Thyroid gland invasion in total laryngectomy and total laryngopharyngectomy: a systematic review and meta-analysis of the English literature.

BACKGROUND: Advanced laryngeal and hypopharyngeal squamous cell carcinomas carry an inherent risk of invading thyroid parenchyma leading to the incorporation of a hemithyroidectomy or total thyroidectomy as part of a total laryngectomy. In some centres, thyroid gland removal occurs routinely during surgery for T3 and T4 laryngopharyngeal carcinoma. However, the incidence of invasion is low, and therefore, thyroid-sparing surgery must be considered for select cases. OBJECTIVE OF REVIEW: The primary goal of the review is to assess the true incidence of thyroid gland invasion in laryngopharyngeal carcinoma. Utilising this data we aim to identify risk factors and clinical predictors of thyroid gland invasion to facilitate in a more targeted approach in the surgical management of advanced laryngopharyngeal carcinoma. TYPE OF REVIEW: A systematic review and meta-analysis of all published data and review of case series at Newcastle upon Tyne Hospitals (NuTH). SEARCH STRATEGY: MEDLINE (1946-2012) and EMBASE (1980-2012) were searched. EVALUATION METHOD: A single reviewer conducted the systematic review with a follow-up ancestry search. Studies publishing case series of T3 and T4 laryngeal and hypopharyngeal carcinoma treated by total laryngectomy or laryngopharyngectomy and partial or total thyroidectomy, with pathological assessment for thyroid gland invasion rates were selected. Articles published prior to 1977 were excluded due to the advent of whole organ sectioning. RESULTS: The literature search identified 16 studies suitable for inclusion, with 1180 cases. The NuTH case series identified 107 patients. The overall pooled incidence of thyroid gland invasion in 1287 patients is 10.7% (95% CI 7.6-14.2). Patients with primary subglottic tumours (relative risk 7.5; 95% CI 4.3-13.0) and disease extension into the subglottis (relative risk 4.3; 95% CI 2.5-7.2) have a significantly higher relative risk of thyroid gland invasion. Radiorecurrent tumours and hypopharyngeal tumours did not have an increased risk of thyroid gland invasion. CONCLUSION: Advanced laryngeal and hypopharyngeal carcinomas involving the subglottis carry a significantly elevated risk of thyroid gland invasion compared with those that spare this subsite. The overall incidence of thyroid gland invasion is low, and therefore, thyroidectomy should be reserved for cases considered to be at risk as opposed to a being a routine measure for all total laryngectomies.

Development and preliminary validation of a patient-reported outcome measure for swallowing after total laryngectomy (SOAL questionnaire).

OBJECTIVES: To develop and validate a laryngectomee-specific questionnaire to investigate swallowing function. This paper describes the generation of questionnaire items, pretesting with laryngectomees and a preliminary validation. DESIGN: This study employed 2 phases: questionnaire development and questionnaire validation. Items were developed from patient (n = 10) and clinician (n = 6) focus groups. Content checking, acceptability and face validity were determined through pretesting with 10 laryngectomees and via consensus feedback from 35 speech and language therapists. During preliminary validation, the 17-item final questionnaire was administered to 3 different groups. Discrimination amongst groups was established by comparing questionnaire responses of a laryngectomee group (n = 19) with known dysphagic (n = 19) and non-dysphagic groups (n = 20). Questionnaire responses from the reference dysphagic group were compared with an instrumental assessment of swallowing, the modified barium swallow (MBS). SETTING: Large urban teaching hospital. PARTICIPANTS: Speech and language therapists, laryngectomees, non-dysphagic volunteers, post-radiotherapy dysphagic patients. MAIN OUTCOME MEASURE: Preliminary validation of SOAL questionnaire. RESULTS: Normal, laryngectomee and dysphagic groups had significantly different SOAL scores, as did laryngectomees with different degrees of swallowing impairment (Kruskall Wallis, P << 0.001). The subjective SOAL score had a strong positive correlation with the reference measure of ratings on the MBS (r = 0.5; P = 0.03). CONCLUSIONS: The swallowing outcome after laryngectomy (SOAL) questionnaire is a simple, self-administered tool to assess swallowing function post-total laryngectomy. Further specific testing with a laryngectomy cohort is necessary for full validation. Its potential value lies in screening for dysphagia in clinics or during long-term follow-up of laryngectomees.

