CPAP cures metabolic syndrome in obstructive sleep apnea (RCT, NEJM)

This is a fascinating study not just because it demonstrates the benefit of CPAP in reducing sugar, blood pressure, cholesterol, and LDL, but more so for its use of a 'sham CPAP' for placebo!

As the commentator notes, it's unclear if the benefits were the direct result of reducing hypoxic events or more indirectly because of increased activity and exercise in the less somnolent. It would be good to control for that.

http://pulmccm.org/main/2012/randomized-controlled-trials/cpap-cures-metabolic-syndrome-in-obstructive-sleep-apnea-rct-nejm/

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Liow: Heavy snorers may have sleep disorder

Our Minister of Health has taken cognizance of the serious health implications of OSA.

http://thestar.com.my/news/story.asp?file=/2012/1/8/nation/10225247&sec=nation

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OSA in Pediatric CNS tumor survivors

An interesting study showing a high prevalence of OSA in children CNS tumor survivors. Rather remarkable is that while SDB is highly prevalent, it is the Obstructive apneas that are more prevalent than Central (14 out of 18). Another subgroup of patients to be on the alert for OSA in.

Excessive daytime sleepiness and sleep-... [Pediatr Blood Cancer. 2011] - PubMed - NCBI:

'via Blog this'

Oropharyngeal examination to predict sleep apnea severity

It's good to see a study that validates what is widely held belief among ENT surgeons. While assessing the oropharyngeal airway ALONE is hardly a holistic approach, a finding of a narrowed passage by Friedman Tongue Position in a patient with excessive daytime sleepiness or other comorbids of OSA (eg. refractory hypertension, ischemic heart disease) has been highly predictive of OSA in my own practice.


Oropharyngeal examination to... [Arch Otolaryngol Head Neck Surg. 2011] - PubMed - NCBI:

'via Blog this'

Things aren't always what they seem at first

Now that 4D IMRT is all the buzz, we are seeing more and more studies on the volume changes of tumors througout the course of chemoradiation. This is imaging science at its best, monitoring progress and titrating treatment according to burden of disease. Perhaps we can learn something in managing other pathologies; like infection for example.

Weekly volume and dosimetric changes during chemoradiotherapy with intensity-modulated radiation therapy for head and neck cancer: a prospective observational study. (http://www.ncbi.nlm.nih.gov/pubmed/20338474)
Bhide SA, Davies M, Burke K, McNair HA, Hansen V, Barbachano Y, El-Hariry IA, Newbold K, Harrington KJ, Nutting CM.
Int J Radiat Oncol Biol Phys. 2010 Apr;76(5):1360-8.

New in OSA

This is music to my ears.

Authors Xu H, Huang W, Yu L, and Chen L. published in Acta Otolaryngolica this week an article entitled 'Sound spectral analysis of snoring sound and site of obstruction in obstructive sleep apnea syndrome.'
(http://www.ncbi.nlm.nih.gov/pubmed/20377505)

They showed objectively what we have known intuitively, that the higher the obstruction the lower the pitch of noise generated. In fact they found that lower obstructions had a greater proportion of >800Hz and >2000Hz first-snore sounds than higher obstructions.

This confirms the way we clinically differentiate stertor and stridor, and might even spawn a new wave of polysomnogram parameters.

I can tell by the way you snore...

Wouldn't it be great if we didn't have to do expensive polysomnograms, read incomprehensible charts, and (in the public setting) wait for months for a sleep study? All just to diagnose OSA and say to a patient ok, now we are sure you need treatment. Especially when he's been falling asleep in your waiting room or just come in with head bandaged after his lorry overturned. You know he has OSA.

Well, it seems the people in Brisbane have found a way.

I have been thinking along the lines of a biochemical marker or something that might be detected in the breath. Imagine bus drivers having to check in for a urine test or breathalyser test before they board and you get the idea.

The sleep team in University of Queensland have reported they can HEAR that you have OSA.

