Virtual vs in-person otolaryngology evaluation: The patient perspective.

OBJECTIVE: To compare patient responses to validated satisfaction surveys for in-person vs virtual otolaryngology ambulatory evaluation. METHODS: National Research Corporation (NRC) Health patient survey answers between April 2020 and February 2021 were divided into in-person and virtual visit modalities. Responses were compared with two group t-tests or Wilcoxon rank sum tests. Relationships between visit modality by gender, age, race, and sub-specialty visit type and satisfaction scores were examined by testing interactions with separate ANOVA models. RESULTS: 1242 in-person and 216 virtual patient satisfaction survey responses were highly favorable for all themes (communication, comprehension of treatment plan, and likelihood of future referral) with both visit modalities. Higher satisfaction for in-person evaluation was seen with communication ("care providers listened" 3.68 (0.67)-on a scale of 1-no to 4-yes, definitely) vs 3.57 (0.78), p = 0.0426; "courtesy/respect" 3.75 (0.62) vs 3.66 (0.69), p = 0.0265)), and comprehension of treatment plan ("enough info about treatment" 3.53 (0.79) vs 3.37 (0.92), p = 0.0120; "know what to do" 3.62 (0.76) vs 3.46 (0.88), p = 0.0023)). No differences were detected for future referral of clinic or provider. There was no association between visit modality and patient sociodemographic factors or sub-specialty visit types. Main effects were observed with respect to race, gender, and sub-specialty visit type. CONCLUSION: Patient satisfaction scores for virtual visit evaluation were high and comparable to in-person evaluation, with a slight preference for in-person. Future studies are needed to identify which patients and conditions are particularly suited for virtual vs in-person delivery of otolaryngology services.

Post-operative Complication Rate Comparison Between Airway Surgery and Upper Airway Stimulation Using NSQIP and ADHERE.

OBJECTIVE: Postoperative complication rates were compared between obstructive sleep apnea surgery (OSAS) and hypoglossal nerve upper airway stimulation (UAS). STUDY DESIGN: Cohort. SETTING: Multi-institutional international databases. METHODS: OSAS data were collected from the NSQIP database (2014; American College of Surgeons National Surgery Quality Improvement Program). UAS data were obtained from the ADHERE registry (Adherence and Outcome of Upper Airway Stimulation for OSA International Registry; 2016-December 2019). ADHERE comorbidities and complications were categorized to match NSQIP definitions. A chi-square test was used for proportion P values. RESULTS: There were 1623 UAS procedures in ADHERE and 310 in NSQIP. The UAS group was older than the OSAS group (mean ± SD, 60 ± 11 vs 42 ± 13 years) but similarly male (75% vs 77%) and overweight (body mass index, 29 ± 4 vs 29 ± 3 kg/m2). There was a higher proportion of hypertension, diabetes, and heart disease in the UAS cohort. Palatopharyngoplasty was the most common surgical procedure (71%), followed by tonsillectomy (25%). UAS operative time was longer (132 ± 47 vs 54 ± 33 minutes). Postoperative length of stay was not normally distributed, as 71% of UAS stays were <1 day as opposed to 40% of OSA stays (P < .0001). Thirty-day return to the operating room related to the procedure was 0.1% for UAS and 4.8% for OSAS (P < .0001). Surgical site infections were 0.13% for UAS and 0.9% for OSAS (P = .046). CONCLUSION: The UAS cohort was older and more likely to have comorbid hypertension, diabetes, and heart disease. Despite baseline differences, the postoperative complication rate was lower with UAS than with OSAS.

Referral Center Experience With Nonpalpable Contraceptive Implant Removals.

