Publications by authors named "Colin Huntley"

43 Publications

Improving outcomes of hypoglossal nerve stimulation therapy: current practice, future directions and research gaps. Proceedings of the 2019 International Sleep Surgery Society Research Forum.

J Clin Sleep Med 2021 Jul 19. Epub 2021 Jul 19.

Divisions of Pediatric Otolaryngology, Pulmonary Medicine, and the Sleep Center; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Otolaryngology - Head and Neck Surgery of University of Cincinnati College of Medicine, Cincinnati, OH.

Hypoglossal nerve stimulation (HGNS) has evolved as a novel and effective therapy for patients with moderate-to-severe obstructive sleep apnea (OSA). Despite positive published outcomes of HGNS, there exist uncertainties regarding proper patient selection, surgical technique, and the reporting of outcomes and individual factors that impact therapy effectiveness. According to current guidelines, this therapy is indicated for select patients, and recommendations are based on the Stimulation Therapy for Apnea Reduction (STAR) trial. Ongoing research and physician experiences continuously improve methods to optimize the therapy. An understanding of the way in which airway anatomy, OSA phenotypes, individual health status, psychological conditions and comorbid sleep disorders influence the effectiveness of HGNS is essential to improve outcomes and expand therapy indications. This manuscript presents discussions on current evidence, future directions, and research gaps for HGNS therapy from the 10th International Surgical Sleep Society expert research panel.
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http://dx.doi.org/10.5664/jcsm.9542DOI Listing
July 2021

Virtual otolaryngologic management of sleep apnea patients: Lessons learned from COVID-19 pandemic.

Laryngoscope Investig Otolaryngol 2021 Jun 5;6(3):564-569. Epub 2021 May 5.

Department of Otolaryngology-Head and Neck Surgery University of Michigan Ann Arbor Michigan USA.

Objective: To discuss the virtual management options and strategies learned during the COVID-19 pandemic for treatment of patients with sleep complaints and sleep disordered breathing presenting to the otolaryngologist.

Methods/results: The addition of a virtual evaluation can be beneficial in assessing the patient presenting to the otolaryngologist with sleep complaints. With the implementation of telemedicine, validated subjective assessment tools, and a limited physical exam, patients can be triaged for the need for treatment implementation, further evaluation or testing, and counseled regarding various management options.In this article, we discuss the lessons learned from the authors' collective experience on how to effectively use telemedicine as a tool in the management repertoire for patients with sleep disorders.

Conclusion: The otolaryngologist will commonly see patients with sleep complaints, particularly patients diagnosed with obstructive sleep apnea not able to tolerate conservative therapies. These patients are well suited for virtual evaluation utilizing telemedicine. The technology and workflows which have been developed during the COVID-19 pandemic can be carried forward for select patients to improve access and efficiency of care.Level of evidence: 5.
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http://dx.doi.org/10.1002/lio2.562DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8223474PMC
June 2021

Upper airway stimulation: Fewer complications, ED presentations, readmissions, and increased surgical success.

Am J Otolaryngol 2021 Apr 7;42(5):103035. Epub 2021 Apr 7.

Thomas Jefferson University Hospital, Department of Otolaryngology - Head and Neck Surgery, 925 Chestnut St, Philadelphia, PA 19107, United States of America.

Objectives: Evaluate the rate of complications, readmissions, emergency department presentations, and surgical success rates amongst three standard surgical treatment options for obstructive sleep apnea: upper airway stimulation, transoral robotic surgery, and expansion sphincter pharyngoplasty.

Study Design: Retrospective cohort.

Setting: Tertiary care center.

Methods: Patients were included who were aged ≥18 years old and underwent upper airway stimulation, transoral robotic surgery, or expansion sphincter pharyngoplasty between January 2011 and May 2020.

Results: 345 patients were identified: 58% (n = 201) underwent upper airway stimulation, 10% (n = 35) underwent transoral robotic surgery, and 32% (n = 109) patients underwent expansion sphincter pharyngoplasty. There were 22 emergency department presentations and 19 readmissions, most of which were experienced by patients receiving transoral robotic surgery (six emergencies, seven readmissions) and expansion sphincter pharyngoplasty (12 emergencies, 11 readmissions). Patients with upper airway stimulation had four emergencies and one readmission. Only 2% of the upper airway stimulation cohort had a complication, whereas this was 20% and 12% for the transoral robotic surgery and expansion sphincter pharyngoplasty cohorts, respectively. Patients experienced the highest surgical success rate with upper airway stimulation (69%), whereas patients who received transoral robotic surgery and expansion sphincter pharyngoplasty had success rates of 50% and 51%, respectively.

Conclusion: Treating obstructive sleep apnea with upper airway stimulation led to lower rates of complications, emergency department presentations, and readmissions in this series. In those for whom upper airway stimulation is appropriate, it may be more effective in successfully treating obstructive sleep apnea than transoral robotic surgery and expansion sphincter pharyngoplasty.
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http://dx.doi.org/10.1016/j.amjoto.2021.103035DOI Listing
April 2021

Hypoglossal nerve stimulation impact on a patient with obstructive sleep apnea and heart failure.

J Clin Sleep Med 2021 05;17(5):1125-1127

Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

A 75-year-old man with body mass index of 30.5 kg/m² and severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 72 events/h was referred for upper airway stimulation (UAS) therapy. Past medical history was significant for cardiovascular disease including congestive heart failure due to ischemic cardiomyopathy with impaired left ventricular function and ejection fraction of 35%. Following evaluation of clinical and polysomnographic data, he was an appropriate candidate for UAS and underwent uncomplicated implantation. Three months postoperatively, polysomnography showed a titrated AHI of 0 events/h. Follow-up cardiac evaluation revealed ejection fraction increase to 47% since implantation. No interval change in medical management or body mass index had occurred. Given the high prevalence of OSA in patients with cardiovascular disease, UAS may become an important adjunct in the comprehensive multidisciplinary treatment of heart failure in patients with OSA. Further clinical studies are required to investigate the impact of UAS on treatment and prognosis of heart disease.
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http://dx.doi.org/10.5664/jcsm.9090DOI Listing
May 2021

Drug-Induced Sleep Endoscopy and Hypoglossal Nerve Stimulation Outcomes: A Multicenter Cohort Study.

Laryngoscope 2021 07 14;131(7):1676-1682. Epub 2021 Jan 14.