Night-to-night variation in snoring sound severity: one night studies are not reliable.

OBJECTIVES: To quantify the night-to-night variation in snoring severity; to compare this with inter-subject variation in snoring intensity: to compare multinight mean snoring scores with self-reported subjective scores. DESIGN: Prospective observational study. SETTING: Subjects were recorded during sleep at their own homes. PARTICIPANTS: Twenty patients with socially disruptive snoring awaiting surgery. MAIN OUTCOME MEASURES: Over four consecutive nights using a solid-state sound recording device, the mean, standard deviation and intra-class correlation coefficient were calculated for (a) the loudest 1% of sound, (b) snore frequency and (c) total snore duration. Results were correlated with Snoring Symptom Inventory scores assessed immediately prior to these recordings. RESULTS: Overall mean and intrasubject standard deviation for the loudest 1% of sound was 65.0 (+/-4.1) dB, for snore frequency was 245 (+/-104) per hour and for total snore duration was 4.3% (+/-2.1). Intraclass correlation coefficients were 0.78, 0.74 and 0.67, respectively, suggesting only moderate reliability of these outcome measures. No significant correlation was found between objective and subjective scores for either endpoint. CONCLUSION: Natural night-to-night variation in snoring severity represents a significant proportion of overall snoring variance, thus one night studies of snoring are not reliable. The random error associated with one-night studies exceeds the expected effect size of snoring interventions and so multi-night studies of at least four nights are recommended to reduce the error. However, even multi-night objective measurements correlate poorly with subjective scores of snoring.

The added value of fibreoptic endoscopic evaluation of swallowing in tracheostomy weaning.

OBJECTIVE: To determine if fibreoptic endoscopic evaluation of swallowing adds information to the clinical assessment of swallowing in tracheostomised patients. DESIGN: A prospective, observational study. SETTING: Addenbrooke's Hospital, Cambridge, UK. PARTICIPANTS: Twenty-five consecutive, adult, tracheostomised patients were recruited over a 3-month period. They were referred to speech and language therapy for a swallowing assessment and were ready to trial cuff deflation. MAIN OUTCOME MEASURES: In current practice the clinical assessment is invariably a precursor to fibreoptic endoscopic evaluation of swallowing and a test would be considered positive when penetration or aspiration are detected. We considered the value of fibreoptic endoscopic evaluation of swallowing following both positive and negative outcomes of the clinical assessment. RESULTS: The positive predictive value of aspiration or penetration was 91% i.e. when a clinical assessment is failed, there is a very high probability the patient would also be failed on fibreoptic endoscopic evaluation of swallowing. However, the negative predictive value was only 64% i.e. over one-third of patients who pass a clinical assessment would later fail a fibreoptic endoscopic evaluation of swallowing. CONCLUSIONS: Despite a small cohort, our data suggest that the assessment of swallowing to aid weaning in tracheostomised patients is currently performed incorrectly; we estimate that over a third of all tracheostomised patients that 'pass' the clinical assessment of swallowing are, in reality, at risk from penetration, aspiration or failed decannulation. This finding supports the use of fibreoptic endoscopic evaluation of swallowing and a change in clinical practice.

Pharyngeal residue across the lifespan: a first look at what's normal.

OBJECTIVES: Without good evidence, post-swallow pharyngeal residue is considered abnormal. Our aim was to document residue from normal food and fluid boluses in young and elderly healthy populations. DESIGN: Prospective, single-blind assessment of residue severity from Fibreoptic Endoscopic Evaluation of Swallowing. SETTING: Tertiary specialist ENT teaching hospital. PARTICIPANTS: Fifty-one healthy participants; twenty-one aged <40 and thirty aged 65+. Each swallowed six representative boluses. OUTCOMES: Two teams independently rated pharyngeal residue severity at 11 anatomical sites. RESULTS: The mean residue scores were less than 1 when averaged across all boluses and anatomic sites. Differences due to age were slight. CONCLUSIONS: Our preliminary data indicate that substantial pharyngeal residue is not common in young or elderly, and probably indicates disordered swallowing.