OBJECTIVE: To describe our experience with office removal of nonpalpable contraceptive implants at our referral center. METHODS: We performed a retrospective cohort study by reviewing the charts of patients referred to our family planning specialty center for nonpalpable or complex contraceptive implant removal from January 2015 through December 2018. We localized nonpalpable implants using high-frequency ultrasonography and skin mapping in radiology, followed by attempted removal in the office using local anesthesia and a modified vasectomy clamp. We abstracted information on demographics, implant location, and outcomes. RESULTS: Of 61 referrals, 55 patients attended their scheduled appointments. Seven patients had palpable implants; six elected removal. The other 48 patients had ultrasound localization, which identified 47 (98%) of the implants; the remaining patient had successful localization with computed tomography imaging. Nonpalpable implants were suprafascial (n=22), subfascial (n=25) and intrafascial (n=1); four of these patients opted to delay removal. Of 50 attempted office removals, all palpable (n=6), all nonpalpable suprafascial (n=21 [100%, 95% CI 83-100%]), and 19 out of 23 (83%, 95% CI 67-98%) subfascial implants were successful. Three of the four patients with failed subfascial implant office removal had successful operating room removal with a collaborative orthopedic surgeon; the other patient sought removal elsewhere. Transient postprocedure neuropathic complaints were noted in 7 out of 23 (30%, 95% CI 12-49%) subfascial and 1 out of 21 (5%, 95% CI 0-13%) suprafascial removals (P=.048). Nonpalpable implants were more likely to be subfascial in nonobese patients (24/34, 71%) as compared with obese (1/13, 8%) patients (P<.001). Seven (28%) of the 25 subfascially located implants had been inserted during a removal-reinsertion procedure through the same incision. CONCLUSION: Most nonpalpable contraceptive implants can be removed in the office by an experienced subspecialty health care provider after ultrasound localization. Some patients may experience transient postprocedure neuropathic pain. Nonpalpable implants in thinner women are more likely to be in a subfascial location.

Previous Surgery and Hypoglossal Nerve Stimulation for Obstructive Sleep Apnea.

OBJECTIVE: To examine whether previous palate or hypopharyngeal surgery was associated with efficacy of treatment of obstructive sleep apnea with hypoglossal nerve stimulation. STUDY DESIGN: Cohort (retrospective and prospective). SETTING: Eleven academic medical centers. SUBJECTS AND METHODS: Adults treated with hypoglossal nerve stimulation were enrolled in the ADHERE Registry. Outcomes were defined by the apnea-hypopnea index (AHI), in 3 ways: change in the AHI and 2 definitions of therapy response requiring ≥50% reduction in the AHI to a level <20 events/h (Response20) or 15 events/h (Response15). Previous palate and hypopharyngeal (tongue, epiglottis, or maxillofacial) procedures were documented. Linear and logistic regression examined the association between previous palate or hypopharyngeal surgery and outcomes, with adjustment for age, sex, and body mass index. RESULTS: The majority (73%, 217 of 299) had no previous palate or hypopharyngeal surgery, while 25% and 9% had previous palate or hypopharyngeal surgery, respectively, including 6% with previous palate and hypopharyngeal surgery. Baseline AHI (36.0 ± 15.6 events/h) decreased to 12.0 ± 13.3 at therapy titration (P < .001) and 11.4 ± 12.6 at final follow-up (P < .001). Any previous surgery, previous palate surgery, and previous hypopharyngeal surgery were not clearly associated with treatment response; for example, any previous surgery was associated with a 0.69 (95% CI: 0.37, 1.27) odds of response (Response20 measure) at therapy titration and a 0.55 (95% CI: 0.22, 1.34) odds of response (Response20 measure) at final follow-up. CONCLUSION: Previous upper airway surgery was not clearly associated with efficacy of hypoglossal nerve stimulation.

Medical abortion with mifepristone and vaginal misoprostol between 64 and 70 days' gestation.