USC Caruso Department of Otolaryngology-Head and Neck Surgery, Keck School of Medicine of the University of Southern California, California, Los Angeles, U.S.A.

Objectives/hypothesis: To determine the association between findings of blinded reviews of preoperative drug-induced sleep endoscopy (DISE) and outcomes of hypoglossal nerve stimulation (HNS) for obstructive sleep apnea (OSA).

Study Design: Cohort study.

Methods: A retrospective, multicenter cohort study of 343 adults who underwent treatment of OSA with HNS from 10 academic medical centers was performed. Preoperative DISE videos were scored by four blinded reviewers using the VOTE Classification and evaluation of a possible primary structure contributing to airway obstruction. Consensus DISE findings were examined for an association with surgical outcomes based on therapy titration polysomnogram (tPSG). Treatment response was defined by a decrease of ≥50% in the apnea-hypopnea index (AHI) to <15 events/hour.

Results: Study participants (76% male, 60.4 ± 11.0 years old) had a body mass index of 29.2 ± 3.6 kg/m . AHI decreased (35.6 ± 15.2 to 11.0 ± 14.1 events/hour; P < .001) on the tPSG, with a 72.6% response rate. Complete palate obstruction (vs. none) was associated with the greatest difference in AHI improvement (-26.8 ± 14.9 vs. -19.2 ± 12.8, P = .02). Complete (vs. partial/none) tongue-related obstruction was associated with increased odds of treatment response (78% vs. 68%, P = .043). Complete (vs. partial/none) oropharyngeal lateral wall-related obstruction was associated with lower odds of surgical response (58% vs. 74%, P = .042).

Conclusions: The DISE finding of primary tongue contribution to airway obstruction was associated with better outcomes, whereas the opposite was true for the oropharyngeal lateral walls. This study suggests that the role for DISE in counseling candidates for HNS extends beyond solely for excluding complete concentric collapse related to the velum.

Level Of Evidence: 3 Laryngoscope, 131:1676-1682, 2021.
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http://dx.doi.org/10.1002/lary.29396DOI Listing
July 2021

A systematic approach to the evaluation and management of obstructive sleep apnea: The Jefferson Protocol.

Am J Otolaryngol 2021 Mar-Apr;42(2):102866. Epub 2020 Dec 29.

Department of Otolaryngology, Head and Neck Surgery, Thomas Jefferson University, 925 Chestnut Street, Otolaryngology, 7th Floor, Philadelphia, PA 19107, United States of America. Electronic address:

Obstructive sleep apnea (OSA) has become increasingly prevalent in the United States. While continuous positive airway pressure (CPAP) therapy remains the gold standard for treatment, surgical intervention can enhance compliance and improve outcomes for those intolerant of CPAP. Since the majority of OSA patients have multilevel obstruction, it is critical that otolaryngologists understand each patient's pattern and anatomic level of obstruction before solidifying a treatment plan. This publication serves as a comprehensive review of evaluation, characterization, and management of OSA. Further, the authors outline their departmental algorithm for identifying ideal surgical candidates and tailoring corresponding surgical interventions.
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http://dx.doi.org/10.1016/j.amjoto.2020.102866DOI Listing
December 2020

Preoperative Screening for Obstructive Sleep Apnea Prior to Endoscopic Skull Base Surgery: A Survey of the North American Skull Base Society.

Allergy Rhinol (Providence) 2020 Jan-Dec;11:2152656720968801. Epub 2020 Nov 12.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: Obstructive sleep apnea (OSA) is a commonly seen comorbidity in patients undergoing endoscopic skull base surgery and its presence may influence perioperative decision-making. Current practice patterns for preoperative screening of OSA are poorly understood.

Objective: The objective of this study was to assess how endoscopic skull base surgeons screen for OSA, and how knowledge of OSA affects perioperative decision-making.

Methods: Seven question survey distributed to members of the North American Skull Base Society.

Results: Eighty-eight responses (10% response rate) were received. 60% of respondents were from academic centers who personally performed >50 cases per year. Most respondents noted that preoperative knowledge of OSA and its severity affected postoperative care and increased their concern for complications. Half of respondents noted that preoperative knowledge of OSA and its severity affects intraoperative skull base reconstruction decision-making. 70% of respondents did not have a preoperative OSA screening protocol. Body mass index and patient history were most frequently used by those who screened. Validated screening questionnaires were rarely used. 76% of respondents agreed or somewhat agreed that a preoperative polysomnogram should ideally be performed for patients with suspected OSA; however, 50% of respondents reported that <20% of their patients with suspected OSA are advised to obtain a preoperative polysomnogram.

Conclusion: This study reveals that most endoscopic skull base surgeons agree that OSA affects postoperative patient care, but only a minority have a preoperative screening protocol in place. Additional study is needed to assess the most appropriate screening methods and protocols for OSA patients undergoing endoscopic skull base surgery.
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http://dx.doi.org/10.1177/2152656720968801DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7672726PMC
November 2020

Reduced Recovery Times with Total Intravenous Anesthesia in Patients with Obstructive Sleep Apnea.

Laryngoscope 2021 04 3;131(4):925-931. Epub 2020 Nov 3.

Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: There is currently no standard of care in terms of anesthesia modality for patients receiving upper airway surgery with comorbid obstructive sleep apnea (OSA). Although both total intravenous anesthesia (TIVA) and volatile gas anesthesia are commonly utilized in ambulatory otolaryngology surgery, it is currently unclear if there are any advantages with one modality over the other. We hypothesize that patients receiving upper airway surgery with comorbid OSA will have quicker recovery times with TIVA.

Study Design: Retrospective chart review from January 2019 to December 2019.

Methods: All patients aged 18 and older receiving upper airway surgery (upper airway stimulation, nasal surgery, modified uvulopalatopharyngoplasty) were included. Patients were excluded when there was incomplete or missing data in the electronic medical record.

Results: Eighty-six patients received gas anesthesia and 62 patients received TIVA. Phase I recovery times were significantly reduced by surgery and by severity of OSA: nasal surgery, upper airway stimulation, and modified uvulopalatopharyngoplasty had a reduction of 35.5 minutes (P < .001), 42.5 minutes (P < .001), and 36 minutes (P = .022), respectively. In terms of severity, mild, moderate, and severe OSA had reductions of 23.5 minutes (P = .004), 52 minutes (P = .004), and 47 minutes (P < .001), respectively. The severity of OSA generally correlated with increased time spent in Phase I: as severity increased, Phase I time increased by 16.8 minutes for the gas cohort (P < .001), whereas in the TIVA cohort, it increased only 4.3 minutes (P = .489).

