Paediatric obstructive sleep apnoea: is a polysomnogram always necessary?

Obstructive sleep apnoea (OSA) is a common entity in children, most present with sleep disturbances such as snoring, choking during sleep, enuresis, restless sleep, or apnoeic spells. Other symptoms include poor school performance, hyperactivity, failure to thrive, heart failure and cor pulmonale. Most authors would concur that the polysomnogram (PSG) is the gold standard for the diagnosis of OSA, and that adenotonsillectomy is the surgical procedure of choice, with high curative rates and relatively low morbidity. Close post-operative monitoring of all children with OSA cannot be over-emphasized. The focus has been, traditionally, to anticipate post-operative airway and respiratory complications in this group of children. We present 73 children with clinical OSA and 36 children with proven OSA on PSG, with only one child having respiratory complications (mixed apnoea), and all with uneventful recovery. In view of our low complication rates, low post-operative morbidity, cost and facility factor, the need for a mandatory overnight PSG pre-operatively is questioned, and clinical criteria for performing a PSG preoperatively are suggested.     

Identifying patients who need close monitoring during and after upper airway surgery for obstructive sleep apnoea

Potentially serious complications have been documented in patients undergoing upper airway surgery for obstructive sleep apnoea (OSA). Consensus is lacking regarding peri- and post-operative monitoring and identification of those patients likely to suffer post-operative complications. This retrospective review of 118 patients treated and 152 surgical procedures undertaken, from January 1998 to December 2003, addresses this issue. The overall peri- and post-operative complication rate was 13.8 per cent, with one patient experiencing upper airway compromise, five patients experiencing post-operative oxygen desaturation within 150 minutes of extubation, six patients experiencing persistent hypertension and four patients suffering secondary haemorrhage. All patients were treated accordingly and recovered well, with no mortality. From these results, it is concluded that patients with severe OSA (apnoea-hypopnoea index > 60 and lowest oxygen saturation < 80 per cent) are at higher risk of post-operative oxygen desaturation. Post-operative hypertension is more likely in patients with a prior history of hypertension. Routine post-operative admission to an intensive care unit for all OSA patients is unnecessary (including patients with severe OSA). However, all patients with OSA should be closely monitored in the post-anaesthesia care area for at least three hours after surgery; based on the outcome of this period and the clinical judgment of the clinician, the patient can then be observed overnight in either the high dependency unit or on a general ward. Patients with mild OSA may be admitted to the 23-hour ambulatory unit post-operatively. Use of continuous positive airway pressure in the immediate post-operative period can reduce the incidence of post-operative respiratory compromise and complications and is strongly recommended.     

Lingual tonsillitis. Report of 3 cases and literature review

Lingual tonsillitits is a relatively uncommon pathology that affects specially patients with previous palatine tonsillectomy and its clinical behaviour is even more notorious than an acute tonsillitis. We report 3 cases hospitalized by our ENT Department analysing the initial symptoms, complementary tests, treatment and clinical evolution. In one of the patients that diagnosis probably was secondary to a complication due to an infectious mononucleosis and finally he was operated by surgical cauterization the lingual tonsils.     

Spontaneous orbital haematoma

Spontaneous orbital haematoma is uncommon in ENT practice. The sudden presentation of proptosis and diplopia may guide the differential diagnosis towards more common pathologies such as an intraorbital complication of acute sinusitis or neoplasm of the orbit. The diagnosis by computed tomography (CT) scan, the management of this orbital disease and the literature in this field are discussed.     

儿童流行性腮腺炎并发急性胰腺炎和感音神经性聋1例及文献复习

目的：探讨流行性腮腺炎并发急性胰腺炎和感音神经性聋的临床特征,听力学表现,早期诊断与预后。方法：报告并分析1例流行性腮腺炎并发急性胰腺炎和感音神经性聋患者的临床资料,并复习有关文献。结果：流行性腮腺炎病毒感染可致多器官损害,出现一种或多种并发症,而同时并发急性胰腺炎和感音神经性聋临床少见,多表现为单侧突发的完全性聋,预后差。结论：流行性腮腺炎可同时并发包括感音神经性聋在内的一种或多种并发症,听性脑干反应对流行性腮腺炎并发感音神经性聋的早期诊断有一定的价值。     

Investigation of cardiac function in children with suspected obstructive sleep apnea

