CLINICAL CONCEPTS IN OTOLARYNGOLOGY
From the 5th Anniversary Cleveland Clinic Otolaryngology Symposium, presented by Cleveland Clinic Florida
| COMPREHENSIVE EXAMINATION OF THE AIRWAY FOR SLEEP DISORDERED BREATHING —David Greene,
MD, Head of Otolaryngology, Cleveland Clinic Florida, and Co-Director, Sleep Center of Excellence, Naples, FL
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| Pathophysiology: causes—small upper airway; loss of muscle tone; collapsing forces overpowering dilating forces;
causes of causes—airway and facial anatomy; obesity; body mass index (BMI); genetics; neurologic problems
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 | Factors leading to work-up: obesity; age >60 yr; alcohol or depressant use; narcolepsy; anatomy—low hyoid; narrow
maxilla; mandibular or maxillary retrusion; long wide soft palate; macroglossia; constricted nasopharynx; narrow posterior
airway space
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| Ventilatory instability and obstructive sleep apnea: cycle; patient with small airway falls asleep; airway starts to collapse,
causing increased resistance and increased CO2; patient arouses from sleep; resuscitative snort (hyperventilation and
decreased CO2); patient resumes sleep with low CO2; central apnea, hypopnea; periodic breathing or loss of respiratory
drive
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| Locations of obstruction and implications: Fujita divided airway into 3 levels of obstruction (Type I [oropharyngeal];
Type II [oro- and hypopharyngeal]; Type III [hypopharyngeal]); 1992 study showed palatal obstruction in 25% of
cases, palate and tongue base in 55% of cases, tongue base alone in 10%, and supraglottic in 10%; not one source of
obstruction (think of airway as floppy tube that has structures along course); obstructive disease multifactorial
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| Focused history: snoring; witnessed sleep apnea; choking, gasping, or resuscitative snort; excessive daytime sleepiness;
dozing; nonrestorative sleep; lack of dreaming; nasal obstruction, mouth breathing, and sore throat; history of airway surgery;
depression; cardiovascular disease, stroke, hypertension, and pulmonology history
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| Practical examination: examination—nose to trachea as well as mental status, affect, and basic cardiopulmonary examination
(speaker auscultates all patients, listening for eg, crackles, rales); staging—simple snoring, continuous positive
airway pressure (CPAP) failure, obesity; place patient within spectrum of disease; decision making—CPAP trial;
surgical algorithm
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| Examination methods: physical examination; endoscopy; cephalometric x-rays; sleep endoscopy; fluoroscopy; manometry;
acoustic pharyngomanometry; computed tomography (CT); magnetic resonance imaging (MRI)
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| Predictors of sleep apnea: obesity; neck size (>17 in in men and >15 in in women); low hyoid; cervical scoliosis; telescoping
of mucosa; rugae of posterior wall; lateral wall hypertrophy; Mallampati class 3 and 4
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| Coding: level 3 new—auscultate chest; examine larynx; listen to heart; look for peripheral edema; do ear, nose and throat
neurologic examination
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| Examination: vital signs—height, weight, BMI; neck size; general appearance—obesity; fatigue; somnolence; syndromic
appearance (no chin, short maxilla [goatee on men]); head and face—retrognathia; maxillary shortening; nose—
fractures; twists; tension nose (nose high and narrow); valve narrowing; valve collapse; Cottle maneuver; tip lift; deviated
septum; turbinate hypertrophy; inflammation; edema; polyps; oxymetazoline (Afrin) test indicates whether patient will benefit
from airway surgery; oral cavity and oropharynx—malocclusion (suggesting microgenia); small dental arch; crowded
teeth; history of extractions and braces (indicating small mandible); maxillary hypoplasia with underbite; retrognathia with
overbite; palate (length; thickness; uvula; mucosal webs; retrodisplacement [especially post-tonsillectomy]); simulated
snore; diagram of palate type (have in chart to circle); tongue (size 1-4; at, below, or above occlusal plane; crenellations);
Friedman system—relationship of tongue to palate stage I, whole airway visible; stage II, tongue up to tip of uvula; stage
III, cannot see airway, but can see palatal structure; stage IV, no visible pathway to airway; have drawings in chart to circle;
tonsil size (0נ have drawings in chart to circle); neck—low hyoid; thickness; fat deposits; short neck; thyromental perpendicular
(blunted cervicomental angle abnormal); neurologic and psychologic factors—depressed affect; somnolence;
memory loss; confusion; psychomotor retardation; pharynx and larynx—fiberoptic endoscopy critical; in nasopharynx,
