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Habitual loud snoring affects nearly a quarter of the adult population. The advent of office-based uvula and palate procedures has resulted in a keen interest in the treatment of snoring. This interest also has spawned increasing attention to the diagnosis and treatment of obstructive sleep apnea. The carbon dioxide laser provides a convenient means for performing office-based uvulopalatoplasty for the treatment of snoring. Advantages, disadvantages, and techniques for performing laser-assisted uvulopalatopasty are discussed. The importance of identifying the presence or absence of obstructive sleep apnea is also addressed.

Over a 10-year period the authors have performed 92 transethmoidal optic nerve decompressions for the treatment of visual loss due to various pathological processes, including 45 cases of trauma, 32 cases of neoplasm, 2 cases of bacterial pansinusitis, 5 cases of sphenoethmoidal mucocele, 4 cases of aspergillosis (all were immunocompetent patients), 2 cases of Wegener's granulomatosis, and 2 cases of sarcoidosis. Forty-eight patients (52%) had preoperative visual acuity of light perception or better, and in 44 patients (48%) the preoperative vision was no light perception. Sixty-five patients (71%) achieved improvement of vision postoperatively. Twenty-four patients (26%) had no change in vision and 3 patients (3%) had deterioration of vision after surgery. The mean percentage of improvement was 40.7% +/- 6.9% in the trauma group, 61.6% +/- 23.2% in the neoplasm group, 66.4% +/- 25.2% in the infectious/mucocele group, and only one patient in the inflammatory group had slight visual improvement from no light perception to counting fingers. Extracranial optic nerve decompression can result in the improvement of visual function in some patients with optic nerve injury from various causes.

We report the first endoscopic surgeries performed with patients under general anesthesia using intraoperative guidance with MRI. The procedures were experimental and intended to test (1) the unusual working environment of a unique new “open-configuration” MRI unit for head and neck surgery, and (2) real-time image guidance. Twelve patients underwent endoscopic sinus surgery while under general anesthesia in a new open MRI unit that provides the surgeon with access to the patient while imaging is performed. Eleven patients had chronic sinusitis (eight of them had bilateral disease), and one had a right nasoethmoid and antral tumor. All 12 surgeries were performed without complications. Both the endoscopic view and the MRI scans were available at the surgical field. The image plane was surgeon controlled, and the MRI updated images in as little as 14 seconds. MRI provided adequate visualization of both the disease and the related anatomy and allowed the surgeon to navigate during the procedure. The intraoperative data reflect the tissue changes during surgery and provide optimum feedback for surgical guidance. Although the operating environment poses some limitations, it has become apparent that intraoperative MRI has a role in the treatment of head and neck disorders and warrants further study. (Otolaryngol Head Neck Surg 1998;119:374-80.)

Blindness can result from traumatic optic neuropathy following facial trauma and can complicate the management of concomitant facial fractures. Traumatic optic neuropathy can cause a substantial delay in the repair of facial fractures, leading to compromised surgical results. It can also result in postoperative visual loss following facial fracture repair. We present four cases of traumatic optic neuropathy that compromised the treatment of facial fractures. The management of facial fractures in patients with traumatic optic neuropathy must proceed cautiously. Delayed primary repair of midface fractures by postponing surgery for 10 to 14 days may be of benefit in avoiding further deterioration of vision. In addition, megadose corticosteroids and/or optic nerve decompression is useful in the management of these patients.

Background and Objective: Laser-assisted uvulopalatoplasty (LAUP) is being used increasingly as a surgical treatment for snoring and obstructive sleep apnea (OSA). There is limited evidence for the success of LAUP in eliminating OSA. This study assesses the efficacy of LAUP in eliminating snoring and OSA and addresses which patients may be the best candidates for LAUP treatment. Study Design/Materials and Methods: From January 1994 to January 1996, 297 patients were evaluated for snoring, with 190 (64%) exhibiting some degree of OSA documented by a PSG: 41/ 190 (22%) mild OSA; 33/190 (17%) moderate OSA; 85/190 (45%) severe OSA; 31/190 (16%) severity unknown. Ninety patients (90/ 297) have undergone LAUP treatment: 58/90 (64%) with OSA and 32/90 (36%) with snoring only. Results: Our results indicate a significant reduction of snoring in patients without OSA, but diminishing success in patients with increasing degrees of OSA. Additionally, LAUP was not efficacious in treating OSA: pre-op respiratory disturbance index (RDI) of 10.8 vs. post-op RDI of 19.5 for mild OSA (P = 0.14); pre-op RDI of 22.9 vs. post-op RDI of 25.4 for moderate OSA (P = 0.43); pre-op RDI of 56.8 vs. post-op RDI of 46.3 (P < 0.05), which is statistically but not clinically significant (i.e., RDI remained in the severe range). Conclusion: We conclude that LAUP is an effective treatment for nonapneic snoring, but does not provide sufficient resolution of OSA, and based on our results, LAUP should be considered as an adjunctive therapy rather than a sole treatment for OSA in most cases.