OBJECTIVE: To evaluate outcomes with mifepristone 200 mg orally followed 24-48 h later by misoprostol 800 mcg vaginally for medical abortion at 64-70 days of gestation. STUDY DESIGN: We reviewed electronic databases and medical records for medical abortion cases at 64-70 days' gestation at British Pregnancy Advisory Service clinics in England and Wales from May 2015 through October 2016. Women selected in-office follow-up or self-evaluation of abortion outcome using a checklist along with low-sensitivity urine pregnancy testing. We excluded cases in which we could not locate records and when women did not proceed with medical abortion, did not use misoprostol following mifepristone if abortion had not occurred and did not attend a scheduled follow-up assessment. We analyzed demographic characteristics, treatment outcomes and significant adverse events. We defined treatment success as complete abortion without surgical evacuation and without continuing pregnancy. RESULTS: Of 2743 cases identified, we could not locate 40 charts and excluded 30 cases, leaving a final sample of 2673. Overall, 2538 (94.9%, 95% CI 94.1-95.8) women had a successful medical abortion. Reasons for failure included continuing pregnancy (n=90, 3.4%, 95% CI 2.7-4.1), retained nonviable pregnancy (n=2, 0.1%, 95% CI 0-0.2) and incomplete abortion (n=43, 1.6%, 95% CI 1.1-2.1). Of those with continuing pregnancies, 81 underwent a uterine aspiration and 9 opted to continue the pregnancy. Thirty-five (1.3%, 95% CI 0.9-1.7) women had significant adverse events; 16 (0.6%, 95% CI 0.3-0.9) underwent an in-hospital aspiration. Pelvic infection (n=4, 0.2%) and transfusion (n=1, 0.03%) occurred rarely. CONCLUSION: Medical abortion from 64 to 70 days with mifepristone and vaginal misoprostol is effective with a low rate of serious adverse events. IMPLICATIONS: Medical abortion between 64 and 70 days of gestation may be offered on an outpatient basis using mifepristone and vaginal misoprostol. Service provision without an in-person follow-up is feasible. Not all women with a continuing pregnancy after medical abortion treatment opt to have an aspiration procedure.

Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry.

Upper airway stimulation (UAS) has been shown to reduce severity of obstructive sleep apnoea. The aim of this study was to identify predictors of UAS therapy response in an international multicentre registry.Patients who underwent UAS implantation in the United States and Germany were enrolled in an observational registry. Data collected included patient characteristics, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS), objective adherence, adverse events and patient satisfaction measures. Post hoc univariate and multiple logistic regression were performed to evaluate factors associated with treatment success.Between October 2016 and January 2018, 508 participants were enrolled from 14 centres. Median AHI was reduced from 34 to 7 events·h-1, median ESS reduced from 12 to 7 from baseline to final visit at 12-month post-implant. In post hoc analyses, for each 1-year increase in age, there was a 4% increase in odds of treatment success. For each 1-unit increase in body mass index (BMI), there was 9% reduced odds of treatment success. In the multivariable model, age persisted in serving as statistically significant predictor of treatment success.In a large multicentre international registry, UAS is an effective treatment option with high patient satisfaction and low adverse events. Increasing age and reduced BMI are predictors of treatment response.

Prospective quantification of fetomaternal hemorrhage with dilation and evacuation procedures.

OBJECTIVE: To describe fetomaternal hemorrhage (FMH) during second-trimester dilation and evacuation (D&E) to evaluate if Rhesus-immune globulin (RhIG) 100 mcg (used in the United Kingdom) and 300 mcg (used in the United States) provide adequate prophylaxis. STUDY DESIGN: We conducted an exploratory prospective descriptive study of women undergoing D&E between 15 weeks 0 days and 23 weeks 6 days of gestation. Enrolled participants had Kleihauer-Betke testing on specimens obtained before and after D&E. We assessed the main outcome measures of FMH in mL suggesting need for more than 100 mcg and 300 mcg RhIG (FMH of 10 mL and 30 mL fetal whole blood, respectively) and association of postprocedure FMH with demographic characteristics and procedure-related variables. RESULTS: The 300 participants had a mean gestational age of 19 weeks 6 days±2 weeks 2 days. The median preprocedure FMH was 0 mL (range 0-50 mL) with 2 (0.67%) women exceeding 10 mL (19 mL and 50 mL). The median postprocedure FMH was 1 mL (range 0-60 mL). Almost all participants had postprocedure FMH <10 mL (n=295, 98.3%) and <30 mL (n=298, 99.3%). All participants under 18 weeks had FMH <10 mL. We found no demographic or procedure-related factors to be predictive of FMH quantity. CONCLUSIONS: FMH occurring with routine second-trimester D&E procedures is minimal. Adequate prophylaxis with RhIG 100 mcg and 300 mcg occurred in >98% of women and in all cases <18 weeks of gestation. This study is the first step to potentially reducing the dose and costs of RhIG administration with D&E. IMPLICATIONS: This study is a first step in quantifying fetomaternal hemorrhage with routine dilation and evacuation procedures; larger trials are needed, especially to understand why some women have recognizable hemorrhage preprocedure. If dosing requirements are too high with current guidelines, lower doses will result in resource and cost savings.

