Objectives/Hypothesis To develop a validated inferior turbinate grading scale. Study Design Development and validation study. Methods Phase 1 development (alpha test) consisted of a proposal of 10 different inferior turbinate grading scales (>1,000 clinic patients). Phase 2 validation (beta test) utilized 10 providers grading 27 standardized endoscopic photos of inferior turbinates using two different classification systems. Phase 3 validation (pilot study) consisted of 100 live consecutive clinic patients (n = 200 inferior turbinates) who were each prospectively graded by 18 different combinations of two independent raters, and grading was repeated by each of the same two raters, two separate times for each patient. Results In the development phase, 25% (grades 1–4) and 33% (grades 1–4) were the most useful systems. In the validation phase, the 25% classification system was found to be the best balance between potential clinical utility and ability to grade; the photo grading demonstrated a Cohen's kappa (κ) = 0.4671 ± 0.0082 (moderate inter‐rater agreement). Live‐patient grading with the 25% classification system demonstrated an overall inter‐rater reliability of 71.5% (95% confidence interval [CI]: 64.8–77.3), with overall substantial agreement (κ = 0.704 ± 0.028). Intrarater reliability was 91.5% (95% CI: 88.7–94.3). Distribution for the 200 inferior turbinates was as follows: 25% quartile = grade 1, 50% quartile (median) = grade 2, 75% quartile = grade 3, and 90% quartile = grade 4. Mean turbinate size was 2.22 (95% CI: 2.07‐2.34; standard deviation 1.02). Categorical κ was as follows: grade 1, 0.8541 ± 0.0289; grade 2, 0.7310 ± 0.0289; grade 3, 0.6997 ± 0.0289, and grade 4, 0.7760 ± 0.0289. Conclusions The 25% (grades 1–4) inferior turbinate classification system is a validated grading scale with high intrarater and inter‐rater reliability. This system can facilitate future research by tracking the effect of interventions on inferior turbinates. Level of Evidence 2c Laryngoscope , 125:296–302, 2015
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Objective The objective of this study is to systematically review polysomnography data and sleepiness in morbidly obese (body mass index [BMI] ≥40 kg/m 2 ) patients with obstructive sleep apnea (OSA) treated with either a maxillomandibular advancement (MMA) or a tracheostomy and to evaluate the outcomes. Data Sources MEDLINE, Scopus, Web of Science, and the Cochrane Library. Review Methods A search was performed from inception through April 8, 2014, in each database. Results Six maxillomandibular advancement studies (34 patients, age 42.42 ± 9.13 years, mean BMI 44.88 ± 4.28 kg/m 2 ) and 6 tracheostomy studies (14 patients, age 52.21 ± 10.40 years, mean BMI 47.93 ± 7.55 kg/m 2 ) reported individual patient data. The pre‐ and post‐MMA means ± SDs for apnea‐hypopnea indices were 86.18 ± 33.25/h and 9.16 ± 7.89/h ( P <. 00001), and lowest oxygen saturations were 66.58% ± 16.41% and 87.03% ± 5.90% ( P <. 00001), respectively. Sleepiness following MMA decreased in all 5 patients for whom it was reported. The pre‐ and posttracheostomy mean ± SD values for apnea indices were 64.43 ± 41.35/h and 1.73 ± 2.68/h ( P =. 0086), oxygen desaturation indices were 69.20 ± 26.10/h and 41.38 ± 36.28/h ( P =. 22), and lowest oxygen saturations were 55.17% ± 16.46% and 79.83% ± 4.36% ( P =. 011), respectively. Two studies reported outcomes for Epworth Sleepiness Scale for 5 patients, with mean ± SD values of 18.80 ± 4.02 before tracheostomy and 2.80 ± 2.77 after tracheostomy ( P =. 0034). Conclusion Data for MMA and tracheostomy as treatment for morbidly obese, adult OSA patients are significantly limited. We caution surgeons about drawing definitive conclusions from these limited studies; higher level studies are needed.
The purpose of this study was to describe current demographics and resource utilization in the treatment of pediatric epiglottitis.Case series from a national database.The Kids' Inpatient Database was systematically searched to extract patients under 19 years old admitted with a diagnosis of epiglottitis and undergoing an airway intervention.Three hundred forty-two sampled admissions were for epiglottitis; 40 of these patients were under the age of 19 and had an airway intervention (intubation or tracheotomy). On average, patients were 4.3 years old (SD = 6.0 years). The average length of stay was 15.6 days (SD = 33.9 and range = 0-199) with average total charges of $74,931 (SD = $163,387, range = $3342-$938,512). Multivariate analysis revealed that admission to a children's facility, admission other than via the emergency room, and nonemergent admission were associated with increased total charges. Twenty-two states reported an admission for pediatric epiglottitis that required airway intervention.In our sample, only 40 patients were identified who were under the age of 19 years and required an airway intervention for the treatment of epiglottitis. Epiglottitis is a rare, expensive, and protracted disease to treat in the postvaccine era. The unique nature of this disease has implications for training future surgeons on proper management of this potentially fatal disease.