In the cases presented herein, the TIA episode occurred in the setting of a long history of migraine. Our findings suggest that in a sample of Southern Italy population, aPL are independently associated with the risk for TIA episode.

We investigated the activated partial thromboplastin time prolongation after addition to citrated plasma of a heparin-antithrombin mixture, expressed as the ratio of the APTT carried out in the presence of the heparin mixture divided by the baseline APTT of the same plasma mixture. Thrombophilia defects are recognized in about one third of the patients presenting with a venous thromboembolic event.

Bechet's disease may be considered an immune-mediated vasculitis involving vessels of all size. We would like to suggest that Bechet's disease should be considered as a prethrombotic state. Howerer, we feel that the hypercoagulable/prethrombotic state of the Bechet's disease remains to be elucidaded.

Knowledge of the location of the hypoglossal/lingual artery neurovascular bundle (HLNVB) is essential in performing tongue base resections for neoplasm and for obstructive sleep apnea. Transoral and transcervical resections of the tongue base may be performed with greater exposure and certainty when the relationship of the HLNVB to local landmarks is understood; knowledge of the HLNVB allows resection of a larger amount of contralateral tongue base during partial glossectomy without violating the contralateral remnant tongue's blood supply. Ten cadaver heads were dissected to determine the position of the HLNVB with respect to soft tissue and bony landmarks at the tongue base. Our results indicate the position of the tongue base HLNVB is significantly inferior and lateral, that is, 2.7 cm inferior and 1.6 cm lateral to the foramen cecum, 0.9 cm superior to the hyoid bone, and 2.2 cm medial to the mandible. This inferolateral location allows the potential for aggressive tongue base resection without neurovascular compromise.

The management of traumatic optic neuropathy remains controversial. In this report, we present the results of 45 patients treated with extracranial optic nerve decompression after at least 12 to 24 hours of corticosteroid therapy without improvement. Vision improved in 32 patients after surgery (71%), and the mean percentage of improvement from preoperative visual deficit was 40.7% ± 6.9% (median improvement 41.2%). Worsening of vision occurred in none of the patients as a result of the surgery, and no intraoperative or postoperative complications were encountered. We present a treatment protocol for traumatic optic neuropathy with the use of megadose corticosteroids and optic nerve decompression. (Otolaryngol Head Neck Surg 1999;120:5-11.)

Mucosa-associated lymphoid tissue (MALT) has recently been recognized as a possible site of origin for low-grade lymphomas of the B-cell type. Though relatively rare, these MALT lymphomas may arise within several sites in the head and neck, and often present diagnostic and therapeutic challenges. We review 4 cases of primary MALT lymphoma of the head and neck, treated with surgical excision (3 cases), irradiation (2 cases), and chemotherapy (1 case), to further characterize this new subtype of head and neck malignancy. The mean time from onset of symptoms to histologic diagnosis was 15 months. Fine needle aspiration identified an atypical lymphoid infiltrate in only 1 of 3 patients. Immunohistochemical analysis was essential in establishing the diagnosis of MALT lymphoma in all 4 of the cases, and demonstrated characteristic negative staining for CD3, CD5, and CD43, positive staining for CD20, and monotypic staining for either κ or Λ; light chain immunoglobulin markers. All patients achieved complete remission after primary therapy, and all remain free of disease with follow-up ranging from 6 to 54 months (mean 33 months). The diagnosis of MALT lymphoma should be considered in cases of atypical lymphoid infiltrates in the head and neck, and increased awareness coupled with detailed immunohistochemical analysis is essential to securing an accurate diagnosis. Clinical remission of MALT lymphoma may be achieved with several modalities, but further study will be required to determine the long-term response to treatment.

