Snoring surgery: which one is best for you?

Excessive snoring is a common problem that is frequently treated surgically. In the early 1980s, uvulopalatopharyngoplasty was introduced to the United States as the first surgical treatment for excessive snoring. It remains in common use, but its limitations created an incentive to develop a procedure that is as effective, but safer and more economical. Several other surgical procedures for snoring were developed, including laser-assisted uvulopalatoplasty, palatal stiffening operations, and radiofrequency ablation. Each of these procedures has its own advantages and limitations; which procedure is the best treatment for excessive snoring is controversial. We present our experience with each of these procedures, along with a thorough review of the literature, to help the otolaryngologist determine which is the best snoring surgery for the individual patient.     

Reappraisal of probing of the congenital obstruction of the nasolacrimal system: is nasal endoscopy essential?

OBJECTIVE: The rate of false passages during probing for congenital nasolacrimal system obstruction (CNLO) is a major limiting factor for a successful outcome. This shortcoming may be decreased with the use of a nasal endoscope during probing. This approach is particularly important in the probing training of ophthalmology residents. METHODS: An experienced pediatric ophthalmologist performed probings on 11 eyes, and a group of ophthalmology residents under his supervision performed probings on another 11 eyes for CNLO. Their claims of a successful or unsuccessful procedure were evaluated with nasal endoscopy by an ear--nose--throat (ENT) surgeon. The age range of the patients was 8-23 months. RESULTS: The ophthalmologist made two false passages, one of which he was aware, out of 11 eyes. The residents had five false passages, two of which were unclear to them, out of another 11 eyes. No false passages occurred in obstructions at the level of the Hasner valve. None of the successful probings required more than a 30 mm probe introduction into the nasolacrimal canal from the inferior punctum. CONCLUSION: It seems justified to have a nasal endoscopic evaluation, performed by an ENT surgeon, for probings during the training program of ophthalmology residents. Difficult cases with stenosis proximal to the inferior meatus, prior false passage experience on a particular case, and any indication for silicone tube implantation will benefit from the use of an endoscope during the procedure. In order to achieve the best results in CNLO, the collaborative teamwork of an ophthalmologist and an ENT specialist is necessary.     

Screening strategies for neonatal hearing loss: which test is best?

OBJECTIVE: The objective of this study was to evaluate the accuracy and cost effectiveness of three different methods of hearing screening in newborns. DESIGN: A prospective, randomized cohort design was used. One hundred and five newborns were tested in this preliminary study. SETTING: The study was conducted in a tertiary care hospital setting in both the well baby and special care nurseries. METHODS: Consenting subjects had their hearing tested using automated auditory brainstem response (AABR), distortion-product otoacoustic emissions, and click-evoked otoacoustic emissions. The time to perform the tests was recorded and the cost of each test was calculated. MAIN OUTCOME MEASURES: The main outcomes measured were the time taken to perform each test, the pass/fail rate for each test, and the estimated cost of the tests. RESULTS: In this small cohort of patients, we found that AABR was the most accurate test, but it took longer to perform and was more expensive than either of the otoacoustic emission tests. However, the sensitivity and specificity of otoacoustic emissions were less than that of AABR. Test time decreased as the examiner gained experience, and we anticipate that experience will also result in better accuracy for the otoacoustic emission tests. CONCLUSIONS: Hearing screening in a hospital-based newborn population is both feasible and cost effective. Although AABR was more expensive, its better accuracy must be considered. As technology improves, the cost of all three tests will diminish. More robust conclusions cannot be made based on this small patient population.     

Persistent epistaxis: what is the best practice?

Epistaxis is the commonest otolaryngological emergency, which is often managed by a nasal pack. A significant number of cases fail to respond to nasal packing and various surgical measures are available to control the nosebleed in these cases. However evidence is sparse regarding the best available surgical option for the management of persistent epistaxis. We designed a retrospective cohort study comparing endoscopic ligation of sphenopalatine artery (ELSA) and all other surgical options (non-ELSA) in the management of persistent epistaxis. All consecutive cases of persistent epistaxis between 1997-2004 (Feb) requiring operative intervention were included in the study and divided in two groups according to the surgical intervention. Postoperative epistaxis was excluded. Non-ELSA group consisted of various procedures including nasal cautery and packing, submucous resection, anterior ethmoid artery ligation, external carotid artery ligation, internal maxillary artery ligation. Both groups were matched for age, sex, risk factors, other medical conditions and medications. The main outcome measures evaluated were immediate success in arresting the bleeding and the mean hospital stay. Recurrence and patient acceptability of the procedure were the secondary variables investigated. We found that ELSA proved to be the best practice to manage persistent epistaxis on all measures of immediate success rate, shorter hospital stay, recurrence rate, and patient satisfaction.     