Total laryngopharyngoesophagectomy with gastric transposition reconstruction: review of long-term swallowing outcomes.

AIM: The aim of this review was to examine long-term swallowing and eating outcomes following laryngopharyngoesophagectomy with gastric pull-up reconstruction. METHODS: Ten patients underwent clinical examination and completed the performance status scale for head and neck questionnaire and also a gastric pull-up swallowing questionnaire designed for this review. Nine of the 10 patients underwent videofluoroscopic examination of swallowing. RESULTS: One patient had a stricture at the orogastric anastomosis, and one patient had bilateral tongue immobility secondary to XIIth nerve palsies. Eight participants reported eating a normal diet, and five reported not limiting their eating environment. Regurgitation, slower eating and reduced capacity were the most common functional limitations. CONCLUSIONS: These results support previous opinions that the gastric pull-up procedure has good swallowing outcomes, and indicate that such outcomes continue in the long term.

Comparing two models of voice care delivery.

Voice care is an important aspect in the successful treatment of patients with non-organic dysphonia. No previous study has examined the specific effect of voice care programmes or the comparative effectiveness of the delivery of these programmes across two healthcare professionals (speech and language therapists and ENT nurses). We describe a pilot study that provides preliminary data that suggests a short, easily deliverable voice care programme is (i) effective in reducing patients' perception of their dysphonia and (ii) equally effectively administered by an ENT nurse compared with a speech and language therapist. The study provides a firm base for continued research.

What are the illness perceptions of people with dysphonia: a pilot study.

BACKGROUND: Patients do not respond to treatment in a predictable manner. Individual preconceptions determine help seeking, compliance and treatment outcome, yet clinicians rarely explore these issues. The illness perception approach sees the patient as an active participant in the healthcare process. AIMS: The aim of this study was to investigate the illness perceptions of people with dysphonia. The subsidiary aims were to correlate the Illness Perception Questionnaire with any psychological distress identified and a self-report measure of dysphonia, and to consider any potential implications for patient management. DESIGN: Prospective, cross-sectional observation. SETTING: Primary and secondary care, two general and four community hospitals. PARTICIPANTS: Fifty adult patients with dysphonia due to benign disease completed three self-administered questionnaires, which investigated their illness perceptions, psychological distress and perceptions of the impact of the presenting 'illness'. MEASURES: The dysphonia was categorised as being due to functional (n=40) or organic (n=10) causes. All the voices were rated by an expert listener according to the GRBAS (grade, roughness, breathiness, aesthenia, strain) scale. PARTICIPANTS completed the Illness Perception Questionnaire, the Vocal Performance Questionnaire and the Hospital Anxiety and Depression scale. RESULTS: Patients showed a wide variation in perception of causation. They had no strong perceptions about the causes, consequences or duration of the presenting dysphonia. Functional dysphonics reported greater consequences, lower perceived control and increased anxiety when compared to patients with organic dysphonia. In terms of cure/control, all patients expected treatment to be helpful but this expectancy reduced as time increased. Anxiety was more associated with functional dysphonia, however, only 17 per cent of the subjects in this group showed clinically significant levels of signs of psychological distress. CONCLUSIONS: Lay illness representations often diverge from the clinician's understanding of the presenting problem and strongly influence treatment behaviour. Early exploration of illness perceptions may enhance health behaviour and maximise the impact of intervention.

Exploring the relationship between severity of dysphonia and voice-related quality of life.