Drug-Induced Sleep Endoscopy and Surgical Outcomes: A Multicenter Cohort Study.

OBJECTIVE: To evaluate the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) examinations using the VOTE Classification and obstructive sleep apnea (OSA) surgical outcomes in a large multicenter, international cohort. METHODS: Retrospective, multi-center cohort study of adults without tonsillar hypertrophy who underwent pharyngeal surgery for OSA. The study included only participants without enlarged tonsils. Four independent reviewers performed blinded review of preoperative DISE videos using the VOTE Classification system and scoring of a primary structure contributing to airway obstruction. DISE findings were examined for an association with surgical outcomes with univariate analyses and multiple regression. RESULTS: Two hundred seventy-five study participants were included from 14 centers. Mean age was 51.4 ± 11.8 years, and body mass index was 30.1 ± 5.2 kg/m2 . There was moderate interrater reliability (kappa = 0.40-0.60) for DISE findings. Oropharyngeal lateral wall-related obstruction was associated with poorer surgical outcomes (adjusted odds ratio (AOR) 0.51; 95% CI 0.27, 0.93). Complete tongue-related obstruction was associated with a lower odds of surgical response in moderate to severe OSA (AOR 0.52; 95% CI 0.28, 0.98), with findings that were similar but not statistically significant in other analyses. Surgical outcomes were not clearly associated with the degree and configuration of velum-related obstruction or the degree of epiglottis-related obstruction. Surgical response was associated with tonsil size and body mass index (inversely). CONCLUSION: DISE findings concerning the oropharyngeal lateral walls and tongue may be the most important findings of this evaluation technique. LEVEL OF EVIDENCE: 2B Laryngoscope, 129:761-770, 2019.

Comparing Postpartum Visit Attendance with a Scheduled 2- to 3-Week or 6-Week Visit after Delivery.

OBJECTIVE: To evaluate whether scheduling a 2- to 3-week versus 6-week postpartum visit results in higher visit attendance. STUDY DESIGN: We conducted a secondary analysis of a quasi-experimental before-after study to compare postpartum visit attendance after changing routine scheduling of visits from 6 weeks to 2 to 3 weeks after delivery. Secondary outcomes include patient satisfaction and breastfeeding continuation at 3 and 6 months postpartum. We collected postpartum visit information through a chart review and conducted telephonic interviews at 3 and 6 months postpartum to assess satisfaction with visit timing and breastfeeding status. We performed multivariable analyses to assess predictors of visit attendance. RESULTS: Women scheduled at 2 to 3 weeks postpartum demonstrated higher visit attendance (90.2%; 95% confidence interval [CI]: 86.6-93.9%) compared with 6 weeks (81.6%; 95% CI: 76.3-86.2%; p < 0.01). Predictors for visit attendance include postpartum visit timing, age, education, parity, prior miscarriage, and high-risk index pregnancy in multivariate analysis. Scheduling at 2 to 3 weeks postpartum increased visit completion in women who were younger and had lower educational attainment, high-risk index pregnancy, and no prior miscarriages. We found no differences in patient satisfaction or breastfeeding continuation at 3 and 6 months postpartum related to postpartum visit timing. CONCLUSION: Scheduling a 2- to 3-week postpartum visit is associated with higher attendance.

Hypoglossal nerve stimulator generator migration: INSPIRE device reimplantation with parallels to cardiac implantable electronic devices.

Implantation rates of hypoglossal nerve stimulators, such as INSPIRE, are increasing. The device is still in its early stages of complication reporting, which to date includes implant related infection requiring device removal, and stimulation lead cuff dislodgement requiring replacement. Here we present a 48-year-old female who experienced generator migration and stimulator lead tension requiring an additional operation in order to resecure the generator device. This proved unsuccessful and a second surgery was performed with complete relocation of the device generator to inhibit device migration. This is the first documented case of INSPIRE migration to date, though the implant generator has comparable likeness to cardiovascular implantable electronic devices (CIEDs) where migration risk factors are better studied. Given our patient's case, we identify obesity and abundant breast tissue as potential risk factors for device migration. We believe such factors can be identified prior to initial device implantation to avoid migration and the need for surgical revision. Superior positioning of the generator proved successful, and can be a solution in those with similar body habitus as TYRX pouching and additional security sutures were ineffective. Also, for revisions requiring tunneling of the stimulation lead as in this case we recommend the use of zero degree endoscope for ease of adhesion lysis.

