Sleep apnea multi-level surgery trial: long-term observational outcomes.

STUDY OBJECTIVES: The sleep apnea multi-level surgery (SAMS) randomized clinical trial showed surgery improved outcomes at 6 months compared to ongoing medical management in patients with moderate or severe obstructive sleep apnea (OSA) who failed continuous positive airway pressure therapy. This study reports the long-term outcomes of the multi-level surgery as a case series. METHODS: Surgical participants were reassessed >2 years postoperatively with the same outcomes reported in the main SAMS trial. Primary outcomes were apnea-hypopnea index (AHI) and Epworth sleepiness scale (ESS), with secondary outcomes including other polysomnography measures, symptoms, quality of life, and adverse events. Long-term effectiveness (baseline to long-term follow-up [LTFU]) and interval changes (6 month to LTFU) were assessed using mixed effects regression models. Control participants were also reassessed for rate of subsequent surgery and outcomes. RESULTS: 36/48 (75%) of surgical participants were reevaluated (mean (standard deviation)) 3.5 (1.0) years following surgery, with 29 undergoing polysomnography. AHI was 41/h (23) at preoperative baseline and 21/h (18) at follow-up, representing persistent improvement of -24/h (95% CI -32, -17; p < 0.001). ESS was 12.3 (3.5) at baseline and 5.5 (3.9) at follow-up, representing persistent improvement of -6.8 (95% CI -8.3, -5.4; p < 0.001). Secondary outcomes were improved long term, and adverse events were minor. Interval change analysis suggests stability of outcomes. 36/43 (84%) of the control participants were reevaluated, with 25 (69%) reporting subsequent surgery, with symptom and quality of life improvements. CONCLUSION: Multi-level upper airway surgery improves OSA burden with long-term maintenance of treatment effect in adults with moderate or severe OSA in whom conventional therapy failed. CLINICAL TRIAL: Multi-level airway surgery in patients with moderate-severe obstructive sleep apnea (OSA) who have failed medical management to assess change in OSA events and daytime sleepiness; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=366019&isReview=true; ACTRN12614000338662.

Hypocalcaemia in pharyngolaryngectomy: Preservation or autotransplantation of parathyroid glands.

OBJECTIVE: To describe transient and permanent hypocalcaemia following partial and total pharyngolaryngectomy with parathyroid gland preservation or autotransplantation. METHODS: Thirty patients underwent partial or total pharyngolaryngectomy by a single surgeon during the period 2009-2020. Intraoperative parathyroid gland preservation or autotransplantation (where the gland appeared devascularized) was routinely performed. Calcium levels performed on day 1, 3 months, and at 12 months postoperatively were collected. Rates of transient and permanent hypocalcaemia were calculated. RESULTS: A total of 13% of patients had transient hypocalcaemia, and 10% permanent hypocalcaemia. Rates of transient and permanent hypocalcaemia in total pharyngolaryngectomy were 14% and 14%, respectively. Partial pharyngectomy hypocalcaemia rates were 13% for transient and 0% for permanent. The majority of patients underwent salvage surgery for oncological resection, often following radiotherapy (63%). Ipsilateral hemithyroidectomy was preferred to total (57% vs 7%), with high rates of concurrent neck dissection (67%) and reconstruction (87%). CONCLUSION: This data supports preservation or autotransplantation of parathyroid glands as a means of reducing permanent postoperative hypocalcaemia. LEVEL OF EVIDENCE: Level IV, case series, retrospective.

Low morbidity high anterior neck approach for removal of a deep intraglossal foreign body: A case report.

INTRODUCTION AND IMPORTANCE: In the era of both new bilateral hypoglossal nerve stimulator and long-standing experience with Sistrunk's procedures, it is notable that the literature scarcely describes high anterior neck approaches, tending to focus on transoral removal of intra-glossal foreign bodies. Herein we describe a case of a low morbidity anterior approach for access to an intra-glossal foreign body and discuss the implications. CASE PRESENTATION: A morbidly obese 73 year old lady presented acutely after inadvertent ingestion of a sewing needle. Initial assessment demonstrated an intraglossal foreign body which subsequently migrated into the deep substance of the tongue. Endoscopic retrieval was attempted but was unsuccessful. A midline transcervical anterior neck incision was made, exposure and midline separation of mylohyoid, and midline dissection of geniohyoid muscles was performed to expose genioglossi muscles and the foreign body removed. The patient recovered well without complication. CLINICAL DISCUSSION: This approach carries low morbidity compared to transoral approaches despite traditional dogma mandating avoidance of open neck approaches. Such approaches have recently been developed for implantation of bilateral hypoglossal nerve stimulators. CONCLUSION: Otolaryngologists should consider midline transcervical approach to retrieve deep intra-glossal foreign bodies, particularly in scenarios where other options may not provide adequate access or may enhance intra-oral morbidity.

Incidence of allergen-specific and total immunoglobulin E positivity in children undergoing adenotonsillectomy.

AIM: To conduct a prospective, consecutive cohort study to evaluate the incidence of allergen-specific and total immunoglobulin E (IgE) in a paediatric population undergoing adenotonsillectomy for sleep-disordered breathing. METHODS: A total of 64 consecutive patients presenting for adenotonsillectomy at a single centre were recruited over a period of 3 months. All patients underwent adenotonsillectomy and had allergen-specific and total IgE serum testing at the time of anaesthesia induction. Pre-operative history and examination were conducted to determine clinical allergy. Caregivers completed the Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire and the Mini Rhinoconjunctivitis Quality of Life Questionnaire at baseline and at 6 weeks post-operatively. RESULTS: A total of 37 (57.8%) patients had either allergen-specific or total IgE positivity. House dust mite was the most prevalent allergen-specific IgE finding, being present in moderate to high levels in 14 (21.9%) patients. A total of 17 (26.6%) patients had a history of atopy, while 34 (53.1%) had examination findings suggestive of allergy. Neither serum IgE testing nor clinical history and examination were independently associated with residual symptoms post adenotonsillectomy. Patients with concomitant serum IgE positivity and clinical allergy had higher residual symptom scores compared to those who did not using both Sleep-Related Breathing Disorder scale of the Paediatric Sleep Questionnaire (P = 0.035) and Mini Rhinoconjunctivitis Quality of Life Questionnaire (P = 0.02) questionnaires. CONCLUSIONS: Our prospective, consecutive cohort of patients reflect a greater incidence of serum IgE positivity compared to historical figures. When utilised with clinical findings on history and examination, serum IgE is a useful adjunct that is associated with greater residual symptoms post-adenotonsillectomy.