look for constriction, adenoid hypertrophy, short anterior-posterior (AP) diameter at palate, and stenosis in those who have
had surgery; in pharynx, look for redundant tissues, telescoping of mucosa, intruding side walls, lateral fat pads, and short AP
diameter behind tongue; in larynx, look for obstruction by tongue, retroverted epiglottis, omega epiglottis, redundant posterior
commissure tissues (means laryngopharyngeal reflux); endoscopic laryngeal staging—full visibility of larynx (1);
arytenoids visible (2); only epiglottis visible (3); only tongue base visible; ability to correct obstruction better if larynx visible;
Mueller maneuver—controversial; valuable tool to identify obstructive tissues (speaker’s opinion); looking for patient
where no collapse at base of tongue and substantial collapse at level of palate and tonsils (can fix this level); perform by having
patient take few breaths, breathe all way out, pinch nose and suck in; driven by patient’s effort; laryngeal staging more
objective
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| Diagnostic studies: polysomnography (PSG) gold standard; overnight oximetry on low-risk patients, PSG if positive
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| Decision making: Stanford method—bimaxillary advancement; now stage II decision; Woodson modification—
snoring (radiofrequency ablation; implant; laser; oral appliance); mild to severe apnea, use examination to guide choice of
procedures; profound apnea with high-risk craniofacial factors, tracheotomy and bimaxillary advancement indicated; uvulopalatopharyngoplasty
(UPPP)—40% success rate; 5% success rate if retroglossal obstruction present; pain from surgery
discourages second stage
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| Treatment options: snoring—radiofrequency ablation of palate; somnoplasty; coblation; Ellman device; Pillar procedure;
injection snoreplasty (less control; some injected substances may be carcinogenic); sleep apnea—CPAP gold
standard; surgical approach—proportional response; escalating interventions for escalating disease; limit morbidity of
procedure; multilevel surgical approach—salvage for profound disease and surgical failure (tracheotomy; bimaxillary
advancement); minimally invasive approaches—Pillar procedure (3 rods put in); radiofrequency ablation of tongue
base (gold standard for retroglossal obstruction; not morbid); tongue suspension
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| Conclusions: surgeons can change anatomy, but cannot always change physiology in sleep apnea; fail 50% of time because
condition multifactorial
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| RADIOFREQUENCY ABLATION OF THE TONGUE BASE —Dr. Greene
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| Treatment options: Riley and Powell protocol—UPPP with genioplasty, hyoid advancement (Phase I); upper and
lower jaws pulled forward (Phase II); moving away from this (not pleasant for patient); approaches to tongue base—
radiofrequency ablation of base of tongue (RFBOT; speaker’s first choice); tongue suspension (Repose system); genioglossus
advancement; hyoid suspension; partial glossectomy vs lingual tonsillectomy
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| RFBOT procedure: first developed with somnoplasty (only technique currently approved by Food and Drug Administration
[FDA]); coblation system—need to know anatomy to avoid drilling into nerve or artery (Ellman tongue device
helpful); goals—energy needed varies with size of tongue; 12 sites over ≥2 sessions; location centered on circumvallate
papillae or posterior; vary pattern each time (eg, inverted pyramid or bowling pins, then boxcars); anatomy—nerves and
vessels going into tongue; fine if midline and posterior; if off to side and posterior, go deep to and parallel to mucosa to
avoid nerves; most bleeding problems result from going too far anteriorly; technique—anesthetize tongue as far back as
possible; if tongue starts to fibrillate, wand too close to nerve; use suction cautery to control bleeding; speaker uses small
tongue retractor (tonsil gag with small blade), pulls tongue forward to expose tongue base; midline ablation sites 45° or
deeper to and parallel to mucosal surface; midline raphe safe zone; use somnoplasty system when starting; keep all sites
posterior
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| PEDIATRIC NECK MASSES —Paul Krakovitz, MD, Pediatric Otolaryngology, Cleveland Clinic Head and Neck Institute,
Cleveland, OH
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| Location of neck masses: classic midline lesions—thyroglossal duct cysts; dermoid cysts; ranulae; teratomas; lateral
neck—branchial cleft cysts and sinuses; laryngoceles; anywhere in neck—thymic lesions; hemangiomas; lymphatic
malformations; vascular malformations; lymph nodes