Etonogestrel implant use in women primarily choosing a combined oral contraceptive pill: A proof-of-concept trial.

OBJECTIVE: We evaluated a novel concept of initiating the etonogestrel implant as a "back-up" method in women who desire using combined oral contraceptives (COC) but want to decrease their risk of unintended pregnancy with a more effective method. STUDY DESIGN: In this prospective cohort study, we planned to include 20 women as a proof-of-concept. We enrolled both new COC starters and continuing COC users and placed an etonogestrel implant. Participants completed daily bleeding diaries and attended follow-up visits at 1, 3, and 6 months. We assessed implant continuation through six months of study participation and side effects with dual hormonal contraceptive use. RESULTS: Between September and December 2016, we enrolled 10 new starters and 10 current COC users. All participants completed 1-month follow-up, and 18 (90%) subjects completed the 3- and 6-month follow-up assessments. Two current COC users had the implant removed for mood changes before 6 months. At the 6-month follow-up visit, 10 women were using both pills and implant, seven relied on the implant only, and one was using a COC only. Three new starters chose implant removal at end of study participation; one for weight gain and acne, another for mood changes, and one for decreased libido. No subjects discontinued the implant for bleeding complaints. CONCLUSION: In this proof-of-concept study, women using COCs were willing to initiate the implant as a "back-up" method to improve pregnancy prevention. Most women continued the implant through 6 months and after completing study participation. IMPLICATIONS: Initiating the etonogestrel implant as a "back-up" method may be an option for women who desire more effective pregnancy prevention while using combined oral contraceptive pills for its bleeding profile or non-contraceptive benefits.

Long-Acting Reversible Contraception Initiation With a 2- to 3-Week Compared With a 6-Week Postpartum Visit.

OBJECTIVE: To evaluate whether a department policy changing the scheduling of the postpartum visit from 6 weeks to 2-3 weeks after delivery is associated with higher long-acting reversible contraception initiation at the postpartum visit. METHODS: We conducted a quasiexperimental before-after study to evaluate long-acting reversible contraception initiation, specifically an intrauterine device or contraceptive implant, at the postpartum visit between women scheduled for follow-up at 6 weeks (before policy change) and 2-3 weeks after delivery (after policy change). Secondary outcomes included postpartum visit completion, overall contraception initiation at the postpartum visit, overall contraceptive use at 6 months after delivery, and repeat pregnancies by 6 months postpartum. We obtained delivery and postpartum information using the electronic medical record and contacted participants 3 and 6 months after delivery to assess contraception use and repeat pregnancies. RESULTS: We enrolled 586 participants between December 2014 and November 2015, of whom 512 women (256 in each cohort) continued to meet eligibility criteria after delivery. Long-acting reversible contraception initiation rates at the postpartum visit were lower in the 2- to 3-week (16.5%, 95% CI 12.2-21.8) compared with the 6-week group (31.1%, 95% CI 25.2-37.7, P<.01), primarily as a result of patient and health care provider preferences for delaying intrauterine device insertion to a later visit. More women completed a scheduled 2- to 3-week postpartum visit (90.2%, 95% CI 86.0-93.3) compared with a 6-week visit (81.6%, 95% CI 76.4-85.9, P<.01). Deferral of any contraception initiation was higher in the 2- to 3-week group (27.3%, 95% CI 21.9-33.4) compared with the 6-week group (15.8%, 95% CI 11.5-21.4, P<.01), but there were no differences in overall contraceptive use patterns at 6 months postpartum. No intrauterine device perforations or expulsions were observed in women who underwent insertion at 2-3 weeks postpartum. Five pregnancies were reported in each cohort by 6 months after delivery. CONCLUSION: Scheduling a visit at 2-3 weeks after delivery was not associated with increased long-acting reversible contraception initiation at this visit despite higher postpartum visit attendance.