I guess I have always had this hunch. Haven't you? There's a rhythmic hiss in the meeting room and you thought it was the air-condition vent until the guy next to you starts nodding. You think the ventilator is leaking when you realise your assistant in OR is stertoring. You know. Nothing scientific. No data to base this on. Just that visceral hunch that there's no way you can be breathing right during sleep if you are hissing with every breath through the day.

But these guys down under have made a science of it and claim over 90% sensitivity and specificity by simply analysing the audio recording of your snore!

Read the Article at HealthJockey.com

Review the scientific papers related to snoring by their lead researcher Dr. Udantha Abeyratne.

Microflap excision

These vocal cords belong to a middle-aged chronic smoker who has suffered from a hoarse voice for close to a year. His wife has been my patient for many years and she decided to bring him to see me. As you can see there is intense leukoplakia on both vocal cords. A CT scan revealed no framework infiltration or extension into the pre-epiglottic space. I had tried several biopsies using a flexible scope but tissue was inadequate.


I put him under for a proper microflap excision today. Seen here is the epithelium and subepithelial layers raised, revealing the vocal ligament and gelatinous lamina propria covering it. One advantage of doing this is that I can directly inspect for deep infiltration and also examine the ventricle and subglottic space (which were free growth).


As the free edge of the vocal cord was not spared by this exophytic lesion, it didn't seem logical to confine my excision to the dorsal surface only. After all, voice-sparing was no longer my concern. More important was to get a good representative specimen. The dilemma/temptation was to get some tissue from the opposite vocal cord but thankfully caution prevailed. Last thing I need is an adhesion anteriorly and ruin his voice forever.

Should the lesion be non-invasive, I can still go in again to do the other side. If it's malignant then some radical modality will be offered. That's the plan.

GERD in the News

A new study, published in the journal "Digestion", determined the diagnostic and therapeutic response of the Reflux Disease Questionnaire (RDQ) using the symptom association probability as reference. The symptom association probability objectively determines with a Fisher exact test whether symptoms are due to reflux events taking all symptom episodes and reflux events into account. In addition, the RDQ's construct validity and its relationship to quality of life were ascertained.



The study shows the RDQ to be a valid and reliable questionnaire with excellent construct validity and a good relationship to quality of life. The diagnostic value of the RDQ in primary care is limited, but combination with an additional proton pump inhibitor treatment course might improve the RDQ's ability to discriminate GORD patients according to their symptom association probability outcome.



Medical News Today





Heartburn could be a precursor to gastro-oesophageal reflux disease, British doctors warn and note that the diagnosis of the disease is a relatively new phenomenon.  Statistics show that over a quarter of Britons have gastro-oesophageal reflux disease, also known as the GORD, and thousands of these are not getting the treatment they need. A noted general practitioner, Dr Rob Hicks, said that the GORD as a diagnosis was a relatively new phenomenon and that although most medical practitioners were aware of it, many patients could still be suffering in ignorance. "What we are trying to do is to raise awareness, because there are many people still suffering from heartburn two or three times a week. I would advise them to see their doctor," Hicks said.



MedIndia.com

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Blame it all on GERD!

'Heavner et al., in two animal studies, have demonstrated that exposure of the eustachean tube to simulated gastric content in rodents creates eustachean tube dysfunction. Velepic et al., in two separate studies, have demonstrated a strong correlation of otitis media and GERD. Using a 24-h double pH probe, they found that approximately 60% of the patients had pathologic GERD. In a 2002 study, Tasker et al. demonstrated that middle-ear effusions taken from 54 children contained pepsin/pepsinogen at concentrations up to 1000-fold greater than those in serum 83% of the time. These data suggest that the reflux of gastric juices could be a major cause for otitis media with effusion in children. The link between otitis media with effusion and pharyngeal reflux was further strengthened in a 2004 study by Keles et al. This dual-probe pH study demonstrated that 48% of the children with chronic otitis media effusion had GERD and 64% of the children had pharyngeal reflux. This study suggests that pharyngeal reflux may play an important role in the causes of chronic otitis media with effusion and also that standard single-channel pH probes evaluating for gastroesphageal reflux frequently will miss pharyngeal reflux.'