Objective Intracapsular tonsillectomy (or tonsillotomy) is a technique rapidly gaining acceptance. Multiple individual clinical trials have been performed, but there remains no clear consensus as to how tonsillotomy compares to traditional methods in regard to complication rates. The purpose of this study is to compile and critically analyze this data. Method MEDLINE was searched using multiple search terms, with the following inclusion criteria: English language, human subjects, and related to complications of tonsillotomy. Multiple tonsillotomy techniques were included. The results of these studies were summated, and the results were analyzed. Random effects modeling was used to calculate summary effect measures. Results Thirty‐three studies met inclusion criteria. The bleeding rate for tonsillectomy was 3.4% ( P <. 01, 95% CI=0.027‐0.041, k=23) with a dehydration re‐visit rate of 3.4% (<0.01, 0.018‐0.049, 13). For tonsillotomy, the rates were 1.5% (<0.01, 0.012‐0.017, 31) and 1.4% (<0.01, 0.006‐0.022, 17), respectively. When stratifying for tonsillotomy technique, the rates were 1.5% (<0.01, 0.014‐0.017, 5) and 1.5% (<0.01, 0.014‐0.017, 4) for coblation and 0.8% (<0.01, 0.006‐0.01, 15) and 1.7% (<0.01, 0.007‐0.026, 10) for microdebrider. Number of days receiving analgesia was 7.045 (<0.01, 6.31‐7.76, 5) for tonsillectomy and 4.09 (3.19‐4.99, 7) for tonsillotomy. There was no difference in blood loss between groups. Conclusion Tonsillotomy appears to compare favorably with tonsillectomy and may offer a reduction in postoperative complications (bleeding and dehydration), as well as less use of analgesics. Subgroup analysis suggests that microdebrider tonsillotomy may have a lower bleeding rate than the coblation technique.
Intracapsular tonsillotomy continues to gain acceptance as an alternative to traditional tonsillectomy. Despite large clinical studies, there is a lack of consensus as to which technique offers lower complication rates. This study seeks to analyze the available data and surmise the complication rates of partial tonsillectomy as compared with traditional tonsillectomy. Data Sources. MEDLINE was searched using multiple search terms.After the MEDLINE search, the following inclusion criteria were applied: English language, human subjects, and related to partial tonsillectomy. Multiple tonsillotomy techniques were included. The results of these studies were summated and the results analyzed. Subgroup analysis was then performed.Thirty-three studies met inclusion criteria. Tonsillotomy had a lower postoperative bleeding rate, lower postoperative dehydration rate requiring medical care, reduced days of analgesic use, and reduced days to return to normal diet compared with tonsillectomy. When separated into higher versus lower quality studies, the differences in bleeding and dehydration were negligible, while differences in return to diet and days of analgesic use persisted. Mean intraoperative blood loss was similar for both techniques. Insufficient data were available to assess tonsil regrowth rates.Tonsillotomy appears to be a safe technique that may offer some advantages over tonsillectomy in terms of postoperative morbidity, but differences in hemorrhage and dehydration were not evident in high-quality studies. Data regarding tonsil regrowth rates and efficacy in treating sleep-disordered breathing are not yet sufficient for formal analysis, which may preclude widespread acceptance of this technique.
Objective The purpose of this study was to determine the effect of tonsillectomy as a single procedure in the treatment of adult obstructive sleep apnea (OSA). Study Design Prospective multi‐institutional study evaluating adults with tonsillar hypertrophy scheduled to undergo tonsillectomy as an isolated surgery. Setting Tertiary care medical centers within the US Department of Defense. Subjects and Methods Adult subjects with tonsillar hypertrophy who were already scheduled for tonsillectomy were enrolled from October 2010 to July 2013. Subjects underwent physical examination, Epworth Sleepiness Scale, Berlin Questionnaire, and polysomnogram before surgery and after. Collected data included demographics, questionnaire scores, apnea‐hypopnea index (AHI), and lowest saturation of oxygen. Results A total of 202 consecutive subjects undergoing tonsillectomy were enrolled. The final analysis included 19 subjects testing positive for OSA. The mean age was 27.9 years; mean body mass index, 29.6; median tonsil size, 3; and most frequent Friedman stage, 1. The AHI before surgery ranged from 5.4 to 56.4 events per hour. The mean AHI decreased from 18.0 to 3.2 events per hour after surgery, a reduction of 82%. The responder rate—with subjects achieving at least a 50% reduction of AHI to a value <15—was 94.7%. Following tonsillectomy, there were statistically significant reductions in median lowest saturation of oxygen level and Epworth Sleepiness Scale and Berlin scores. Conclusions Adult tonsillectomy alone has beneficial effect in OSA management, particularly in young overweight men with large tonsils, moderate OSA, and low Friedman stage.