OBJECTIVES: To explore whether severity and/or consistency of dysphonia are linked to voice-related quality of life. DESIGN: Cross-sectional study. SETTING: Specialist voice clinics, University Teaching Hospital. PARTICIPANTS: Sixty adult patients attending with a primary complaint of dysphonia. Exclusion criteria were those below 16 years of age, transexual patients and those with a persistent dysphonia of >2 years. MAIN OUTCOME MEASURES: Voice-related quality of life as assessed by VoiSS. EXPLANATORY FACTORS: Severity of dysphonia as judged by perceptual ratings of voice (GRBAS); a visual analogue scale to judge best, worst and today's voice. RESULTS: There was a highly significant correlation between perceptual dysphonia severity as assessed by GRBAS and the total, impairment and emotional subsets of the VoiSS questionnaire (r from 0.48 to 0.64). There was a similar and highly significant correlation between best, worst and today's self-rated voice and the total, impairment and emotional subsets of the VoiSS questionnaire (r from -0.40 to -0.60). However, none of the self-rated parameters was demonstrably better at explaining the effect on quality of life. CONCLUSIONS: An increasingly negative effect on quality of life appears to be associated with an increase in the severity of dysphonia. Further research on the role of quality of life measures in the assessment and treatment of dysphonia would be of value.

Fibreoptic endoscopic evaluation of swallowing and videofluoroscopy: does examination type influence perception of pharyngeal residue severity?

OBJECTIVES: The aim of the study was to investigate whether the type of instrumental swallowing examination (Fibreoptic Endoscopic Evaluation of Swallowing (FEES) or videofluoroscopy) influences perception of post-swallow pharyngeal residue. DESIGN: Prospective, single-blind assessment of residue from simultaneous videofluoroscopy and FEES recordings. All raters were blind to participant details, to the pairing of the videofluoroscopy and FEES examinations and to the other raters' scores. SETTING: Tertiary specialist ENT teaching hospital. PARTICIPANTS: Fifteen adult participants consecutively recruited; seven women and eight men aged between 22 and 73, mean age 53. All participants underwent one FEES examination and one videofluoroscopy examination performed simultaneously. INCLUSION CRITERIA: referred to speech and language therapy for assessment of dysphagia. EXCLUSION CRITERIA: nil by mouth or judged to be at high risk of aspiration. MAIN OUTCOME MEASURES: The FEES and videofluoroscopy examinations were recorded simultaneously. Fifteen speech and language therapists independently scored pharyngeal residue as none, coating, mild, moderate or severe. All examinations were scored twice by all raters. RESULTS: Intra- and inter-rater agreement were similar for both examinations. There were significant differences between FEES and videofluoroscopy pharyngeal residue severity scores (anova, P < 0.001). FEES residue scores were consistently higher than videofluoroscopy residue scores. CONCLUSIONS: Pharyngeal residue was consistently perceived to be greater from FEES than from videofluoroscopy. These findings have significant clinical implications as FEES and videofluoroscopy findings are used to judge aspiration risk and to make recommendations for oral intake. Further research is required to examine the impact of FEES and videofluoroscopy examinations on treatment decisions.

Variation in invasive and noninvasive measurements of isovolumetric bladder pressure and categorization of obstruction according to bladder volume.

PURPOSE: We developed a noninvasive test that provides an estimate of isovolumetric bladder pressure by measuring the pressure required to interrupt voiding using controlled inflation of a penile cuff. We noted variation in serial measurements obtained during a single void and, therefore, we determined whether this represents variation in detrusor contraction strength, as predicted in previous studies, or measurement error. MATERIALS AND METHODS: A total of 36 symptomatic men underwent simultaneous invasive and noninvasive pressure flow studies. Corresponding values of isovolumetric bladder pressure and cuff interruption pressure were recorded at each flow interruption and grouped according to bladder volume to calculate measurement error and bias at various points during a void. Individual variation in the 2 measurements across a range of normalized bladder volumes was then examined using ANOVA. RESULTS: Cuff interruption pressure showed a consistent level of accuracy as an estimate of isovolumetric bladder pressure across a range of volumes. There were similar, statistically significant differences in isovolumetric bladder pressure and cuff interruption pressure recorded at specific volume increments with the highest values seen in the mid range and the lowest seen at lower bladder volumes (each p <0.01). When plotting, the maximum recorded value of cuff interruption pressure in each individual on our proposed noninvasive pressure flow nomogram provided the best diagnostic accuracy for obstruction. CONCLUSIONS: This study shows that cuff interruption pressure varies in the expected manner with bladder volume and provides a consistent estimate of isovolumetric bladder pressure throughout a void. These data provide important guidance for interpreting noninvasive pressure flow studies and classifying obstruction on the proposed nomogram.