Conclusion: Patients having upper airway surgery with comorbid OSA that received TIVA (propofol and remifentanil) spent significantly less time in Phase I and the recovery room overall compared to those receiving volatile gas anesthesia in the form of sevoflurane, and this correlated with the severity of OSA.

Level Of Evidence: 3. Laryngoscope, 131:925-931, 2021.
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http://dx.doi.org/10.1002/lary.29216DOI Listing
April 2021

Tolerance of Continuous Positive Airway Pressure After Sinonasal Surgery.

Laryngoscope 2021 03 16;131(3):E1013-E1018. Epub 2020 Sep 16.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: For patients with obstructive sleep apnea (OSA) undergoing sinonasal surgery, there is a lack of consensus on the risk and appropriate postoperative use of continuous positive airway pressure (CPAP). The aim of this study was to assess the tolerability of restarting CPAP on postoperative day one.

Study Design: Prospective cohort study.

Methods: A prospective study on patients with OSA on CPAP who required a septoplasty/turbinectomy and/or functional endoscopic sinus surgery (FESS) was performed. Data from the memory card of a patient's CPAP machine and subjective information were obtained on the day of surgery and at scheduled follow-up visits. All subjects were instructed to restart CPAP on the first postoperative night.

Results: A total of 14 patients were analyzed; nine underwent FESS and five had a septoplasty/turbinectomy. There were no postoperative complications encountered. The only significant change in the first postoperative week was a reduction in the percentage of nights used over 4 hours (P < .05). By the third postoperative visit, average 22-item Sino-Nasal Outcome Test, Nasal Obstruction Symptom Evaluation, and CPAP tolerance scores improved from preoperative values. CPAP pressures, residual apnea-hypopnea index, and number of hours and mean percentage of nights used remained stable throughout the study period.

Conclusions: Both quality-of-life and CPAP outcomes improved or remained the same when restarting CPAP immediately postoperatively. Combined with a lack of significant complications, this study suggests that CPAP is well-tolerated when restarted the day after a septoplasty/turbinectomy or FESS.

Level Of Evidence: 4 Laryngoscope, 131:E1013-E1018, 2021.
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http://dx.doi.org/10.1002/lary.28968DOI Listing
March 2021

Evaluation of Surgical Learning Curve Effect on Obstructive Sleep Apnea Outcomes in Upper Airway Stimulation.

Ann Otol Rhinol Laryngol 2021 May 13;130(5):467-474. Epub 2020 Sep 13.

University Hospitals, Cleveland, OH, USA.

Objective: An increasing number of facilities offer Upper Airway Stimulation (UAS) with varying levels of experience. The goal was to quantify whether a surgical learning curve exists in operative or sleep outcomes in UAS.

Methods: International multi-center retrospective review of the ADHERE registry, a prospective international multi-center study collecting UAS outcomes. ADHERE registry centers with at least 20 implants and outcomes data through at least 6-month follow-up were reviewed. Cases were divided into two groups based on implant order (the first 10 or second 10 consecutive implants at a given site). Group differences were assessed using Mann-Whitney U-tests, Chi-squared tests, or Fisher's Exact tests, as appropriate. A Mann-Kendall trend test was used to detect if there was a monotonic trend in operative time. Sleep outcome equivalence between experience groups was assessed using the two one-sided tests approach.

Results: Thirteen facilities met inclusion criteria, contributing 260 patients. Complication rates did not significantly differ between groups ( = .808). Operative time exhibited a significant downward trend ( < .001), with the median operative time dropping from 150 minutes for the first 10 implants to 134 minutes for the subsequent 10 implants. The decrease in AHI from baseline to 12-month follow-up was equivalent between the first and second ten (22.8 vs 21.2 events/hour, respectively,  < .001). Similarly, the first and second ten groups had equivalent ESS decreases at 6 months (2.0 vs 2.0, respectively,  < .001). ESS outcomes remained equivalent for those with data through 12-months.

Conclusions: Across the centers' first 20 implants, an approximately 11% reduction operative time was identified, however, no learning curve effect was seen for 6-month or 12-month AHI or ESS over the first twenty implants. Ongoing monitoring through the ADHERE registry will help measure the impact of evolving provider and patient specific characteristics as the number of implant centers increases.
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http://dx.doi.org/10.1177/0003489420958733DOI Listing
May 2021

Comparison of Traditional Upper Airway Surgery and Upper Airway Stimulation for Obstructive Sleep Apnea.

Ann Otol Rhinol Laryngol 2021 Apr 29;130(4):370-376. Epub 2020 Aug 29.

Wayne State University, Detroit, MI, USA.

Objective: To compare patients with moderate-severe obstructive sleep apnea (OSA) undergoing traditional single and multilevel sleep surgery to those undergoing upper airway stimulation (UAS).

Study Design: Case control study comparing retrospective cohort of patients undergoing traditional sleep surgery to patients undergoing UAS enrolled in the ADHERE registry.

Setting: 8 multinational academic medical centers.

Subjects And Methods: 233 patients undergoing prior single or multilevel traditional sleep surgery and meeting study inclusion criteria were compared to 465 patients from the ADHERE registry who underwent UAS. We compared preoperative and postoperative demographic, quality of life, and polysomnographic data. We also evaluated treatment response rates.

Results: The pre and postoperative apnea hypopnea index (AHI) was 33.5 and 15 in the traditional sleep surgery group and 32 and 10 in the UAS group. The postoperative AHI in the UAS group was significantly lower. The pre and postoperative Epworth sleepiness scores (ESS) were 12 and 6 in both the traditional sleep surgery and UAS groups. Subgroup analysis evaluated those patients undergoing single level palate and multilevel palate and tongue base traditional sleep surgeries. The UAS group had a significantly lower postoperive AHI than both traditional sleep surgery subgroups. The UAS group had a higher percentage of patients reaching surgical success, defined as a postoperative AHI <20 with a 50% reduction from preoperative severity.

Conclusion: UAS offers significantly better control of AHI severity than traditional sleep surgery. Quality life improvements were similar between groups.
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http://dx.doi.org/10.1177/0003489420953178DOI Listing
April 2021

Upper Airway Stimulation versus Untreated Comparators in Positive Airway Pressure Treatment-Refractory Obstructive Sleep Apnea.

