Obstructive sleep apnea for the rhinologist.

PURPOSE: Obstructive sleep apnea (OSA) is a ubiquitous disease defined by repetitive partial or complete cessation of airflow during sleep caused by upper airway collapse. Otolaryngologists play a crucial role in the management of OSA, which is rapidly evolving with the advent of new surgical techniques and medical devices. Here we review the medical and surgical treatment options for OSA with a focus on unique considerations for patients with OSA who undergo nasal, sinus, and skull base surgery. RECENT FINDINGS: Treatment of OSA includes both nonsurgical and surgical options. Positive airway pressure (PAP) therapy remains the first-line medical treatment for OSA, but alternatives such as oral appliance and positional therapy are viable alternatives. Surgical treatments include pharyngeal and tongue base surgery, hypoglossal nerve stimulation therapy, and skeletal surgery. Nasal surgery has been shown to improve sleep quality and continuous positive airway pressure (CPAP) tolerance and usage. Sinus and skull base patients with comorbid OSA have special perioperative considerations for the rhinologist to consider such as the need for overnight observation and timing of CPAP therapy resumption. SUMMARY: OSA patients present with special considerations for the rhinologist. Patients with moderate to severe OSA may benefit from overnight observation after ambulatory surgery, especially those with an elevated BMI, cardiopulmonary comorbidities, and those who are not using CPAP regularly at home. Though CPAP may be safely resumed in the perioperative setting of nasal, sinus, and skull base surgery, the exact timing depends on patient, surgeon, and systemic factors such as severity of OSA, CPAP pressures required, extent of surgery, and the postoperative monitoring setting. Lastly, nasal and sinus surgery can improve sleep quality and CPAP tolerance and compliance in patients with OSA.

Patient's Perception of Nasal Function and Cosmesis After Maxillomandibular Advancement for Obstructive Sleep Apnea.

Background: Maxillomandibular advancement (MMA) remains one of the most effective surgeries for the treatment of obstructive sleep apnea (OSA), but it can be difficult to manage nasal and midfacial esthetics for patients requiring significant maxillary advancement. Objective: To evaluate changes in the Standardized Cosmesis and Health Nasal Outcomes Survey (SCHNOS) after the modified MMA approach. Methods: This prospective study was conducted on subjects undergoing MMA at a tertiary referral center from September 2020 to August 2021. Nasal function, cosmesis, and sleepiness were assessed perioperatively with the SCHNOS, visual analog scale for nasal function and cosmesis, and Epworth sleepiness scale (ESS). Objective polysomnography data were also investigated. Results: Thirty-one subjects met inclusion criteria. After MMA, SCHNOS-O (obstruction domain) improved from 44.38 ± 26.21 to 19.03 ± -4.75 (p < 0.001). The SCHNOS-C (cosmesis domain) improved significantly from 13.95 ± 19.32 to 5.27 ± 8.93 (p = 0.029). Specific items evaluating self-esteem, nasal straightness, and symmetry showed significant improvement (p = 0.006, 0.025, 0.044). The ESS also improved from 9.41 ± 6.11 to 3.26 ± 3.03 (p < 0.001), and it correlated with nasal obstruction scores. Conclusion: In this study, patients' perception of nasal obstruction and appearance improved after applying the nasal modifications to MMA described for OSA.

A Minimally Invasive Nasal Endoscopic Approach to Distraction Osteogenesis Maxillary Expansion to Restore Nasal Breathing for Adults with Narrow Maxilla.

Background: Patients with narrow high-arch palate present with limited response to standard septal, turbinate, and valve procedures for nasal obstruction. Objective: To measure the effectiveness of minimally invasive nasal endoscopic (MINE) Lefort I osteotomy among subjects with narrow high-arched palate in managing nasal obstruction. Methods: Prospective cohort study was performed where subjects with narrow high-arched palate underwent MINE distraction osteogenesis maxillary expansion (DOME) from August 2019 to January 2021. Nasal obstruction symptom evaluation (NOSE) score, mean time to opioid cessation, and mean duration of cranial nerve V2 hypoesthesia were evaluated. Results: Among 12 subjects, the. mean NOSE score decreased from 58.89 to 15.83 (p = 0.004). There were no complaints of lip mobility or deformity. Conclusion: MINE-DOME can reduce nasal obstruction in a certain phenotype of patients and further improve patient-centric outcomes by limiting the approach to the Lefort I osteotomy to an endoscopic nasal approach.

The Effect of Nasoseptal Flap Elevation on Post-Operative Olfaction and Sinonasal Quality of Life: A Prospective Double-Blinded Randomized Controlled Trial.