The reliability and validity of patient self-rating of their own voice quality.

OBJECTIVES: To provide preliminary data on the reliability and validity of dysphonic patients rating their own voice quality. DESIGN: Prospective reliability/validity assessment of voice ratings in dysphonic patients. SETTING: The Royal Free Hampstead NHS Primary Care Trust. PARTICIPANTS: Thirty-five adult dysphonia patients recruited from ENT referrals to a speech and language therapy department. Exclusion criteria were (i) a hearing impairment which may affect auditory discrimination and (ii) a diagnosis of cognitive impairment which may affect task comprehension. MAIN OUTCOME MEASURES: Patient intra-rater reliability was assessed by test-retest ratings, using G (Grade), R (Rough), B (Breathy), A (Asthenic), S (Strained) (GRBAS). Validity was assessed by comparing (i) patient-clinician inter-rater reliability, (ii) patients' GRBAS ratings with their Vocal Performance Questionnaire (VPQ) responses. RESULT: (i) Patients had lower intrarater reliability than clinicians (for G of GRBAS, kappa = 0.51 versus 0.74); (ii) patients consistently rated their voices more severely than clinicians (for G of GRBAS, mean rating = 1.4 versus 1.0); (iii) clinician-patient inter-rater agreement was no better than chance (paired t-test, all P < 0.05); (iv) patient ratings correlated significantly with vocal performance scores (r > 0.4, P < 0.05). CONCLUSIONS: Patients appear to have good validity and consistency using GRBAS as a self-perception tool. However, validity measured in terms of agreement with clinician ratings is poor. Voice patients may rate what they perceive rather than what they hear. Disagreement between patient and clinician ratings has implications for therapy aims, prognosis, patient expectations and outcomes. Where disagreement persists, the clinician may have to determine whether therapy priorities need redesigning to reflect patients' perceived needs, or to evaluate whether patient perceptions and expectations are unrealistic.

A nomogram to classify men with lower urinary tract symptoms using urine flow and noninvasive measurement of bladder pressure.

PURPOSE: Bladder pressure during voiding can be estimated by a noninvasive technique using controlled inflation of a penile cuff. This test provides a valid and reliable estimate of isovolumetric bladder pressure but to our knowledge the role of the test for the routine clinical treatment of patients with lower urinary tract symptoms (LUTS) has yet to be demonstrated. As a first step, we evaluated a proposed nomogram for the diagnosis of bladder outlet obstruction in men with LUTS using noninvasive measurements of pressure and flow. MATERIALS AND METHODS: Using a combination of theoretical calculation and experimental data the existing International Continence Society pressure flow nomogram was modified to allow noninvasive measurement of isovolumetric bladder pressure in place of detrusor pressure at maximum urine flow. Accuracy of the nomogram for classifying obstruction was then tested in a group of 144 men with LUTS who underwent an invasive and a noninvasive pressure flow study. RESULTS: The modified nomogram identified men with obstruction with 68% positive predictive value and 78% negative predictive value. Predictive accuracy could be improved by adding an additional criterion of obstruction, that is maximum urine flow less than 10 ml second, whereby an identifiable 69% of all cases could be classified as obstructed (88% positive predictive value) or not obstructed (86% negative predictive value). In the remaining 31% of patients invasive pressure flow studies would provide additional information, although some results would remain equivocal. CONCLUSIONS: The proposed nomogram combined with the additional flow rate criterion can classify more than two-thirds of cases without recourse to invasive pressure flow studies. We must now evaluate the usefulness of this classification for the treatment of men with LUTS.

An automated penile compression release maneuver as a noninvasive test for diagnosis of bladder outlet obstruction.