Ann Am Thorac Soc 2020 12;17(12):1610-1619

Department of Otolaryngology and Department of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania.

Understand the impact of insurance coverage on sleep apnea outcomes for patients awaiting upper airway stimulation. Examine the natural history of impact of upper airway stimulation treatment versus insurance denial (comparators) on sleep apnea outcomes. A parallel-arm experimental study design was used to compare objective sleep apnea measures and patient-reported outcomes in those who received upper airway stimulation approval versus denial in a multinational prospective study (NCT02907398). Wilcoxon rank-sum test and logistic regression models were used to assess for differences of objective and subjective outcome changes in those who underwent upper airway stimulation versus no treatment comparators. A greater reduction in apnea-hypopnea index was observed in those who underwent upper airway stimulation ( = 230, follow-up: 360 ± 171 d) versus no treatment ( = 100, follow-up: 272 ± 278 d), that is, -19.1 ± 15.8 versus -8.1 ± 20.9, respectively,  < 0.001, with consistent findings observed with nocturnal hypoxia measures. Concordantly, a greater improvement noted with subjective measures of dozing propensity was observed in patients undergoing upper airway stimulation versus comparators (Epworth Score, -5.1 ± 5.5 vs. 1.8 ± 3.7, respectively,  < 0.001) and overall sleep-related patient-reported outcomes. Women and those with previous oral appliance use had a lower odds of insurance approval (odds ratio [OR], 0.40; 95% confidence interval [95% CI], 0.22-0.71 and OR, 0.35; 95% CI, 0.18-0.69, respectively). Objective and subjective sleep apnea burden was more improved in those receiving upper airway stimulation versus not. Results underscore the need to optimize clinical care pathways focused on effective treatment of patients with obstructive sleep apnea who are not upper airway stimulation-insurance eligible and prioritize public health policy initiatives to address insurance-based sex-specific disparities.
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http://dx.doi.org/10.1513/AnnalsATS.202001-015OCDOI Listing
December 2020

Preferential use of total intravenous anesthesia in ambulatory otolaryngology surgery during the COVID-19 pandemic.

Am J Otolaryngol 2020 Sep - Oct;41(5):102570. Epub 2020 Jun 1.

Department of Otolaryngology - Head and Neck Surgery, Thomas Jefferson University Hospital, 925 Chestnut St., 6th Floor, Philadelphia, PA 19146, USA.

The novel coronavirus (SARS-CoV-2 or COVID-19) pandemic has impacted nearly every aspect of otolaryngologic practice. The transition from office-based evaluation to telemedicine and the number of postponed elective surgical cases is unprecedented. There is a significant need to resume elective surgical care for these patients at the appropriate time. As practices begin to move towards resuming elective and same day ambulatory surgery, safety of both the patient and healthcare team is of paramount importance. Usage of total intravenous anesthesia (propofol and remifentanil) over volatile gas anesthesia (e.g., sevoflurane) may increase the number of patients able to safely receive care by reducing potential spread of the virus through reduction in coughing and significantly decreasing the time spent in the recovery room.
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http://dx.doi.org/10.1016/j.amjoto.2020.102570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7263220PMC
September 2020

Feasibility of Early Discharge after Open Hypopharyngeal Surgery for Dysphagia.

Ann Otol Rhinol Laryngol 2020 Sep 14;129(9):894-900. Epub 2020 May 14.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To determine the rate of surgical complications, unplanned readmission, and functional status after open hypopharyngeal surgery for dysphagia with early return to oral diet and hospital discharge.

Methods: Retrospective chart review of patients who underwent open hypopharyngeal surgery for management of dysphagia from March 2013 to June 2018 at a single academic institution. A clear liquid diet is restarted the day of surgery and is advanced to a soft diet on postoperative day one. Univariate and multivariate logistic regression was performed to identify risk factors for postoperative complications and unplanned readmission.

Results: Ninety patients met eligibility criteria; 62 patients underwent open cricopharyngeal myotomy, 13 underwent Zenker's diverticulectomy, 15 had a Zenker's diverticulopexy. Mean inpatient length of stay was 2.0 ± 2.0 days (range 0-11 days); 57 patients (63.3%) were discharged on the same day as surgery or on postoperative day one. Seven patients (7.8%) had postoperative complications; the most common complication was esophageal leak (n = 6). Six patients (6.7%) had unplanned readmissions within 30 days. Mean time to unplanned readmission was 12 days (range 2-19 days). Open diverticulectomy was associated with an increased risk of unplanned readmission with an OR = 7.63 (95% CI 1.29, 45.45,  = .025). At last follow-up, 70% of patients had an increased functional oral intake by at least one scale score (FOIS) after surgery (mean follow-up 0.8 ± 1.1 years, range 0.02-5.1 years).

Conclusion: An early diet and discharge may be safe for patients undergoing open surgery without a mechanical or suture closure of their esophageal mucosa, whereas in those undergoing diverticulectomy, NPO status and a radiological check before resuming drinking and eating are advised.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0003489420916216DOI Listing
September 2020

3D printed temporal bone as a tool for otologic surgery simulation.

Am J Otolaryngol 2020 May - Jun;41(3):102273. Epub 2019 Aug 2.

Health Design Lab, Thomas Jefferson University, Philadelphia, PA, United States of America.

Purpose: In this face validity study, we discuss the fabrication and utility of an affordable, computed tomography (CT)-based, anatomy-accurate, 3-dimensional (3D) printed temporal bone models for junior otolaryngology resident training.

Materials And Methods: After IRB exemption, patient CT scans were anonymized and downloaded as Digital Imaging and Communications in Medicine (DICOM) files to prepare for conversion. These files were converted to stereolithography format for 3D printing. Important soft tissue structures were identified and labeled to be printed in a separate color than bone. Models were printed using a desktop 3D printer (Ultimaker 3 Extended, Ultimaker BV, Netherlands) and polylactic acid (PLA) filament. 10 junior residents with no previous drilling experience participated in the study. Each resident was asked to drill a simple mastoidectomy on both a cadaveric and 3D printed temporal bone. Following their experience, they were asked to complete a Likert questionnaire.

Results: The final result was an anatomically accurate (XYZ accuracy = 12.5, 12.5, 5 μm) 3D model of a temporal bone that was deemed to be appropriate in tactile feedback using the surgical drill. The total cost of the material required to fabricate the model was approximately $1.50. Participants found the 3D models overall to be similar to cadaveric temporal bones, particularly in overall value and safety.