Biopsy of the olfactory epithelium from the superior nasal septum: is it possible to obtain neurons without damaging olfaction?

IntroductionOlfactory epithelium biopsy has been useful for studying diverse otorhinolaryngological and neurological diseases, including the potential to better understand the pathophysiology behind COVID-19 olfactory manifestations. However, the safety and efficacy of the technique for obtaining human olfactory epithelium are still not fully established.ObjectiveThis study aimed to determine the safety and efficacy of harvesting olfactory epithelium cells, nerve bundles, and olfactory epithelium proper for morphological analysis from the superior nasal septum.MethodsDuring nasal surgery, 22 individuals without olfactory complaints underwent olfactory epithelium biopsies from the superior nasal septum. The efficacy of obtaining olfactory epithelium, verification of intact olfactory epithelium and the presence of nerve bundles in biopsies were assessed using immunofluorescence. Safety for the olfactory function was tested psychophysically using both unilateral and bilateral tests before and 1 month after the operative procedure.ResultsOlfactory epithelium was found in 59.1% of the subjects. Of the samples, 50% were of the quality necessary for morphological characterization and 90.9% had nerve bundles. There was no difference in the psychophysical scores obtained in the bilateral olfactory test (University of Pennsylvania Smell Identification Test [UPSIT®]) between means before biopsy: 32.3 vs. postoperative: 32.5, p = 0.81. Also, no significant decrease occurred in unilateral testing (mean unilateral test scores 6 vs. 6.2, p = 0.46). None out of the 56 different odorant identification significantly diminished (p > 0.05).ConclusionThe technique depicted for olfactory epithelium biopsy is highly effective in obtaining neuronal olfactory tissue, but it has moderate efficacy in achieving samples useful for morphological analysis. Olfactory sensitivity remained intact.     

Early hearing screening: what is the best strategy?

OBJECTIVES: A discussion concerning the relevance of universal newborn hearing screening has been conducted in France since the end of the 1990s. As a contribution to the choice of strategy to be implemented, we evaluated and compared the results of this screening and its impact on the parent-infant relationship as a function of the time at which screening was performed: during the infant's stay in the maternity unit, in the first strategy (strategy 1), or 2 months after birth, in the second strategy (strategy 2). PATIENTS AND METHOD: Five thousand seven hundred and ninety infants participated in the study: 3202 were included in the first strategy and 2588 were included in the second strategy. Within this population, 143 mother-infant pairs were submitted to psychological assessment. We compared the number of infants screened, the number of first positive tests, the number of false-positive tests and the number of infants not reviewed after screening. Adverse effects on the parent-infant relationship were evaluated in terms of maternal anxiety and the quality of early interactions. RESULTS: A statistically significant difference in favor of newborn screening was demonstrated for the number of infants screened: 95.72% for the first strategy [95.0%; 96.4%], 64.18% for the second strategy [62.3%; 66.0%]; the number of first positive tests: 1.11% during newborn screening [0.7%; 1.5%], 3.13% in the second strategy [2.3%; 4.0%]; the number of false-positive tests: 0.29% in the first strategy [0.10%; 0.49%] and 2.65% in the second strategy [1.88%; 3.42%]; and the number of infants not reviewed after screening: 8.8% during newborn screening [0.0%; 18.4%] and 38.5% in the second strategy [25.2%; 51.7%]. Analysis of the results of the psychological assessment showed that screening per se did not have any impact on maternal anxiety or on the quality of early interactions, regardless of the screening strategy used. However, the result of the test had a significant impact. Announcement of a positive result increased maternal anxiety and induced a deterioration of the mother's psychological state which affected the quality of early interactions. As the number of positive results is significantly lower in newborn hearing screening, there are consequently fewer psychological side effects with this strategy than with the second strategy. CONCLUSION: This study demonstrates that universal newborn hearing screening is the most efficient strategy.     