BACKGROUND: The use of nasoseptal flaps (NSF) for defect reconstruction in endoscopic endonasal approaches (EEA) to cranial base pathology has markedly reduced rates of cerebrospinal fluid leak. However, the effect of NSF use on post-operative olfaction remains unclear. OBJECTIVE: To evaluate the impact of NSF use during EEA on binarial and uninarial olfaction, and sinonasal quality of life (QOL). METHODS: This was a prospective double-blinded randomized controlled trial. Patients undergoing EEA for sellar pathology were recruited from the University of Pittsburgh Medical Center from December 2014 to May 2017. Subjects were randomized pre-operatively to a side of NSF harvest. Olfaction and QOL were assessed pre-operatively and 6 to 12 months post-operatively using the University of Pennsylvania Smell Identification Test, "Sniffin' Sticks," and Sinonasal Outcomes Test 22. The side of dominant uninarial olfaction was determined using "Sniffin' Sticks." RESULTS: Thirty-one patients were enrolled. Sixteen underwent EEA without NSF (control group) and 15 with NSF. A dominant side of olfaction was identified in 14 patients with NSF; 8 patients were randomized to NSF harvest on the dominant side and the remaining 6 on the non-dominant side. NSF elevation resulted in a 4% decrease in University of Pennsylvania Smell Identification Test scores, but was not statistically significant compared to controls. Similarly, NSF elevation on the side of dominant olfaction resulted in a 6% decrease, but was not statistically significant when compared to the non-dominant elevation group. Change in rhinologic QOL as determined by the Sinonasal Outcomes Test 22 was not significantly different between any of the groups. CONCLUSIONS: The use of NSF during EEA for sellar pathology does not have a significant effect on olfaction or rhinologic QOL. The presence of a dominant side of olfaction is not a primary consideration when deciding the side of NSF harvest.

Catastrophic Hemorrhage After Chemoradiation for Advanced Stage Oropharyngeal Carcinoma: A Case Series.

OBJECTIVES/HYPOTHESIS: We have seen several incidences of catastrophic bleeding in patients with advanced oropharyngeal squamous cell carcinoma treated nonoperatively. Aside from advanced disease, these patients have not had traditional risk factors for major hemorrhage. STUDY DESIGN: Retrospective chart review. METHODS: Patients treated nonoperatively for oropharyngeal squamous cell carcinoma were compared to determine characteristics that may predisposed to bleeding. Five patients with bleeding were identified and compared with a cohort of stage- and treatment-matched patients without bleeding. Blinded imaging review was performed to characterize the tumor site and its relationship to vasculature using standardized systems. RESULTS: Comparing the bleeder versus nonbleeder groups pre-treatment, the bleeder group had larger tumors (15.4 vs. 8.3 cm2 ), greater rates of parapharyngeal fat effacement (80% vs. 20%), and always involved the facial artery. Post-treatment, endophytic ulcerated tumor beds occurred in 100% of bleeders versus 0% of nonbleeders. CONCLUSIONS: Catastrophic oropharyngeal bleeding may be encountered after cytoreductive therapy. Large deeply invasive tumors seem to set the necessary circumstances. Rapid vascular control with interventional radiology has been largely effective therapy. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:1049-1052, 2021.

Can Ophthalmologic Examination Predict Abducens Nerve Recovery After Endoscopic Skull Base Surgery?

OBJECTIVES: While abducens nerve palsy (ANP) is a known risk in the setting of some endoscopic endonasal skull base surgery (ESBS), frequency and prognosis of post-operative palsy remain unknown. Our goals were to determine the frequency and prognosis of ANP after high-risk ESBS, and identify factors associated with recovery. METHODS: Retrospective case series of all patients with pathology at highest risk for abducens nerve injury (pituitary adenoma, chordoma, meningioma, chondrosarcoma, cholesterol granuloma) generated a list of patients with abducens nerve palsy after ESBS performed from 2011-2016. A validated ophthalmologic clinical grading scale measuring lateral rectus duction from 0 to -5 (full motion to inability to reach midline) was measured at multiple time points to assess recovery of ANP. RESULTS: Of 655 patients who underwent ESBS with increased risk of abducens injury, 40 (6.1%) post-operative palsies were identified and 39 patients with dedicated examination at multiple time points were included in subsequent analysis. Complete resolution was noted in 25 patients (64%) within 12 months. While 19 of 23 (83%) with a partial palsy had complete resolution, only six of 16 (38%) with a complete palsy resolved entirely (P = .005; Fisher's exact test). All six patients with delayed onset of palsy resolved (P = .070; Fisher's exact test). Meningioma and chordoma had higher rates of both temporary and permanent post-operative ANP (P < .0001; Fisher's exact). CONCLUSIONS: The frequency of post-operative ANP following ESBS is low, even in high-risk tumors. While only a minority of complete abducens nerve palsies recover, patients with partial or delayed palsy post-operatively are likely to recover function without intervention. LEVEL OF EVIDENCE: IV Laryngoscope, 131:513-517, 2021.

The Difficult Airway after Endoscopic Endonasal Skull Base Surgery: A Case Series and Management Algorithm.