Conclusions: 3D printed temporal bone models can be used as an affordable and inexhaustible alternative, or supplement, to traditional cadaveric surgical simulation.
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http://dx.doi.org/10.1016/j.amjoto.2019.08.004DOI Listing
October 2020

Elevated Central and Mixed Apnea Index after Upper Airway Stimulation.

Otolaryngol Head Neck Surg 2020 May 17;162(5):767-772. Epub 2020 Mar 17.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.

Objective: Upper airway stimulation (UAS) is used to treat patients with moderate to severe obstructive sleep apnea (OSA). The aim of this study is to report the incidence and potential predictors of elevated central and mixed apnea index (CMAI) after UAS.

Study Design: Retrospective chart review of patients undergoing UAS.

Setting: Tertiary care center.

Subjects And Methods: Included patients underwent UAS for OSA at our institution between 2014 and 2018. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. CMAI ≥5 was considered elevated. Post hoc univariate analysis was performed to evaluate factors associated with elevated CMAI.

Results: In total, 141 patients underwent UAS at our institution. This included 94 men and 47 women with a mean age of 61.2 ± 11.0 years and a mean body mass index of 29.1 ± 3.9 kg/m. Five patients had an elevated CMAI after surgery during UAS titration. Demographics, comorbid conditions, and device settings were not associated with an elevated postoperative CMAI ( > .05).

Conclusion: The occurrence of an elevated CMAI after surgery may represent treatment-emergent events. Demographics, comorbid conditions, and UAS device settings were not associated with central and mixed apneic events.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0194599820912740DOI Listing
May 2020

Effect of Gender, Age, and Profound Disease on Upper Airway Stimulation Outcomes.

Ann Otol Rhinol Laryngol 2020 Aug 16;129(8):772-780. Epub 2020 Mar 16.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To evaluate treatment outcomes of upper airway stimulation (UAS) in obstructive sleep apnea (OSA) patients based on patient age, gender, and preoperative disease severity.

Methods: Retrospective chart review of patients undergoing UAS from 2014 to 2018 at a tertiary care center. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. Profound OSA was defined as AHI >65 and age ≥65 was considered advanced age. The primary outcome measured was initial treatment response, defined as a post-operative AHI <20 with a >50% reduction from baseline.

Results: 145 patients underwent UAS at our institution including 98 males and 47 females with a mean age of 61.7 ± 11.5 years, mean BMI of 29.1 ± 3.9 kg/m, and mean preoperative AHI of 34.1 ± 18.2 events/hour. After surgery, patients had a significantly lower mean AHI of 8.6 ± 15.0 events/hour (<0.001). Older patients had a lower initial treatment response rate (78%) when compared to their younger counterparts (94%) ( 0.005). Male gender and profound disease status did not significantly impact treatment response rates; young age was the only variable found to predict early treatment response on multivariate analysis ( 0.003).

Conclusion: Although the overall OSA population showed significant postoperative AHI reduction with UAS, patients age ≥65 years were less likely to have an initial response to treatment, when compared to their younger counterparts. A larger proportion of elderly patients and patients with profound OSA had residual moderate disease (AHI > 15) after UAS.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0003489420911656DOI Listing
August 2020

Qualitative Assessment of the Effect of Continuous Positive Airway Pressure on the Nasal Cavity.

Am J Rhinol Allergy 2020 Jul 26;34(4):487-493. Epub 2020 Feb 26.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania.

Background: For patients with obstructive sleep apnea (OSA), there is a lack of knowledge regarding the impact of continuous positive airway pressure (CPAP) on the nasal cavity. There is a significant need for evidence-based recommendations regarding the appropriate use of CPAP following endoscopic sinus and skull base surgery.

Objective: The goal of this study is to translate a previously developed cadaveric model for evaluating CPAP pressures in the sinonasal cavity by showing safety in vivo and quantifying the effect of positive pressurized air flow on the nasal cavity of healthy individuals where physiologic effects are at play.

Methods: A previously validated cadaveric model using intracranial sensor catheters has proved to be a reliable technique for measuring sinonasal pressures. These sensors were placed in the nasal cavity of 18 healthy individuals. Pressure within the nose was recorded at increasing levels of CPAP.

Results: Overall, nasal cavity pressure was on average 85% of delivered CPAP. The amount of pressure delivered to the nasal cavity increased as the CPAP increased. The percentage of CPAP delivered was 77% for 5 cmHO and increased to 89% at 20 cmHO. There was a significant difference in mean intranasal pressures between all the levels of CPAP except 5 cmHO and 8 cmHO ( < .001).

Conclusion: On average, only 85% of the pressure delivered by CPAP is transmitted to the nasal cavity. Higher CPAP pressures delivered a greater percentage of pressurized air to the nasal cavity floor. Our results are comparable to the cadaver model, which demonstrated similar pressure delivery even in the absence of anatomic factors such as lung compliance, nasal secretions, and edema. This study demonstrates the safety of using sensors in the human nasal cavity. This technology can also be utilized to evaluate the resiliency of various repair techniques for endoscopic skull base surgery with CPAP administration.
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http://dx.doi.org/10.1177/1945892420908749DOI Listing
July 2020

The Role of Cricopharyngeal Myotomy After Anterior Cervical Decompression and Fusion Operations.

World Neurosurg 2020 05 7;137:146-148. Epub 2020 Feb 7.

Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.

Background: Anterior cervical spine surgeries have low morbidity, sufficient surgical corridor, and quick recovery times. Although largely considered a safe and effective procedure to address cervical myelopathy, radiculopathy, and deformity, dysphagia is a frequent yet poorly understood adverse event. One treatment is cricopharyngeal myotomy (CPM), which aids in swallowing for patients with refractory issues after anterior cervical decompression and fusion (ACDF).

Case Description: Here we describe our experience with 6 patients requiring revision ACDF with preoperative dysphagia who were treated with concurrent revision and CPM. Our series demonstrated that CPM is an effective and safe procedure used in combination with an ACDF. In our series, we had 6 patients with dysphagia preoperatively who were all able to undergo ACDF without worsening of their dysphagia despite having risk factors predisposing them to this complication. In our series, 83% of patients either improved or experienced resolution of their symptoms with only 1 patient failing to improve.