Excessive obesity is related to daily symptoms of nasal blockage: the Skövde population-based study

This study has as its focus on obesity as a factor of importance for nasal blockage. A random sample of 1.900 adults stratified according to age and gender were recruited from the general population. The study included a structured interview about symptoms of nasal blockage and asthma, and a clinical examination with nasal endoscopy. Smoking habits were evaluated by a questionnaire on current and previous smoking. A response rate of 73% was achieved. There was a statistically significant relationship between subjectively experienced daily nasal blockage and registered heavy overweight, but no relationship was found between nasal blockage and age, gender, diabetes or asthma. The odds ratio (OR) for individuals with excessive obesity to have daily symptoms of nasal blockage was 3.7 [95% CI 1.6-7.6]. In patients with nasal blockage, obesity as a cause should be taken into consideration.     

How good are patients at determining which side of the nose is more obstructed? A study on the limits of discrimination of the subjective assessment of unilateral nasal obstruction

BACKGROUND: The subjective sensation of nasal obstruction is of great importance to the patient and surgeon because it is this symptom that causes the patient to present for investigation and treatment. Although there are several studies in the literature looking at the correlation (or lack of correlation) between objective and subjective measures of nasal obstruction, there is no information on the minimum objective change in obstruction measured as nasal airway resistance or flow, which can be detected by a patient. The aim of this study was to measure the minimum difference in unilateral airflow that can be reliably detected by a patient. METHODS: Sixty participants with a common cold were recruited. One hundred twenty unilateral measurements of objective and subjective nasal obstruction were obtained using the technique of posterior rhinomanometry and a 100-mm visual analog scale (VAS). RESULTS: Seventy-seven percent of the participants correctly discriminated between the high- and low-flow nasal passages using the VAS. Ninety-five percent of subjects correctly discriminated on the VAS between the high- and low-flow nasal passages when the difference inflow between the nasal passages was at least 100 cm3/s. CONCLUSION: This study provides new knowledge about the limits of subjective sensation of nasal obstruction. At a level of 100 cm3/s difference in unilateral nasal flow, 95% of subjects with acute rhinitis can correctly identify the more obstructed nasal passage when using a VAS. With smaller differences in unilateral flow, the percentage of correct responses declines rapidly toward 50% as expected by chance alone.     

Pediatric rhabdomyosarcoma of the head and neck: is there a place for surgical management?

OBJECTIVE: To review and evaluate the place of surgical treatment in the management of rhabdomyosarcoma of the head and neck in children. DESIGN: Retrospective analysis of patient charts from January 1, 1972, to December 31, 1998. SETTING: Tertiary pediatric referral center. PATIENTS: Twenty-nine consecutive children with nonorbital head and neck rhabdomyosarcoma. INTERVENTIONS: Surgery, chemotherapy, and radiotherapy. MAIN OUTCOME MEASURES: Disease-free survival and long-term morbidity from treatment. RESULTS: Twenty patients had parameningeal and 9 had nonparameningeal head and neck tumors. All were treated with chemotherapy. For 18 patients, diagnostic biopsies were performed and they received radiotherapy. Eleven patients underwent surgery as definitive therapy. Using the Intergroup Rhabdomyosarcoma Study (IRS) staging system, 5 of these 11 patients had complete resection of tumor (IRS group I) and avoided radiotherapy. The other 6 patients required radiation because of compromised, regional, or incomplete resection of tumor. One had undergone regional resection with nodal involvement, and 2 had compromised resections with microscopic residual disease (IRS group II). Three had incomplete resections with gross residual tumor (IRS group III). Only 1 patient who underwent surgery ultimately died from recurrence at 2.7 years after an incomplete resection. The other 10 patients were relapse free at a median follow-up of 3.7 years (range 0.8-21.0 years). Long-term surgical morbidity was seen in 36% (4/11) of the patients and included facial nerve paralysis, trismus, and cosmetic deformity. CONCLUSIONS: Children with localized disease of the head and neck are able to undergo complete surgical resection, with low long-term surgical morbidity. By undergoing complete surgical resection, these children are able to avoid radiotherapy and its long-term complications, with no compromise in survival.