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| Thyroglossal duct cyst: most common congenital lesion in midline of neck (possibly in neck in general); found anywhere
from foramen cecum to pyramidal lobe of thyroid; thyroid tissue present in 45% of cases, but unusual for cyst to be
only thyroid tissue; work-up for midline mass—ultrasonography (checking for normal thyroid tissue); Sistrunk
procedure—resection of thyroglossal duct cyst, taking midportion of hyoid bone with it, and in towards base of tongue;
recurrence rate low; best not to incise and drain congenital lesions when hot and infected because this makes them difficult
to remove later
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| Dermoid cysts: classically in submental region; mimic thyroglossal duct cysts
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| Branchial cleft cysts and sinuses: trapped remnants from cervical sinus of His; epithelium-lined; fluctuant; high propensity
to form abscesses because of connection with oral cavity; obtain CT to further evaluate; think about branchio-
oto-renal syndrome (look for history of hearing loss or renal problems)
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| First branchial cleft: type 1—duplication of external auditory canal; periauricular; may go around facial nerve; type 2—
in same location; ectoderm- and mesoderm-derived (adnexal structures within them); end inferior to external canal or
between bony and cartilaginous junction
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| Second branchial cleft: most common type; anterior to sternocleidomastoid (SCM) muscle; run between internal and external
carotid arteries, ending in tonsillar fossa; deep to second-arch structures and superficial to third-arch structures
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| Third branchial cleft: uncommon; found lower in neck; anterior to SCM, deep to third-arch structures and superficial to
fourth-arch structures; enter pharynx at level of thyrohyoid
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| Fourth branchial cleft: least common; present as left-sided neck mass, recurring thyroiditis or lower neck abscess; enter at
apex of piriform sinus (inferior to superior laryngeal nerve)
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| Procedure for removal: begin with laryngoscopy or oral examination (tract often ends intraorally); inject open fistula
with saline; speaker uses methylene blue to help find tract or fistula; dissect in mouth, then go in through neck and remove
cyst or fistula and follow back to mouth
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| Ranula: pseudocyst that develops from trauma to sublingual glands; for plunging ranula, speaker recommends external
approach as it comes through mylohyoid, then intraorally remove sublingual gland and remainder of ranula
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| Vascular malformations: hemangiomas—common in neck; proliferative stage during first year of life (presents during
first months of life); peak at 1 yr of age and slowly involute, but not totally; treatment options include interferon (side effects),
oral steroids, intralesional steroids, or watchful waiting (best choice unless functional impairment, bleeding, or skin necrosis
present)
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| Lymphatic malformations: macrocystic or microcystic; treatment—sclerotherapy; surgical excision; do not commonly
become infected; high rate of recurrence after surgery because microcystic lesions do not follow natural planes
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| SCM tumors of infancy: avoid biopsy; typically, child presents at 4 to 6 wk of age; history of traumatic delivery; palpation
reveals firm mass at SCM and torticollis; diagnose with ultrasonography; mass usually resolves with physical therapy
and neck exercises
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| Lymphadenopathy (infectious): viral—usually bilateral; nodal architecture usually preserved on ultrasonography;
potentially large and can mimic neoplasm; bacterial—usually follows infection; Staphylococcus, Streptococcus, and
in newborns consider gram-negative bacteria; cat-scratch fever—lymphadenopathy (potentially impressive), mild fever,
and malaise; most of time, history of feline exposure; infecting agent Bartonella henselae; diagnose with indirect
fluorescent antibody test; prevention best treatment (most antibiotics have low efficacy); mycobacterial infections—
tuberculosis (uncommon); atypical mycobacteria—scrofula; unilateral, matted lymphadenopathy; frequently in submandibular
triangle; skin involvement (classically); can mimic cancer; dirt as source; purified protein derivative (PPD)
usually negative; diagnosis with biopsy; treatment controversial (surgical excision or medical therapy); medical therapy
difficult
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| Draining neck fistulas: differential diagnosis includes cat-scratch fever (suppurated, biopsied, and now draining),