PURPOSE: We tested the hypothesis that the previously described penile urethral compression release (PCR) maneuver provides a valid diagnosis of bladder outlet obstruction (BOO) using automated rather than manual penile compression by controlled inflation of a penile cuff. We also investigated urodynamic events underlying generation of the PCR index. MATERIALS AND METHODS: A total of 150 subjects attending for pressure flow studies were studied using conventional and noninvasive cystometry. Patients were classified into urodynamic diagnostic groups using standard invasive studies. The PCR index was calculated for each individual from noninvasive penile cuff data and the results were summarized for each group. ROC analysis of the PCR index was performed to define an optimum threshold for BOO diagnosis. Simultaneous invasive and noninvasive data were used to define the relationship between the PCR index, bladder contractility and the maximum flow rate. RESULTS: The mean PCR index +/- SD was significantly higher in the BOO group compared to the normal cystometry group (215% +/- 84% vs 93% +/- 39, p <0.01). ROC analysis showed that a PCR index of greater than 160% diagnosed BOO with 78% sensitivity, 84% specificity and a positive predictive value of 69%. There was a strong positive correlation between the PCR index and isovolumetric detrusor pressure, which is a measure of bladder contractility (r = 0.44, p <0.01). CONCLUSIONS: The results of this study suggest that the PCR index combines valid estimates of bladder contractility and the maximum flow rate, and it represents a clinically useful, noninvasive urodynamic parameter for the diagnosis of BOO.

Noninvasive measurement of bladder pressure. Does mechanical interruption of the urinary stream inhibit detrusor contraction?

PURPOSE: As part of developing a noninvasive method to measure bladder pressure using an inflatable penile cuff, we tested the hypothesis that detrusor contraction is maintained without inhibition during the test. MATERIALS AND METHODS: Five healthy volunteers and 26 male patients with lower urinary tract symptoms underwent interruption of established urine flow by controlled inflation of a cuff placed around the penis with simultaneous invasive bladder pressure monitoring. After interruption of flow the cuff was rapidly deflated and voiding was allowed to resume. The bladder pressure was recorded before, during and after interruption of flow by cuff inflation. RESULTS: During flow interruption an isovolumetric increase in detrusor pressure was observed. When the cuff was deflated the detrusor pressure quickly returned to preinflation values and urine flow immediately resumed. Intra-abdominal pressure did not change during the cuff inflation cycle. CONCLUSIONS: Mechanical interruption of urine flow by controlled inflation of a penile cuff during voiding does not inhibit detrusor contraction. This finding further validates our noninvasive technique of bladder pressure measurement and supports ongoing studies into its clinical usefulness.

Noninvasive measurement of bladder pressure by controlled inflation of a penile cuff.

PURPOSE: A noninvasive test providing reliable objective quantification of bladder pressure during the voiding cycle would make an important contribution to the management of lower urinary tract symptoms. We developed a new noninvasive test to measure bladder pressure in males based on controlled inflation of a penile cuff during voiding. We compared the new technique with simultaneous invasive bladder pressure measurement. MATERIALS AND METHODS: We evaluated 7 volunteers and 32 patients. A conventional pressure flow study was performed first. The bladder was refilled, a penile cuff was fitted and after voiding commenced the cuff was inflated in steps of 10 cm. water every 0.75 seconds until urine flow was interrupted. The cuff was rapidly deflated, allowing flow to resume, and the cycle was repeated until the end of voiding. The flow rate was graphed against cuff pressure for each interruption cycle to determine the pressure at which flow was interrupted. This pressure was compared with simultaneous invasive isovolumetric bladder pressure. RESULTS: Invasive and noninvasive pressure measurements agreed well. Average cuff pressure at interruption of flow exceeded mean simultaneous isovolumetric bladder pressure plus or minus standard deviation by 14.5 +/- 14.0 cm. water. CONCLUSIONS: The new method provides noninvasive quantitative information on voiding bladder pressure in males. Further study is required to assess whether the technique can contribute to the management of lower urinary tract symptoms.

Transmission of penile cuff pressure to the penile urethra.

