Service Profile of Orthognathic Surgery of a Medical School

Orthognathic surgeries are very important for both the correction of dentofacial deformities as well as for the treatment of obstructive sleep apnea/hypopnea syndrome. Nowadays, most of the population presents some type of morphological and/or functional disorder of the stomatognathic system.AimThe present study aims at assessing the information from the individuals treated in the Orthognathic Surgical Service of a Medical School.MethodsSearch in medical records - 2004-2008, identification procedures, individual characteristics, malocclusion and surgery.ResultsThe number of surgical treatments due to dentofacial deformities has been increasing. Maxillary advancement surgery alone comprised the highest number in the sample.ConclusionOrthognathic surgery cases have been increasing in the last years and maxillary advancement alone comprised the highest number of surgical treatments.     

Maxillomandibular Advancement for Persistent Obstructive Sleep Apnea After Phase I Surgery in Patients Without Maxillomandibular Deficiency

Objective To assess the outcomes of maxillomandibular advancement (MMA) for the treatment of persistent obstructive sleep apnea syndrome (OSA) after phase I reconstruction in patients who do not have maxillomandibular deficiency. Methods From January 1997 to September 1998, 25 patients previously treated with phase I reconstruction (uvulopalatoplasty, genioglossus advancement, and/or hyoid suspension) who did not have maxillary and mandibular deficiencies underwent MMA for persistent OSA. Variables examined include age, sex, body mass index (BMI), respiratory disturbance index (RDI), lowest oxygen saturation (LSAT), and cephalometric data. In addition, a minimum of 6 months after surgery, questionnaires containing a 10‐cm visual analogue scale (0 = no change, 10 = drastic change) were mailed to the patients. The questionnaire subjectively assessed the patient's perception of the facial appearance after surgery, whether there was pain or discomfort of the temporomandibular joint, the overall satisfaction with the treatment outcomes, and whether the patient would recommend the operation to other patients. Results Nineteen (76%) questionnaires were completed and returned by 15 men and 4 women. The mean age was 45.3 ± 6.6 years and the mean BMI was 33.1 ± 7.1 kg/m². The mean RDI improved from 63.6 ± 20.8 to 8.1 ± 5.9 events per hour, and the mean LSAT improved from 73.3 ± 13.2% to 88.1 ± 4.1%. One patient was defined as an incomplete responder (RDI >20). One patient reported transient pain and discomfort of the temporomandibular joint. Although all of the patients felt that there were changes in their facial appearance after surgery, 18 of the 19 patients gave either a neutral or a favorable response to their facial esthetic results. All of these patients were satisfied with the overall outcomes and would recommend the treatment to others. Conclusion MMA is a highly effective treatment for persistent OSA after phase I surgery in patients who otherwise do not have maxillomandibular deficiency. The patient satisfaction is extremely high. Furthermore, previous concerns of unfavorable postoperative facial esthetics and temporomandibular joint dysfunction do not appear to be significant.     

Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy

OBJECTIVES: To study complications of powered intracapsular tonsillectomy and adenoidectomy (PITA) in pediatric patients with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective chart review and long-term follow-up in office or by telephone interview. METHODS: We studied 278 patients who underwent PITA between September 2000 and October 2002. Outcome measures were postoperative bleeding, velopharyngeal insufficiency, need for hospital readmission, tonsil regrowth, and return of snoring or sleep apnea symptoms. RESULTS: All 278 children treated by PITA had immediate resolution of symptoms of OSA. Complications were noted in 11 patients (3.9%). Nine patients (3.2%) experienced tonsil regrowth with snoring, two of whom evolved to a return of OSA that was definitively managed by means of a complete tonsillectomy. Two patients (0.7%) had self-limited bleeding. None of the patients developed persistent velopharyngeal insufficiency or required hospital readmission. CONCLUSIONS: Microdebrider-assisted PITA is a safe and effective alternative for children otherwise treated with traditional tonsillectomy for symptoms of OSA due to adenotonsillar hypertrophy. This series suggests a 3.9% overall rate of complications, with the most common noted as tonsillar regrowth without recurrence of OSA. Prospective trials with longer follow-up may define higher complication rates.     

悬雍垂腭咽成形术后鼻咽瘢痕狭窄的治疗

目的探讨悬雍垂腭咽成形术（uvulopalatopharyngoplasty，UPPP）术后鼻咽瘢痕狭窄的治疗。方法回顾性分析1997年11月至2006年2月北京协和医院耳鼻咽喉科治疗的UPPP术后鼻咽狭窄6例患者的临床资料。2例中度（Ⅱ型）狭窄，采用转咽部双黏膜瓣法，重建黏膜化的新软腭外侧游离缘，并修复咽侧裸露的创面，扩大咽腔。4例重度（Ⅲ型）狭窄，曾行1-次鼻咽狭窄矫治术后失败，其中1例放置网状记忆合金支架后咽闭锁。除了采用上述转咽部双黏膜瓣修复外，4例Ⅲ型患者术后佩戴中空的鼻咽支撑物扩张半年。结果6例随访9个月～4年，鼻塞等不适症状去除。鼻咽气道狭窄校正，无鼻咽反流症状。间断佩戴自制的牙托式鼻咽扩张支架，能明显减少对日常工作和交往的干扰。结论手术扩大狭窄咽腔，重度者术后佩戴牙托式鼻咽扩张支架，是目前治疗UPPP术后鼻咽狭窄较理想的方法。     