OBJECTIVES: To analyze difficult airway situations affecting patients after endoscopic endonasal surgery (EES) for skull base tumors and to develop an airway management algorithm. STUDY DESIGN: Case series with chart review. SETTING: Single tertiary care center. SUBJECTS AND METHODS: Eleven difficult airway events occurred among patients after EES for skull base tumors, as identified through a retrospective review of our institutional Difficult Airway Management Team registry from January 2008 to March 2016. Data from these events included patient demographics, event characteristics, airway management techniques, and outcomes. Results were used to design a difficult airway protocol. RESULTS: The majority of patients were obese (63.6%) and had a dural defect (90.9%), each of which was repaired with a vascularized flap. The most common reasons for the difficult airway call were concern for using mask ventilation in a patient with a dural defect (27.3%) and difficult airway anatomy (27.3%). Two patients did not require airway intervention; 8 were intubated; and 1 underwent cricothyroidotomy. Videolaryngoscopy was the most common first-attempt intubation technique, followed by conventional direct laryngoscopy. Effective adjunctive techniques included intubation through a laryngeal mask airway and bougie-guided intubation. As compared with simple mask ventilation, laryngeal mask airway-assisted ventilation was associated with a decreased incidence of postevent cerebrospinal fluid leak. There were no incidences of postevent pneumocephalus, cardiopulmonary arrest, or mortality. CONCLUSIONS: We propose a difficult airway algorithm for patients following EES of the skull base, with sequential recommendations for airway management methods and commentary on adjunctive techniques.

Upper Airway Stimulation for Obstructive Sleep Apnea: Results from the ADHERE Registry.

Objective Upper airway stimulation (UAS) is an alternative treatment option for patients unable to tolerate continuous positive airway pressure (CPAP) for the treatment of obstructive sleep apnea (OSA). Studies support the safety and efficacy of this therapy. The aim of this registry is to collect retrospective and prospective objective and subjective outcome measures across multiple institutions in the United States and Germany. To date, it represents the largest cohort of patients studied with this therapy. Study Design Retrospective and prospective registry study. Setting Ten tertiary care hospitals in the United States and Germany. Subjects and Methods Patients were included who had moderate to severe OSA, were intolerant to CPAP, and were undergoing UAS implantation. Baseline demographic and sleep study data were collected. Objective and subjective treatment outcomes, adverse events, and patient and physician satisfaction were reviewed. Results The registry enrolled 301 patients between October 2016 and September 2017. Mean ± SD AHI decreased from 35.6 ± 15.3 to 10.2 ± 12.9 events per hour ( P < .0001), and Epworth Sleepiness Scale scores decreased from 11.9 ± 5.5 to 7.5 ± 4.7 ( P < .0001) from baseline to the posttitration visit. Patients utilized therapy for 6.5 hours per night. There were low rates of procedure- and device-related complications. Clinical global impression scores demonstrated that the majority of physicians (94%) saw improvement in their patients' symptoms with therapy. The majority of patients (90%) were more satisfied with UAS than CPAP. Conclusions Across a multi-institutional registry, UAS therapy demonstrates significant improvement in subjective and objective OSA outcomes, good therapy adherence, and high patient satisfaction.

Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series.

INTRODUCTION: An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments. METHODS: We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT). RESULTS: Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event. CONCLUSION: An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

Stridor and apnea as the initial presentation of primary hypoparathyroidism.

We present a previously undescribed case of stridor and apnea as the initial presentation of primary hypoparathyroidism. A neonate presenting with these symptoms was initially diagnosed with laryngopharyngeal reflux and laryngomalacia. After failing medical management, she underwent supraglottoplasty with improvement of stridor, but persistent apneic events. Further work-up showed severe hypocalcemia due to hypoparathyroidism. Subsequent genetic testing revealed a diagnosis of Bartter Syndrome Type V, a rare cause of primary hypoparathyroidism. Although uncommon, hypocalcemic tetany can present as apneic episodes in the setting of unrecognized primary hypoparathyroidism. Electrolyte abnormalities should be explored in neonates with recurrent apnea of unknown etiology.

Update on universal annual influenza immunization recommendations for children.

PURPOSE OF REVIEW: To provide an update of current recommendations and research findings on universal annual influenza immunization of children. RECENT FINDINGS: The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention and the American Academy of Pediatrics now recommend annual influenza vaccination for all children 6 months through 18 years. New research has examined the effect of 'herd immunity' associated with immunizing all school-aged children, the suboptimal antigenic match between the trivalent vaccine strains and circulating virus strains of last 2007-2008 influenza season, the efficacy of live attenuated influenza vaccine versus trivalent inactivated influenza vaccine, and the tolerance for influenza vaccine in infants less than 6 months of age. With a goal of improving the overall rates of influenza immunization and an eye toward the anticipated increase in volume with expansion of the universal recommendations in children, Advisory Committee on Immunization Practices and American Academy of Pediatrics emphasize the value of extending the timeframe for immunization beyond December and into April, establishing school-based immunization programs and other alternative vaccination sites outside medical homes, and conducting large, population-based studies that examine the overall impact of universal childhood influenza immunization. SUMMARY: Annual influenza vaccination recommendations have been expanded, and research continues on vaccine efficacy, administration, and cost associated with vaccinating all school-aged children.