OBJECTIVE: To assess the prevalence of cardiac failure in a group of children with suspected obstructive sleep apnea (OSA) and to assess the need for preoperative electrocardiograms (ECGs) and chest radiographs (CXRs) in children with OSA. DESIGN: Case record review of 271 children having (adeno)tonsillectomy for symptoms of OSA. METHOD: Preoperative ECGs and CXRs were assessed for signs of right atrial or ventricular hypertrophy or failure. Case records were assessed for evidence of cardiac failure during anaesthesia. RESULTS: One child with congenital heart disease had signs of cardiac failure preoperatively. No other cases of atrial or ventricular hypertrophy or failure were found. CONCLUSIONS: Cardiac failure appears to be uncommon in children with symptoms of OSA. Preoperative ECG and CXR are essential in only selected cases.     

Negative-pressure pulmonary edema after resection of mediastinum thyroid goiter

Negative-pressure pulmonary edema (NPPE) is an uncommon but life-threatening complication of acute or chronic upper airway obstruction; however, there are few reports of NPPE after giant goiter resection. We report a case with severe NPPE induced by the resection of a mediastinum thyroid goiter. The patient was successfully treated by non-invasive positive airway ventilation (NPPV).     

Negative-pressure pulmonary edema after resection of mediastinum thyroid goiter

Negative-pressure pulmonary edema (NPPE) is an uncommon but life-threatening complication of acute or chronic upper airway obstruction; however, there are few reports of NPPE after giant goiter resection. We report a case with severe NPPE induced by the resection of a mediastinum thyroid goiter. The patient was successfully treated by non-invasive positive airway ventilation (NPPV).     

Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery

The aim of this study was to evaluate prevalence of obstructive sleep apnea among patients undergoing bariatric surgery and the predictive value of various clinical parameters: body mass index (BMI), neck circumference (NC) and the Epworth Sleepiness Scale (ESS). We performed a prospective, multidisciplinary, single-center observational study including all patients on the waiting list for bariatric surgery between June 2009 and June 2010, irrespective of history or clinical findings. Patients visited our ENT outpatient clinic for patient history, ENT and general examination and underwent a full night polysomnography, unless performed previously. As much as 69.9% of the patients fulfilled the criteria for OSA (mean BMI 44.2 ± SD 6.4 kg/m²); 40.4% of the patients met the criteria for severe OSA. The regression models found BMI to be the best clinical predictor, while the ROC curve found the NC to be the most accurate predictor of the presence of OSA. The discrepancy of the results and the poor statistical power suggest that all three clinical parameters are inadequate predictors of OSA. In conclusion, in this large patient series, 69.9% of patients undergoing BS meet the criteria for OSA. More than 40% of these patients have severe OSA. A mere 13.3% of the patients were diagnosed with OSA before being placed on the waiting list for BS. On statistical analysis, increased neck circumference, BMI and the ESS were found to be insufficient predictors of the presence of OSA. Polysomnography is an essential component of the preoperative workup of patients undergoing BS. When OSA is found, specific perioperative measures are indicated.     

Disordered breathing during sleep in patients with mucopolysaccharidoses

OBJECTIVE: Obstructive sleep apnoea (OSA) has been reported as a feature of children with mucopolysaccharidoses (MPS). However, the incidence and severity of OSA with respect to disease type is poorly defined. The aim of the present study was to measure objectively the degree of OSA in a group of children with a range of MPS syndromes. METHODS: In a cross-sectional study, cardiopulmonary sleep studies were performed during unsedated sleep in 26 children with MPS over a period of 2 years. Scores of OSA severity based upon clinical history and upon objective sleep study data were made in each case and compared. RESULTS: OSA was present in 24/26 patients, and ranged in severity from mild to severe. OSA was most marked in MPS type IH (Hurler syndrome) followed by types IHS (Hurler--Scheie syndrome) and II (Hunter syndrome). Frequent arousals and poor sleep quality, not suspected clinically, were noted in several patients. There was agreement between the clinical and objective scoring systems in only 17/26 patients (65%) with clinical history scores tending to underestimate the most severe cases (5/26 cases) and overestimate the severity in the mild cases (4/26 cases). CONCLUSIONS: Obstructive respiratory problems are frequent in MPS patients and there are differences in severity of OSA between the different MPS types. Assessments of the severity of OSA based upon clinical history alone are inadequate. Our results suggest that objective sleep studies are necessary to evaluate these cases, to monitor clinical outcome and to assess the effects of therapeutic intervention. Prospective studies in larger numbers of patients are needed to validate these observations.     