Nasal surgery for snoring in patients with obstructive sleep apnea

OBJECTIVE: To evaluate the efficacy of nasal surgery to relieve snoring and to identify predictive factors. STUDY DESIGN: Prospective comparative study. METHODS: Fifty-two consecutive patients (51 males; mean age, 38 yr; body mass index, 25.4 +/- 5.2 kg/m2) were enrolled. All patients had been previously diagnosed with obstructive sleep apnea (apnea/hypopnea index, 38.5 +/- 33.2 events/hr) and symptomatic nasal obstruction secondary to deviated nasal septum. Septomeatoplasty alone was the treatment in this study cohort. Snoring was assessed by Snore Outcome Survey (SOS), and nasal obstruction was assessed by visual analogue scale (VAS) and anterior rhinomanometry at baseline and approximately 3 months after nasal surgery. RESULTS: Body mass index remained unchanged (P > .05) after surgery. Significantly improved SOS (P < .001), VAS (P < .001), and total nasal resistance (P = .002) were noted after nasal surgery. Eighty-six percent of patients had improved SOS scores, and average improvement was 46%. Complete relief of snoring was reported by the sleep partners of six (12%) patients. Change in SOS scores (22.5 +/- 14.5 vs. 10.1 +/- 10.4) significantly differed (P = .01) between tonsil size grade (TON) 0/I and TON II/III groups. Other baseline variables did not significantly differ (P > .05) in SOS score changes. CONCLUSIONS: In patients with obstructive sleep apnea suffering from both snoring and nasal obstruction, nasal surgery for deviated septum relieves snoring in 12%. The tonsil size affects the outcome of nasal surgery for snoring.     

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.     

Radiofrequency ablation for the treatment of obstructive sleep apnea: a meta-analysis

Objectives/Hypothesis: Recent studies suggest that radiofrequency ablation (RFA) is a treatment option for patients with obstructive sleep apnea (OSA). This study investigates the effectiveness of RFA in treating OSA using a critical literature review and meta‐analysis. Study Design: Critical literature review and meta‐analysis. Methods: Two independent searches of PubMed 1966‐present were performed to identify publications pertaining to RFA and OSA. Effectiveness of the procedure was measured by comparing the Epworth Sleepiness Scale (ESS), respiratory disturbance index (RDI), and lowest O₂ saturation before and after tissue ablation. Results: Sixteen studies met the inclusion criteria. The study found a 31% reduction in short‐term ESS (odds ratios (OR) 0.69, 95% confidence interval (CI) 0.63–0.75), which was maintained beyond 12 months (OR 0.68, 95% CI 0.43–0.73). Likewise, RFA resulted in a 31% reduction in short term (<12 month) (OR 0.69, 95% CI 0.61–0.77) and 45% reduction (OR 0.55, 95% C.I. 0.45–0.72) in long‐term (>24 month) RDI levels. Short‐term results of the lowest O₂ saturations failed to demonstrate improvement (OR 1.03, 95% CI 0.88–1.20). Conclusion: RFA seems to be a clinically effective tool that reduces ESS scores and RDI levels in patients with OSA syndrome. The procedure should be considered a valid treatment option for patients who refuse or are unable to tolerate continuous positive airway pressure.     

A comparison of the Fujita classification of awake and drug-induced sleep endoscopy patients

Only a few studies have compared the outcomes of patients kept awake during endoscopic examination and subjects submitted to drug-induced sleep endoscopy.ObjectiveThis study aimed to compare the endoscopic findings of patients submitted to outpatient endoscopy and endoscopic examination with sedation by propofol based on the Fujita Classification.MethodThis cross-sectional cohort study enrolled 34 patients. The subjects underwent ENT examination, nasal endoscopy with Müller's maneuver, and drug-induced sleep endoscopy with propofol. The Fujita Classification was used to compare the two modes of endoscopic examination. The examinations were correlated to patient clinical data such as BMI, age, and OSAS severity.ResultsThere was no agreement between the two modes of endoscopic examination, whether for the group in general or for the analyzed subgroups.ConclusionThere was no agreement between the endoscopic findings of endoscopic examinations done with the patient awake or in drug-induced sleep.     

Transoral robotic lingual tonsillectomy in adults: preliminary results

Conclusion: Hypertrophy of lingual tonsils can be safely and effectively managed by transoral robotic surgery via a minimally invasive approach. The operating costs can be relatively high although the advantages to patients seem to justify the procedure. Transoral robotic surgery can represent the definitive treatment in hypertrophy of the lingual tonsils. Objective: The purpose of this work was to assess the feasibility, safety, and outcomes of transoral robotic surgery for lingual tonsillar hypertrophy in adults with obstructive sleep apnea. Methods: Retrospective medical records of six patients who underwent tongue base resection using the da Vinci Surgical Robotic System from September, 2012 through December, 2013 in a tertiary care hospital were evaluated. Demographic data, preoperative and postoperative polysomnography and Epworth Sleepiness Scale (ESS) scores, robot docking time, operative and postoperative aspects including surgical time, amount of bleeding, and early and late complications were collected and analyzed. Results: All patients successfully underwent lingual tonsillectomy using the da Vinci Surgical system. Transnasal endotracheal entubation was performed in all patients and they were all extubated before leaving the operation room. No tracheotomies were performed perioperatively for airway management. The patients were discharged on the fifth postoperative day. Operative time, estimated blood loss, and postoperative complication profiles were within the expected and acceptable limits for lingual tonsillectomy. There was a statistically significant decrease in apnea hypopnea index (AHI) (mean AHI from 27.5 to 6.3) and ESS scores (from 14.1 to 7.1).