scrofula, dental source, and actinomycosis
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| Lymphadenopathy (other sources): sialadenitis; neurofibroma; laryngocele; thymic cyst; toxoplasmosis; drug-induced
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| Kawasaki disease: noninfectious inflammatory disorder; unilateral lymphadenopathy; high fever; risk for cardiac involvement
and aneurysms
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| Malignant neoplasms: Hodgkin’s lymphoma—more common in >10-yr age group; asymptomatic neck mass; constitutional
symptoms (weight loss, fever, and night sweats); non-Hodgkin’s lymphoma—any age; presents with disseminated
disease; constitutional symptoms common; rhabdomyosarcoma—when isolated to neck, most common in children <6 yr of
age; peaks at ages 2 yr to 5 yr and 15 yr to 19 yr; metastases uncommon (except with meningeal spread); treatment options include
biopsy and surgical excision if possible, otherwise radiation therapy and chemotherapy; long-term survival ≤90%;
other—salivary gland neoplasms; neuroblastoma; metastatic disease
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| Work-up: history—when mass first noted; travel; playing in dirt; cat exposure; rate of growth; constitutional symptoms;
behavioral changes; examination—location; quality (firm, fixed, rubbery); laterality; whether fluctuant; changes in
overlying skin; other lymphadenopathy; work-up—ultrasonography; MRI for lymphatic or vascular lesions; consider
CT; chest x-ray; laboratory studies—complete blood count; comprehensive metabolic panel; test for Epstein-Barr virus;
Bartonella and Toxoplasma titers; lactate dehydrogenase; PPD
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Educational Objectives
| The goal of this program is to provide the listener with information on examination and treatment of sleep-disordered
breathing, radiofrequency ablation of the tongue base, and neck masses in children. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Discuss the pathophysiology and anatomic causes of sleep-disordered breathing.
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| 2. Perform a comprehensive examination of patients for snoring and sleep apnea.
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| 3. List treatment options for sleep-disordered breathing.
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| 4. Discuss radiofrequency ablation of the tongue base for retroglossal obstruction in obstructive sleep apnea.
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| 5. Evaluate and treat pediatric neck masses.
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Suggested Reading
Dickson PV, Davidoff AM: Malignant neoplasms of the head and neck. Semin Pediatr Surg 15:92, 2006; Foley
DS, Fallet ME: Thyroglossal duct and other congenital midline cervical anomalies. Semin Pediatr Surg 15:70, 2006;
Meuwly JY et al: Multimodality imaging evaluation of the pediatric neck: techniques and spectrum of findings. Radiographics
25:931, 2005; Herzog M et al: The prognostic value of simulated snoring in awake patients with suspected
sleep-disordered breathing: introduction of a new technique of examination. Sleep 29:1456, 2006; Petropoulos I et al:
Thymic cyst in the differential diagnosis of paediatric cervical masses. B-ENT 2:35, 2006; Gorur K et al: An unusual
presentation of neck dermoid cyst. Eur Arch Otorhinolaryngol 262:353, 2005; Hanikeri M et al: The management of
midline transcranial nasal dermoid sinus cysts. Br J Plast Surg 58:1043, 2005; Michaelson PG et al: Validations of a
portable home sleep study with twelve-lead polysomnography comparisons and insights into a variable gold standard. Ann
Otol Rhinol Laryngol 115:802, 2006; Polotsky VY, O’donnell CP: Genomics of Sleep-disordered Breathing. Proc
Am Thorac Soc 4:121, 2007; Pang KP et al: Severity of obstructive sleep apnea: correlation with clinical examination
and patient perception. Otolaryngol Head Neck Surg 135:555, 2006; Lin HS et al: Factors associated with noncompliance
to treatment with positive airway pressure. Arch Otolaryngol Head Neck Surg 133:69, 2007; Ridder GJ et al:
Cat-scratch disease: Otolaryngologic manifestations and management. Otolaryngol Head Neck Surg 132:353, 2005;
Waldhausen JH: Branchial cleft and arch anomalies in children. Semin Pediatr Surg 15:64, 2006; Why pauses in
breathing during sleep should be a wake-up call. Heart Advis 9:2, 2006.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, Dr. Greene
reports relationships with Ellman International, Inc. and Arthrocare.
Drs. Greene and Krakovitz were recorded at 5th Anniversary Cleveland Clinic Florida Otolaryngology Symposium,
held March 16-18, 2006, in Naples, FL, and sponsored by Cleveland Clinic Florida. The Audio-Digest Foundation thanks
the speakers and the sponsors for their cooperation in the production of this program.
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