Reduction of Burnout in Mental Health Care Providers Using the Provider Resilience Mobile Application.

This pilot study examined the usability, acceptability, and effectiveness of a free Provider Resilience (PR) mobile application (app) designed by the National Center for Telehealth and Technology to reduce provider burnout. Outpatient mental health providers (N = 30) used the PR app for 1 month. Participants rated the PR app on the System Usability Scale with an overall score of 79.7, which is in the top quartile for usability. Results of paired sample t tests on the Professional Quality of Life Scale indicated significant decreases on the Burnout (t = 3.65, p < .001) and Compassion Fatigue (t = 4.54, p < .001) subscales. The Provider Resilience app shows promise in reducing burnout and compassion fatigue in mental health care providers.

Intrauterine Contraception.

Currently, there are only two basic types of intrauterine devices (IUDs): copper and hormonal. However, other types of IUDs are under development, some of which are in clinical trials around the world. Continued development has focused on increasing efficacy, longer duration of use, and noncontraceptive benefits. This review discusses currently available intrauterine contraceptives, such as the Cu380A IUD and levonorgestrel-releasing intrauterine systems; novel intrauterine contraceptives that are available in select parts of the world including the intrauterine ball, low-dose copper products, frameless devices, and intrauterine delivery systems impregnated with noncontraceptive medication; and novel products currently in development.

Snoring exclusively during nasal breathing: a newly described respiratory pattern during sleep.

PURPOSE: The aim of this study is to describe a distinctive respiratory pattern seen in subjects with inferior turbinate hypertrophy, nasal obstruction, and a polysomnogram-proven diagnosis of primary snoring or mild obstructive sleep apnea. These subjects demonstrated increased snoring with purely nasal breathing and alleviation of snoring with oral breathing. The study design is case series with chart review. The setting was a university-based tertiary care hospital. METHODS: A retrospective chart review was performed for patients with complaints of nasal obstruction with associated inferior turbinate hypertrophy and a polysomnogram-proven diagnosis of mild obstructive sleep apnea or primary snoring. Demographic and polysomnography information were collected and analyzed. Snoring and airflow patterns were reviewed. RESULTS: Twenty-five subjects were identified as having met the inclusion and exclusion criteria on polysomnography for either primary snoring or mild obstructive sleep apnea with inferior turbinate hypertrophy and no other significant nasal deformity or abnormality. Seventeen (68 %) of these patients had polysomnograms which demonstrated snoring during nasal breathing and alleviation of snoring with oral breathing. Of the 17 who snored during nasal breathing, ten of the subjects were female and seven of the subjects were male. The mean age was 27 years (range 18 to 68 years). The mean apnea-hypopnea index was 2.3 events/h (range 0 to 9.7 events/h). The mean body mass index was 25 kg/m(2) (range 20 to 43 kg/m(2)). CONCLUSION: Our study describes a newly recognized pattern of snoring in patients with a polysomnogram-proven diagnosis of either primary snoring or mild obstructive sleep apnea. This pattern of breathing demonstrates patients who snore during nasal breathing even with known nasal obstruction present and subsequently have resolution or improvement of the snoring with oral breathing.

Continuous lesser palatine nerve block for postoperative analgesia after uvulopalatopharyngoplasty.

OBJECTIVES: Uvulopalatopharyngoplasty (UPPP) is a commonly performed surgical intervention used to treat obstructive sleep apnea (OSA) syndrome. Continuous peripheral nerve blocks have been shown to reduce postoperative pain and opioid requirements for other surgical procedures but have not been described previously for palate surgery. We present the use of a continuous lesser palatine nerve block catheter as a part of the multimodal postoperative pain management for UPPP. CASE REPORT: Three patients were scheduled to undergo elective UPPP and tonsillectomy for OSA with scheduled postoperative hospital admission. Each patient gave written consent to share the details of his or her case. Upon completion of the surgical procedure, but before emergence from general anesthesia, a 20-G multiorifice epidural catheter was inserted into the left nasal passage, passed into the oropharynx, and either tunneled posteriorly within the anterior portion of the soft palate with the aid of a 16-G angiocatheter or placed submucosally within the soft palate by the surgeon. Each catheter was secured using clear adhesive dressings along the cheek and anchored to the ipsilateral shoulder. A continuous infusion of ropivacaine 0.2% at 2 mL/h was delivered using a disposable infusion device postoperatively, in addition to the prescribed oral and intravenous opioids. No immediate or long-term complications due to catheter placement were identified during the patient follow-up. DISCUSSION: Continuous lesser palatine nerve block may be a useful regional anesthetic technique in the multimodal postoperative pain management of opioid-sensitive OSA patients undergoing UPPP and deserves further study.