Sternoclavicular joint septic arthritis manifesting as a neck abscess: a case report

Septic arthritis of the sternoclavicular joint is an uncommon condition, and the diagnosis can be missed until a complication occurs. The sternoclavicular joint is more often involved in ankylosing spondylitis, degenerative arthritic conditions (i.e., rheumatoid arthritis and osteoarthritis), and primary and secondary metastatic conditions. The patient described in this case report came to the otolaryngology department on two occasions for treatment of a unilateral cutaneous neck abscess. The correct diagnosis was not made until the second visit. The author reviews the clinical course, diagnosis, and treatment of this uncommon disease.     

Sudden cardiorespiratory arrest in adults with acute epiglottitis. Report of 2 cases

We report two adult cases of sudden cardiorespiratory arrest because an acute epiglottitis that ocurred in our hospital. Although it is an uncommon pathology nowdays with good prognosis generally, we try to call the attention about this complication which can happen of unforseeable way even in previous absence of respiratory obstruction. One of the patients required coniotomy in ICU due to impossibility of orotracheal intubation (OI) and the other died in spite of an urgent performance.     

Presentation of rhinosinugenic intracranial abscesses

Intracranial abscesses secondary to rhinosinugenic disease are uncommon and the incidence is poorly documented. It is generally believed that individuals at risk of developing this complication can be identified by presenting clinical features. A ten year retrospective Scottish national survey 1976-1985 of intracranial abscesses was carried out. Clinical and or radiological evidence of nasal/paranasal aetiology in abscesses localised to the frontal lobe, extradural or subdural spaces allowed 23 surgery or autopsy confirmed abscesses to be classified as rhinosinugenic. 12 abscesses occurred in individuals aged 0-19 years, two in patients with risk factors for intracranial spread, 8 of 11 adults had similar predisposing features (p less than 0.01). This is a rare complication and individuals at risk in the first two decades of life can seldom be identified prospectively on clinical grounds.     

口面肌功能治疗对阻塞性睡眠呼吸暂停研究进展

目的 系统回顾口面肌功能治疗(OMT)相关文献,就OMT的动作、机制及对阻塞性睡眠呼吸暂停(OSA)的疗效进行分析。 方法 使用Pubmed、CNKI、万方医学进行搜索截至2020年6月前的相关文献。 结果 共回顾24篇研究,包括14篇研究成人OSA,10篇研究儿童OSA,其中有20项研究均显示治疗前后AHI有改善,但改善程度主要取决于OSA严重程度及治疗时间。 结论 研究证明OMT对治疗单纯打鼾、成人轻至重度OSA、儿童OSA均有效果,可作为治疗OSA的一种重要替代治疗。但OSA的发病机制尚不完全清楚,且相关临床试验和样本数量较少,仍需进一步研究。     

Identification of Obstructive Sleep Apnea in Patients Who Snore

As the field of sleep medicine has evolved, the clinical implications of obstructive sleep apnea (OSA) in snoring patients have become well accepted. Recent advances in surgical therapy for snoring allow otolaryngologists to offer simple outpatient treatment to patients with this problem. However, because the incidence of OSA in snorers seeking medical attention is unknown, the appropriate pretreatment evaluation of these patients is a subject of continued debate. Ninety-four snoring patients were recruited for a study to determine the incidence of OSA in this highly selected population. Subjects answered an extensive sleep questionnaire to determine factors that might suggest a diagnosis of OSA. Level III ambulatory sleep studies were performed on each participant. The incidence of OSA in this group was 72% (42% severe and 30% mild to moderate). Twenty of the subjects with OSA also underwent formal level I sleep studies, and the diagnosis of OSA was confirmed in each instance. Although there was a relationship between body mass index and OSA and certain questions correlated with OSA, the sensitivity and specificity of these data alone or in combination were too low to recommend their use in lieu of a formal sleep study. Given the remarkably high incidence of OSA in this group, which may reflect that seen by otolaryngologists who treat snoring, a sleep study should be performed to diagnose OSA and institute therapy for this condition. Level III ambulatory monitoring devices may be the most cos-teffective alternative for evaluating this high-risk population.     