Conclusions: Given its efficacy and safety, patients planned for ACDF with preoperative dysphagia should be evaluated by ENT for potential CPM.
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http://dx.doi.org/10.1016/j.wneu.2020.01.180DOI Listing
May 2020

Safety of Outpatient Type 1 Thyroplasty.

Ear Nose Throat J 2020 Jan 5:145561319894414. Epub 2020 Jan 5.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: Type 1 thyroplasty is an established procedure for the treatment of vocal fold paralysis to improve voice and swallowing outcomes. At our institution, we commonly perform this procedure on an outpatient basis in medically stable patients. With this study, we assess the safety of outpatient thyroplasty by examining complication and readmission rates, need for revision surgery, and predictors of these outcome measures.

Methods: We performed a retrospective review of patients undergoing outpatient type 1 thyroplasty for vocal fold paralysis between 2013 and 2018 at our institution. We documented the etiology of paralysis, comorbidities, and demographic data. Our primary outcome measures were complications, need for readmission, and need for revision surgery.

Results: During the study period, 160 patients met our inclusion criteria. Mean age at time of surgery was 62.1 ± 13.9 years; there were 82 (51%) males and 78 (49%) females. Nine (5.6%) patients experienced major complications after surgery and 7 (4.4%) patients required unplanned readmission. Mean time to complication was 6.9 ± 9.7 days. There were no instances of postoperative airway compromise requiring intervention. There were no mortalities. Of those who underwent primary surgery, 22 (14%) patients required revision surgery.

Conclusion: Given that complications tend to occur in a delayed fashion rather than in the acute postoperative period, same-day discharge seems reasonable as compared to overnight observation in medically stable patients undergoing type 1 thyroplasty.

Level Of Evidence: IV.
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http://dx.doi.org/10.1177/0145561319894414DOI Listing
January 2020

Does Insurance Status Impact Delivery of Care with Upper Airway Stimulation for OSA?

Ann Otol Rhinol Laryngol 2020 Feb 22;129(2):128-134. Epub 2019 Sep 22.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA).

Methods: Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients.

Results: In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS.

Conclusion: Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA.

Level Of Evidence: 4.
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http://dx.doi.org/10.1177/0003489419878454DOI Listing
February 2020

Results of the ADHERE upper airway stimulation registry and predictors of therapy efficacy.

Laryngoscope 2020 05 14;130(5):1333-1338. Epub 2019 Sep 14.

Department of Otorhinolaryngology-Head and Neck Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.

Objective/hypothesis: The ADHERE Registry is a multicenter prospective observational study following outcomes of upper airway stimulation (UAS) therapy in patients who have failed continuous positive airway pressure therapy for obstructive sleep apnea (OSA). The aim of this registry and purpose of this article were to examine the outcomes of patients receiving UAS for treatment of OSA.

Study Design: Cohort Study.

Methods: Demographic and sleep study data collection occurred at baseline, implantation visit, post-titration (6 months), and final visit (12 months). Patient and physician reported outcomes were also collected. Post hoc univariate and multivariate analysis was used to identify predictors of therapy response, defined as ≥50% decrease in Apnea-Hypopnea Index (AHI) and AHI ≤20 at the 12-month visit.

Results: The registry has enrolled 1,017 patients from October 2016 through February 2019. Thus far, 640 patients have completed their 6-month follow-up and 382 have completed the 12-month follow-up. After 12 months, median AHI was reduced from 32.8 (interquartile range [IQR], 23.6-45.0) to 9.5 (IQR, 4.0-18.5); mean, 35.8 ± 15.4 to 14.2 ± 15.0, P < .0001. Epworth Sleepiness Scale was similarly improved from 11.0 (IQR, 7-16) to 7.0 (IQR, 4-11); mean, 11.4 ± 5.6 to 7.2 ± 4.8, P < .0001. Therapy usage was 5.6 ± 2.1 hours per night after 12 months. In a multivariate model, only female sex and lower baseline body mass index remained as significant predictors of therapy response.

Conclusions: Across a multi-institutional study, UAS therapy continues to show significant improvement in subjective and objective OSA outcomes. This analysis shows that the therapy effect is durable and adherence is high.

Level Of Evidence: 2 Laryngoscope, 130:1333-1338, 2020.
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http://dx.doi.org/10.1002/lary.28286DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7217178PMC
May 2020

Inclusion of the first cervical nerve does not influence outcomes in upper airway stimulation for treatment of obstructive sleep apnea.

Laryngoscope 2020 05 28;130(5):E382-E385. Epub 2019 Aug 28.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, U.S.A.

Objectives/hypothesis: Upper airway stimulation (UAS) has demonstrated efficacy in the management of obstructive sleep apnea (OSA). Branches of the hypoglossal nerve that selectively activate tongue protrusor and stiffener muscles are included within the stimulation cuff electrode. The first cervical nerve (C1) is often also included to stimulate additional muscles contributing to tongue protrusion and stabilization. The purpose of this study was to determine whether inclusion of the C1 translates into treatment efficacy, decreased voltage requirement, and improved outcomes in patients utilizing UAS.

Study Design: Single-center, retrospective cohort study.

Methods: One hundred fourteen patients who received a UAS implant at our institution and underwent posttreatment polysomnography were evaluated. Stimulation cuff electrodes in 87 patients included the C1; those in the remaining 27 patients did not include the C1. Demographic data, voltage data, and pre- and posttreatment apnea-hypopnea index (AHI), O nadir, and Epworth Sleepiness Scale (ESS) data were collected for all patients.

Results: There was no significant difference in stimulation voltage, or posttreatment AHI, O nadir, and ESS between the two cohorts. Treatment success, as measured by posttreatment AHI < 20 with a 50% reduction, was similar regardless of C1 inclusion. The same was seen for the percent of patients with AHI < 15 and AHI < 5 after treatment. The distributions of age and body mass index, as well as pre-treatment AHI, O nadir, and ESS were also not significantly different between treatment groups.

Conclusions: The current study has demonstrated that inclusion of the C1 in the stimulation cuff electrode of the upper airway stimulator may not provide any additional benefit in therapy for OSA.

Level Of Evidence: 4 Laryngoscope, 130:E382-E385, 2020.
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http://dx.doi.org/10.1002/lary.28256DOI Listing
May 2020

Effect of uvulopalatopharyngoplasty (UPPP) on atherosclerosis and cardiac functioning in obstructive sleep apnea patients.

