efficacy and its tolerance by patients with OSAS. METHODS: The charts of 84 apneic patients were retrospectively analyzed, and patients were contacted by telephone to answer an oral questionnaire. The median follow-up time was 5 years. RESULTS: Based on the apnea-hypopnea index, a complete or partial response was obtained in 71% of the cases. The mean apnea-hypopnea index decreased significantly from 38 to 14 (p < 0.001) with the tongue-retaining device. The subjective intensity of snoring decreased by 68% (p < 0.0001) and the Epworth Sleepiness Scale score decreased from 9 to 6 (p < 0.05). An age of more than 60 years associated with a mandibular protrusion distance inferior or equal to 7 mm was predictive of a nonresponse (odds ratio [OR]: 7.25; 95% confidence interval [CI]: 1.43-36.7; p < 0.02). The compliance rate, as determined by answers to the questionnaire, was 52% after 5 years of follow-up. Nasal obstruction was a negative predictor of good compliance (OR: 6.94; 95% CI: 0.28-0.79; p < 0.005), whereas patients with Class I occlusion were more compliant than patients with Class II or III occlusions (OR: 3.83; 95% CI: 1.00-2.81; p < 0.05). CONCLUSIONS: Tongue-retaining device performance tended to be similar to that of the mandibular advancement device. Thus, teams trained in tongue-retaining device fabrication and fitting may propose it as an alternative to continuous positive airway pressure, taking nasal obstruction into consideration as a contraindication.

Complications/adverse effects of maxillomandibular advancement for the treatment of OSA in regard to outcome.

OBJECTIVE: To evaluate adverse effects/postoperative complications and surgical response rate of maxillomandibular advancement for the treatment of severe obstructive sleep apnea syndrome. STUDY DESIGN: Case series with chart review. SETTING: Otolaryngology Head and Neck Surgery Department in a teaching hospital. SUBJECTS AND METHODS: A total of 59 consecutive severe sleep apnea patients underwent maxillomandibular advancement. Systemic complications were evaluated from medical charts. Functional adverse effects and cosmetic consequences were evaluated by questionnaires. The treatment outcome was assessed by polysomnography. RESULTS: Fifty patients were evaluated. They had a mean age of 46.4 +/- 9.0 years. No serious postoperative complication was observed. The most frequent local complication was mental nerve sensory loss. Most patients reported cosmetic changes. The mean apnea-hypopnea index decreased from 65.5 +/- 26.7 per hour to 14.4 +/- 14.5 per hour (P < 0.0001). Light-sleep stages were also decreased (P < 0.0001), whereas deep-sleep stages were increased (P < 0.001). CONCLUSION: Maxillomandibular advancement can induce local adverse effects and cosmetic changes, but they seem to be considered as secondary to the patients according to the surgical outcome.

The succinate dehydrogenase genetic testing in a large prospective series of patients with paragangliomas.

CONTEXT: Germline mutations in SDHx genes cause hereditary paraganglioma. OBJECTIVE: The aim of the study was to assess the indications for succinate dehydrogenase (SDH) genetic testing in a prospective study. DESIGN: A total of 445 patients with head and neck and/or thoracic-abdominal or pelvic paragangliomas were recruited over 5 yr in 20 referral centers. In addition to classical direct sequencing of the SDHB, SDHC, and SDHD genes, two methods for detecting large genomic deletions or duplications were used, quantitative multiplex PCR of short fluorescent fragments (QMPSF) and multiplex ligation-dependent probe amplification (MLPA). RESULTS: A large variety of SDH germline mutations were found by direct sequencing in 220 patients and by QMPSF and MLPA in 22 patients (9.1%): 130 in SDHD, 96 in SDHB, and 16 in SDHC. Mutation carriers were younger and more frequently had multiple or malignant paraganglioma than patients without mutations. A head and neck paraganglioma was present in 97.7% of the SDHD and 87.5% of the SDHC mutation carriers, but in only 42.7% of the SDHB carriers. A thoracic-abdominal or pelvic location was present in 63.5% of the SDHB, 16.1% of the SDHD, and in 12.5% of the SDHC mutation carriers. Multiple paragangliomas were diagnosed in 66.9% of the SDHD mutation carriers. A malignant paraganglioma was documented in 37.5% of the SDHB, 3.1% of the SDHD, and none of the SDHC mutation carriers. CONCLUSIONS: SDH genetic testing, including tests for large genomic deletions, is indicated in all patients with head and neck and/or thoracic-abdominal or pelvic paraganglioma and can be targeted according to clinical criteria.