Laser-assisted uvulopalatoplasty (LAUP) is being used increasingly as a surgical treatment for snoring and obstructive sleep apnea (OSA). There is limited evidence for the success of LAUP in eliminating OSA. This study assesses the efficacy of LAUP in eliminating snoring and OSA and addresses which patients may be the best candidates for LAUP treatment.From January 1994 to January 1996, 297 patients were evaluated for snoring, with 190 (64%) exhibiting some degree of OSA documented by a PSG: 41/ 190 (22%) mild OSA; 33/190 (17%) moderate OSA; 85/190 (45%) severe OSA; 31/190 (16%) severity unknown. Ninety patients (90/ 297) have undergone LAUP treatment: 58/90 (64%) with OSA and 32/90 (36%) with snoring only.Our results indicate a significant reduction of snoring in patients without OSA, but diminishing success in patients with increasing degrees of OSA. Additionally, LAUP was not efficacious in treating OSA: pre-op respiratory disturbance index (RDI) of 10.8 vs. post-op RDI of 19.5 for mild OSA (P = 0.14); pre-op RDI of 22.9 vs. post-op RDI of 25.4 for moderate OSA (P = 0.43); pre-op RDI of 56.8 vs. post-op RDI of 46.3 (P0.05), which is statistically but not clinically significant (i.e., RDI remained in the severe range).We conclude that LAUP is an effective treatment for nonapneic snoring, but does not provide sufficient resolution of OSA, and based on our results, LAUP should be considered as an adjunctive therapy rather than a sole treatment for OSA in most cases.

Objective: To assess whether there is an increased risk of osteotomies causing fractures that extend into the orbit or cranial base in patients who undergo ethmoid sinus surgery. Design: Anatomic investigation in a cadaver model. Methods: Twenty-eight medial and lateral osteotomies were performed in 14 fresh-frozen cadaver heads after bilateral sphenoethmoidectomies (endoscopic technique, n=26; external technique, n=2). Anatomic examination performed by inspection after removal of dorsal nasal skin followed by rigid endoscopic intranasal examination. Results: Complete osteotomies were obtained in every case. There were no major comminutions along the osteotomies, but there was a 25% rate of minor comminutions. In no case did fractures extend into either the orbit or the base of the skull. In every case, the path of the osteotome was separated from the ethmoid surgical cavity by a relatively thick buttress of bone composed of the anterior lacrimal crest and the ascending process of the maxilla. The enlarged maxillary ostia created by the sinus surgery was not altered by the osteotomies or by dorsal narrowing. Conclusions: Nasal osteotomies can be performed with minimal risk of comminution or uncontrolled extension of the fracture lines following extensive ethmoid and sphenoid sinus surgery. These findings may not apply in patients with preexisting injuries or when osteotomies do not preserve the triangular nasal buttress. (Arch Otolaryngol Head Neck Surg. 1995;121:1315-1318)

The ‘two-step’ model proposed by Jensen and his collaborators for explaining estrogen action conceptualized hormone-free estrogen receptors (ER) to be cytoplasmic, and hormone-filled, transformed ER to be nuclear. Applying monoclonal antibodies which recognized epitopes in ER and formaldehyde-fixed tissues, King et al demonstrated exclusively nuclear staining in target tissues utilizing immunoperoxidase technique. Recently these antibodies have become commercially available enabling other investigators to conduct studies. In this report, using these monoclonal antibodies we have demonstrated that a change in the concentration of formaldehyde alters the staining pattern yielding cytoplasmic instead of nuclear staining in calf uterus, MCF-7 cells, and ER(+) human breast cancer. In addition, neutralization of the antibody activity was not achieved with freshly prepared ER(+) cytosols. Formaldehyde-treated cytosols were essential. These results ought to caution investigators in determining in vivo location of antigens based on the staining pattern obtained in fixed tissues. Furthermore, this effect of formaldehyde on estrogen receptors may be applicable to other steroid hormone receptors.