Incidence of serious complications after uvulopalatopharyngoplasty

OBJECTIVES: Uvulopalatopharyngoplasty (UPPP) is the most common surgical treatment for obstructive sleep apnea (OSA). Anatomic and physiologic abnormalities associated with OSA can make perioperative management difficult. Only single-site case series provide current estimates of the incidence of perioperative complications, with a pooled crude serious complication rate of 3.5% and a crude mortality rate of 0.4%. The primary objective of this study was to calculate the incidence of perioperative morbidity and mortality in a large, multisite cohort of UPPP patients. STUDY DESIGN: Prospective cohort study of adults undergoing inpatient UPPP with or without other concurrent procedures METHODS: The serious complication and 30-day mortality rates were calculated from the Department of Veterans Affairs (VA) National Surgical Quality Improvement Program database of prospectively collected outcomes of all VA inpatient surgeries nationally 1991 to 2001. Serious complications were defined by 15 specific life-threatening complications. Deaths were captured whether the patient was in the hospital or discharged. RESULTS: Veteran patients (n = 3130) had a mean age of 50 years and were predominantly male (97%). The serious nonfatal complication rate was 1.5% (47/3,130) (95% confidence interval [CI] 1.1%, 1.9%). The 30-day mortality rate was 0.2% (7/3130) (95% CI 0.1%, 0.4%). There was no significant effect of year of surgery or patient age on the risk of serious complication or death. CONCLUSION: The incidence of serious nonfatal complications and 30-day mortality after UPPP are 1.5% and 0.2%, respectively, in a large cohort of UPPP patients at veteran hospitals.     

The characteristics of children with epiglottitis who develop the complication of pulmonary edema

A review was performed of 234 consecutive cases of epiglottis that occurred during a 20-year period to delineate the rate of, and clinical characteristics associated with, the complication of pulmonary edema. As a result of the prior utilization of a "dual" management protocol, there were 170 children who received endotracheal intubation, and 64 children managed without placement of an artificial airway. In all, five children (2.1%) of varying ages developed this complication--all experienced severe airway obstruction progressing to respiratory arrest, with evidence of pulmonary edema developing shortly after endotracheal intubation. Two of these five children died due to complications resulting from upper airway obstruction-induced cardiorespiratory arrest. By contrast, no child with milder degrees of airway obstruction managed without an artificial airway exhibited clinical evidence of pulmonary edema. Several possible mechanisms for the development of this complication are described. Pulmonary edema associated with epiglottitis is an uncommon complication that can occur following endotracheal intubation in those patients with marked respiratory insufficiency. An artificial airway should be instituted in all cases of pediatric epiglottitis--the potential complication of pulmonary edema should be anticipated before placement of an artificial airway, especially in those patients with a severe degree of upper airway obstruction.     

阻塞性睡眠呼吸暂停与肿瘤相关性进展

阻塞性睡眠呼吸暂停(OSA)作为一种世界流行的慢性疾病,近年来其发生率逐年增加。OSA的主要特点是上气道反复塌陷,由此引起反复的呼吸暂停、低通气和频繁血氧饱和度下降,进而引发睡眠片段化、睡眠结构紊乱,患者通常伴有白天嗜睡、注意力不集中等。长期的睡眠片段化和微觉醒状态与许多慢性疾病结局相关,比如高血压、心肌梗死、2型糖尿病、阿尔兹海默病等。另外,OSA还与肿瘤密切相关。随着OSA和低氧血症严重程度的增加,相关的多种肿瘤的发生率与死亡率也增加,如肺癌、乳腺癌、鼻咽癌、前列腺癌、中枢神经系统的肿瘤等。论文对阻塞性睡眠呼吸暂停的概况、与肿瘤相关的统计学证据进行综述,并讨论了OSA与肿瘤相关的分子机制、治疗等方面的内容,旨在为阻塞性睡眠呼吸暂停与肿瘤的相关研究及临床实践提供参考依据,为进一步研究治疗方法提供新思路。     

Tuberculous pyomyositis of the temporal muscle in a nonimmunocompromised woman: diagnosis by sonography

Pyomyositis (PM) is an uncommon cause of acute bacterial infection occurring in skeletal muscle. This disease is rare in non-tropical areas, and PM caused by Mycobacterium is very rare in a non-immunocompromised person. The presence of temporal area swelling may lead to a differential diagnosis toward more common pathologies, such as a complication of mastoiditis or a neoplasm of the temporal area. This article describes a case of tuberculous pyomyositis in a non-immunocompromised woman, the diagnosis of which was confirmed by sonographically guided fine-needle aspiration.