Hunsaker Mon-Jet tube ventilation: a 15-year experience.

OBJECTIVE/HYPOTHESIS: The Hunsaker Mon-Jet tube (HMJT) (Xomed, Jacksonville, FL) has been used effectively for subglottic ventilation. We previously reported a series of 552 patients over a 10-year period with no major complications. This is a continuation of that series with an additional 5 years of cases. STUDY DESIGN: Retrospective consecutive case series. METHODS: Patients who were ventilated with the HMJT for microlaryngeal surgery at the University of Washington Medical Center over a 15-year period (1995-2010) were identified from the Voice Disorders database. Charts were reviewed for demographic data, laryngeal diagnosis, and anesthetic parameters. Main outcome measure was the rate of complications. RESULTS: Fifty-seven complications occurred in 49 cases out of 839 cases (5.8% complication rate). In descending order, the complications were hypoxia (SpO(2) <90%, n = 30, 3.6%), hypercarbia (end tidal CO(2) of >60 mm Hg, n = 17, 2.0%), airway obstruction (n = 4, 0.5%), barotrauma (n = 2, 0.2%), seeding of blood into trachea (n = 2, 0.2%), submucosal injection of air (n = 1, 0.1%), and mucosal damage (n = 1, 0.1%). Factors associated with complications included high body mass index (P = .04), American Society of Anesthesiology class III or IV (P = .01), history of heart disease (P = .02), history of previous laryngeal surgery (P = .02), longer duration of case (P = .006), and laser use (P = .005). CONCLUSIONS: Although subglottic ventilation via an HMJT is a safe alternative to traditional endotracheal intubation in an appropriately selected population, practitioners should remain vigilant about the known complications.

Surgical therapy of obstructive sleep apnea: a review.

Obstructive sleep apnea (OSA) is a disease characterized by intermittent and repetitive narrowing of the airway during sleep. Surgical therapies for the treatment of OSA aim to improve airway patency by addressing selected site(s) of obstruction. Because several areas may each be responsible for the narrowing, different surgical modalities have also been developed. In this review, we give an overview of surgery for each of potential obstruction site(s). As a consequence of the multi-factorial and heterogeneous etiology of OSA, surgical therapies need to be selected and performed specifically for each patient, as there is no perfect surgery that will fit all patients. As with any other treatment modalities for OSA, surgical therapies have variable efficacy, but are a very important tool on OSA management in selected patients and have been shown effectiveness in decreasing the morbidity and mortality associated with the disease.

A lingual abscess caused by Streptococcus intermedius.

Lingual abscesses are rare. We describe a case in a healthy female with no recent history of trauma. The organism recovered by culture of drainage material collected prior to antibiotic treatment was Streptococcus intermedius, an organism recognized as flora of the oropharynx and associated with abscess formation. The isolate was resistant to clindamycin, which was the antibiotic therapy that the patient received.

Vacuum-assisted closure therapy for reconstruction of soft-tissue forehead defects.

We sought to examine the efficacy of vacuum-assisted closure (VAC) therapy for the reconstruction of full-thickness forehead defects and to determine the appropriate therapeutic strategies for its use. Medical records and photographs were reviewed for 3 patients with full-thickness tissue loss of the forehead region treated with a VAC system. All 3 patients had complete formation of healthy granulation tissue with VAC therapy alone. One patient was treated to full reepithelization of her wound; the other 2 patients underwent successful surgical closure after VAC reduction of the defect. The treatment was well tolerated, with no complications. Although this represents an initial study, it seems that the protocol for VAC therapy presented herein is a reliable technique for the repair of forehead defects that provides excellent functional and aesthetic outcomes.