Acta Otolaryngol 2019 Sep 3;139(9):793-797. Epub 2019 Jul 3.

a Department of Otolaryngology Head & Neck Surgery, Beijing Anzhen Hospital, Capital Medical University , Beijing , China.

Obstructive sleep apnea OSA) is associated with several cardiovascular comorbidities including hypertension, arteriosclerosis, and heart failure. Uvulopalatopharyngoplasty (UPPP) is a frequently performed surgical treatment for OSA. To analyze if UPPP can improve cardiac parameters associated with atherosclerosis and reduce the cardiac burden in OSA patients. A prospective cohort study was performed at a single tertiary care center where OSA patients undergoing UPPP were evaluated. Preoperative and 6-month postoperative cardiac parameters namely carotid artery intima-media thickness (CIMT), arterial stiffness parameters, echocardiography, and polysomnography (PSG) results were compared. Fifty three patients were included in the study. The success and response rate of UPPP was 60.4%. Following the surgery, significant reduction in arterial stiffness index (β) (12.4 ± 4.1 vs. 11.2 ± 4.0,  = .01), and elasticity modulus (Ep) (172.8 ± 68.3 vs. 156.6 ± 55.3,  = .05) was noticed. Additionally, echocardiographic parameters namely velocity across aortic valve (121.9 ± 22.9 vs. 109.4 ± 17.7,  = .01) and velocity across pulmonary valve (107.4 ± 16.4 vs. 94.2 ± 16.9,  < .01) significantly decreased following UPPP. UPPP significantly improves parameters related to carotid atherosclerosis and has the potential to reduce cardiac burden in OSA patients.
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http://dx.doi.org/10.1080/00016489.2019.1633475DOI Listing
September 2019

The Impact of Upper Airway Stimulation on Swallowing Function.

Ear Nose Throat J 2019 Sep 29;98(8):496-499. Epub 2019 May 29.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University, Philadelphia, PA, USA.

Objective: To evaluate the impact of upper airway stimulation therapy (UAS) on swallowing function in patients with obstructive sleep apnea.

Study Design: Prospective cohort study.

Setting: Academic medical center.

Participants And Outcome Measures: We recorded demographic, preoperative polysomnogram (PSG), operative, and postoperative PSG data. We assessed the patients swallowing function using the Eating Assessment Tool (EAT-10) dysphagia questionnaire. This was administered both pre- and postoperatively. The postoperative EAT-10 survey was administered at least 3 months after UAS implantation.

Results: During the study period, 27 patients underwent UAS implantation, completed the pre- and postoperative EAT-10 questionnaire, met inclusion/exclusion criteria, and were included in the study. The cohort consisted of 16 men and 11 women with a mean age of 63.63 years. The mean preoperative BMI, Epworth Sleepiness Scale (ESS), and Apnea Hypopnea Index (AHI) were 29.37, 10.33, and 34.90, respectively. The mean postoperative ESS and AHI were 5.25 and 7.59, respectively. These were both significantly lower than the preoperative values ( = .026 and < .001). The mean pre- and postoperative EAT-10 scores were 0.37 and 0.22, respectively ( = .461).

Conclusion: Our data suggest that UAS likely does not lead to postoperative dysphagia.
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http://dx.doi.org/10.1177/0145561319853519DOI Listing
September 2019

Esophageal adenocarcinoma in a first-degree relative increases risk for esophageal adenocarcinoma in patients with Barrett's esophagus.

United European Gastroenterol J 2019 03 29;7(2):225-229. Epub 2018 Nov 29.

Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.

Background: The significance of a family history of esophageal adenocarcinoma in the progression to esophageal adenocarcinoma in patients with Barrett's esophagus has not been thoroughly evaluated. The purpose of this study is to evaluate the presence of esophageal adenocarcinoma in a first-degree relative in patients with Barrett's esophagus.

Methods: A retrospective cohort study was conducted of patients with Barrett's esophagus at a tertiary care center undergoing radiofrequency ablation. Family history, demographics, and pathology and endoscopy reports were assessed in all patients.

Findings: Three hundred and one patients with Barrett's esophagus were assessed. Nineteen patients who had a diagnosis of esophageal adenocarcinoma on index endoscopy were excluded. Nineteen (6.7%) patients had a first-degree relative with esophageal adenocarcinoma. Four (21.1%) of these patients progressed to esophageal adenocarcinoma. Of patients without first-degree relative with esophageal adenocarcinoma 22/263 (8.7%) progressed to esophageal adenocarcinoma. In a logistic regression model adjusted for sex and the number of radiofrequency ablation treatments, we found that family history of esophageal adenocarcinoma was a significant independent predictor of progression to esophageal adenocarcinoma (odds ratio = 5.55, 95% confidence interval: 1.47-20.0).

Conclusion: Our study indicates that Barrett's esophagus patients with a first-degree family member with esophageal adenocarcinoma are at 5.5-fold higher risk for disease progression to esophageal adenocarcinoma. Family history of esophageal adenocarcinoma in Barrett's esophagus patients should be considered in patient surveillance and radiofrequency ablation treatment, beyond recommended guidelines.
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http://dx.doi.org/10.1177/2050640618817098DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6498799PMC
March 2019

Evaluation of cranial base repair techniques utilizing a novel cadaveric CPAP model.

Int Forum Allergy Rhinol 2019 07 12;9(7):795-803. Epub 2019 Feb 12.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Although recent guidelines for obstructive sleep apnea recommend early postoperative use of continuous positive airway pressure (CPAP) after endonasal skull base surgery, the time of initiation of CPAP is unclear. In this study we used a novel, previously validated cadaveric model to analyze the pressures delivered to the cranial base and evaluate the effectiveness of various repair techniques to withstand positive pressure.

Methods: Skull base defects were surgically created in 3 fresh human cadaver heads and repaired using 3 commonly used repair techniques: (1) Surgicel™ onlay; (2) dural substitute underlay with dural sealant onlay; and (3) dural substitute underlay with nasoseptal flap onlay with dural sealant. Pressure microsensors were placed in the sphenoid sinus and sella, both proximal and distal to the repair, respectively. The effectiveness of each repair technique against various CPAP pressure settings (5-20 cm H O) was analyzed.

Results: Approximately 79%-95% of positive pressure administered reached the sphenoid sinus. Sellar pressure levels varied significantly across the 3 repair techniques and were lowest after the third technique. "Breach" points (CPAP settings at which sellar repair was violated) were lowest for the first group. All 3 specimens showed a breach after the first repair technique. For the second repair technique, only a single breach was created in 1 specimen at 20 cm H O. No breaches were created in the third group.