PURPOSE: We developed a noninvasive method to measure voiding bladder pressure by inflating a penile cuff to interrupt flow. We tested the underlying assumption that cuff pressure is transmitted to the penile urethra. MATERIALS AND METHODS: In 35 men we simultaneously recorded penile cuff and urethral pressure during 2 experimental protocols for 6 cuffs of various widths and manufactures. Initially a urethral pressure transducer was placed at the mid point of the cuff and urethral pressure was continuously recorded during cuff inflation. In experiment 2 cuff pressure was set at 120 cm. water and the urethral pressure profile was measured by withdrawing the urethral transducer through the cuff width. RESULTS: There was excellent agreement of cuff with urethral pressure over the range of 0 to 200 cm. water for cuffs 37 to 54 mm. wide. Narrower cuffs showed wider variation with less efficient transmission of cuff pressure to the urethral lumen. Similarly maximum pressure in the urethral pressure profile showed best agreement for cuffs 38 and 46 mm. wide. Wider cuffs produced higher and narrower cuffs produced lower transmitted pressure within the urethra. Cuff performance was also related to penile size. Results had good within-subject repeatability. CONCLUSIONS: We demonstrated that pressure transmission from cuff to urethra is optimal at a cuff width of 40 to 50 mm. and recommended this width for other investigations of noninvasive bladder pressure measurement.

Relation between heart rate and pulse transit time during paced respiration.

Pulse transit time (PTT) is a simple, non-invasive measurement, defined as the time taken from a reference time for the pulse pressure wave to travel to the periphery. PTT is influenced by heart rate, blood pressure changes and the compliance of the arteries, but few quantitative data are available describing the factors which influence PTT. The aim of this study was to investigate the relationship between the cardiac beat-to-beat interval (RR) and PTT, using paced respiration to generate changes in both variables. We analysed PTT and RR interval from 15 normal healthy subjects during paced breathing, and the cross-correlation function between PTT and RR was used to quantify their relationship. Over the 15 subjects, the maximum change in PTT ranged from 7 to 23 ms with a mean +/- standard deviation of 14 +/- 5 ms, and that in RR interval from 86 to 443 ms (241 +/- 102 ms). Examining changes over time, the best correlation (r = +0.69, p < 0.01) was obtained when PTT was advanced relative to RR, with a change in RR followed by a corresponding change in PTT 3.17 +/- 0.76 beats later. We conclude that there is a strong relationship between PTT changes and RR interval changes, but these changes are not in phase.

Objective benefit of laser palatoplasty for non-apnoeic snoring.

Laser palatoplasty (LPP) is widely used for the treatment of non-apnoeic snoring, despite the lack of objective data supporting its use. We report measurements of snoring in a prospective study of LPP, and we compare the results with a previous study of uvulopalatopharyngoplasty (UPPP). Twenty patients with an apnoea/hypopnoea index < 20 h-1 underwent LPP for habitual snoring. Overnight sound recordings were compared before and 6 months after operation using three objective indices; L, (the level exceeded by the loudest 1% of sound), L5 (the level exceeded by the loudest 5% of sound) and P50 (% total sleep time above 50 dBA). The subjective impression of snoring severity (Wilcoxon test, P < 0.001), and objective indices L1 and P50 (t-test, P < 0.001) showed significant reductions after LPP. The mean change in L1 was 4.2 dBA, comparable to that we previously reported for UPPP, while P50 was reduced to less than one-third its preoperative value. No other sleep variables changed significantly following LPP. We conclude that LPP results in reduced snoring volume comparable to that following UPPP.

Psychometric performance before and after laser palatoplasty for non-apnoeic snoring.

Psychometric tests are an objective way of examining cognitive functioning, and have shown impairment in patients with obstructive sleep apnoea. Non-apnoeic snoring may cause reduced concentration, but psychometric tests have been used rarely in this population. We investigate whether their use can demonstrate an improvement in cognitive performance in 20 non-apnoeic snorers following Laser Palatoplasty (LPP). The subjects completed psychometric tests, Beck Anxiety and Depression Inventories and an Epworth Sleepiness Scale on two occasions before LPP and once postoperatively. The only index to show any significant change with LPP was the Beck Depression Inventory (P < 0.005), which was reduced by a mean of 1.6 units following surgery. There was also a highly significant improvement in information processing between the preoperative tests, for which no explanation could be found. Our results suggest that commonly applied psychometric tests are unable to demonstrate significant improvements following surgery for non-apnoeic snoring. However, we have demonstrated for the first time a significant reduction in depression following surgery, which is evidence that snoring is more than a social nuisance.