Conclusion: Different skull base repair techniques have varying ability to withstand CPAP. Both second and third repair techniques performed in a nearly similar fashion with regard to their ability to withstand positive pressure ventilation.
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http://dx.doi.org/10.1002/alr.22313DOI Listing
July 2019

Dysfunctional hypoglossal nerve stimulator after electrical cardioversion: A case series.

Laryngoscope 2019 08 15;129(8):1949-1953. Epub 2018 Nov 15.

Department of Otolaryngology-Head and Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Objectives/hypothesis: Upper airway stimulation has demonstrated marked improvements in apnea-hypopnea index, oxygen desaturation index, and quality-of-life measures in patients with moderate to severe obstructive sleep apnea (OSA) who cannot tolerate continuous positive airway pressure. Cardiac arrhythmias are common in patients with OSA and can require electrical cardioversion. We describe the first four reported cases of hypoglossal nerve stimulator (HGNS) dysfunction after electrical cardioversion and illustrate our operative approach to device troubleshooting and repair.

Study Design: Retrospective case series.

Methods: A retrospective review of 201 HGNS implantations performed at two academic institutions revealed four cases of HGNS device dysfunction after electrical cardioversion requiring surgical revision. Preoperative and postoperative device performance metrics and electrical cardioversion specifications were retrospectively assessed and compiled for this case series. The senior authors (R.J.S., M.S.B.) detail operative planning and approach for HGNS implantable pulse generator (IPG) replacement.

Results: At least two patients with HGNS device dysfunction had received cardioversion via anterolateral electrode pad placement. Three patients had received multiple shocks. All four patients experienced a change in device functionality or complete cessation of functionality after electrocardioversion. Operatively, each patient required replacement of the IPG, with subsequent intraoperative interrogation revealing proper device functionality.

Conclusion: Counseling for patients with HGNS undergoing external electrical cardioversion should include possible device damage and need for operative replacement. Anteroposterior electrode pad placement should be considered for patients with HGNS who require electrocardioversion. Operative replacement of an HGNS system damaged by electrocardioversion begins with IPG replacement and intraoperative device interrogation.

Level Of Evidence: 4 Laryngoscope, 129:1949-1953, 2019.
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http://dx.doi.org/10.1002/lary.27488DOI Listing
August 2019

A cadaveric model for measuring sinonasal continuous positive airway pressure-a proof-of-concept study.

Int Forum Allergy Rhinol 2019 02 15;9(2):197-203. Epub 2018 Nov 15.

Department of Otolaryngology-Head & Neck Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.

Background: Obstructive sleep apnea is a common respiratory disorder that can have negative effects on health and quality of life. Positive pressure therapy (CPAP) is the primary treatment. There is a lack of consensus on the risk of postoperative CPAP after endoscopic sinus or skull base surgery. We present a proof-of-concept cadaver model for measuring sinonasal pressure delivered by CPAP.

Methods: Three fresh cadaver heads were prepared by removing the calvaria and brain. Sphenoidotomies were made and sellar bone was removed. Pressure sensors were placed in the midnasal cavity, sphenoid sinus, and sella. CPAP was applied and the delivered pressure was recorded at increasing levels of positive pressure. Paired t tests and intraclass correlation coefficients were used to analyze results.

Results: Increases in positive pressure led to increased pressure recordings for all locations. Nasal cavity pressure was, on average, 81% of delivered CPAP. Pressure was highest in the sphenoid sinus. The effect of middle turbinate medialization on intrasphenoid pressure was not statistically significant in 2 heads. Intrasellar pressure was 80% of delivered CPAP with lateralized turbinates and 84% with medialized turbinates. Pressure recordings demonstrated excellent reliability for all locations. All heads developed non-sellar-based cranial base leaks at higher pressures. Cribriform region leaks were successfully sealed with DuraSeal®.

Conclusion: Our proof-of-concept cadaver model represents a novel approach to measure pressures delivered to the nasal cavity and anterior skull base by CPAP. With further study, it may have broader clinical application to guide the safe postoperative use of CPAP in this population.
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http://dx.doi.org/10.1002/alr.22235DOI Listing
February 2019

Comparing Upper Airway Stimulation to Transoral Robotic Base of Tongue Resection for Treatment of Obstructive Sleep Apnea.

Laryngoscope 2019 04 12;129(4):1010-1013. Epub 2018 Sep 12.

Department of Otolaryngology-Head and Neck Surgery, Philadelphia, Pennsylvania, U.S.A.

Objectives: Transoral robotic surgery (TORS) and upper airway stimulation (UAS) are modalities for treating tongue base obstruction contributing to obstructive sleep apnea (OSA). We aim to compare patients with OSA undergoing TORS to those undergoing UAS.

Methods: We retrospectively reviewed patients treated with TORS and UAS using the senior authors' surgical database. We evaluated demographic, preoperative polysomnography (PSG), postoperative PSG, complication, hospital length of stay, and hospital readmission data to compare the two cohorts.

Results: Seventy-six patients underwent UAS. This included 50 men and 26 women. The mean age and body mass index were 61.92 and 29.38. The mean pre- versus postoperative apnea hypopnea index (AHI) and O nadir were 36.64 versus 7.20 and 80.27% versus 88.77%, respectfully. The rate of surgical success and postoperative AHI less than 15 and 5 were 86.84%, 89.47%, and 59.21. All patients underwent ambulatory surgery, and no one was readmitted. Twenty-four patients underwent TORS. This included 20 men and four women with a mean age and body mass index BMI of 46.42 and 29.63. The mean pre- versus postoperative AHI and O nadir were 35.70 versus 20.05 and 80.50% versus 84.10%, respectfully. The rate of surgical success and postoperative AHI less than 15 and 5 were 54.17%, 50.00%, and 20.83%. The mean length of stay was 1.33 days, and four patients were readmitted. We found significant differences in age, postoperative AHI and O nadir, surgical success and postoperative AHI less than 15 and 5, length of stay, and rate of readmission.

Conclusions: UAS is successful in treating OSA showing improved outcomes, length of stay, and readmission compared to TORS.

Level Of Evidence: 3 Laryngoscope, 129:1010-1013, 2019.
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http://dx.doi.org/10.1002/lary.27484DOI Listing
April 2019