Should we blame everything on GERD? The above discussion, excerpted from 'SPECIAL COMMENTARY: Should otolaryngologists perform pH probe studies?' by Craig W. Senders in Current Opinion in Otolaryngology & Head and Neck Surgery 2006, 14:38–40 seems to say so.

In the past decade or so, more and more 'mysterious' diseases of ENT are finding its origin in acid. From globus pharyngicus, recurrent tonsillitis, chronic pharyngitis to sinusitis. Now, good old 'glue ear' has a new culprit to blame. And which otolaryngologist hasn't been wondering along those lines? It seems in the fragmented world of subspecialised medicine, diseases are pulling us back together!

Heavner SB, Hardy SM, White DR, et al. Function of the eustachian tube
after weekly exposure to pepsin/hydrochloric acid. Otolaryngol Head Neck
Surg 2001; 125:123–129.
Velepic M, Rozmanic V, Velepic M, Bonifacic M. Gastroesophageal reflux, allergy
and chronic tubotympanal disorders in children. Int J Pediatr Otorhinolaryngol
2000 Oct 16; 55 (3):187–190
Velepic MM, Velepic MS, Starcevic R, et al. Gastroesophageal reflux and sequelae
of chronic tubotympanal disorders in children. Acta Otolaryngol 2004
Oct; 124 (8):914–917
Tasker A, Dettmar PW, Panetti M, et al. Is gastric reflux a cause of otitis
media with effusion in children? Laryngoscope 2002 Nov; 112 (11):1930–
1934
Keles B, Ozturk K, Gunel E, et al. Pharyngeal reflux in children with chronic
otitis media with effusion. Acta Otolaryngol 2004 Dec; 124 (10):1178–
1181

Effects of gastroesophageal reflux disease in laryngeal carcinoma

GERD as a contributory factor to laryngeal carcinoma is much appreciated in the ORL community, but just how strong is it as a risk? Should it be aggresively investigated and treated if the risk is high?

An Italian retrospective investigates the association with 36 consecutive non-smoking and non-drinking patients with histologically confirmed SCC of the larynx vs a control, a group of 125 lifetime non-smoking and non-drinking cancer-free subjects. Patients with laryngeal cancer had a higher prevalence of gastroesophageal reflux disease than the control subjects (P < 0.0001).

PubMed

Genetic Differences Determine Taste Perception

By Daniel DeNoon
WebMD Medical News
Scientists looked at a specific taste receptor for a bitter substance known as PTC. Small changes in the genes made big differences in the receptor's ability to recognize the bitter chemical. This helps explain why some people can't taste PTC at all while others find it terribly bitter - and still others find it bitter in varying degrees.
Read the full article

Men 20-29 most at risk for sleep apnea

by GLOBES Correspondent
'According to a new study, men in their 20s are most at risk for sleep apnea, and need to be screened the most. The study, carried out by the Technion-Israel Institute of Technology, showed that men aged 20 to 29 with severe sleep apnea have 10 times the risk of dying from heart related ailments than their non-sleep apnea peers in the general population, and a much higher risk than older men with sleep apnea.

The Technion study, which appears in the March 2005 European Respiratory Journal, was based on the largest population of sleep apnea patients (nearly 15,000 men) ever to be studied. All were recorded in the Technion sleep clinics in Israel from 1991 through 2000. The researchers compared the risk of dying for men with severe sleep apnea -- having at least 50 breathing stops per hour -- with the general population.'
read the FULL ARTICLE

Lives together, beds apart

by PAULA GANZI LICATA, Newsday.com
'While many older couples remain young valentines at heart, experts say, the increase of snoring, sleep disorders and stirring in bed often spurs partners to consider separate bedrooms. Hertz recommends separate beds or bedrooms for some patients, but stresses taking gradual steps to determine a solution. If the sleep disorder is just movement, as in restless leg syndrome, separate beds in the same room will work, she said. But if the disorder is a noise issue such as snoring, separate rooms may be needed.'
read FULL ARTICLE

Laryngopharyngeal reflux reviewed

'Over the last 3 decades, many reports have implicated refluxed gastric acid as a cause of, or as a contributory factor in, development of chronic laryngeal and pharyngeal disorders. Although this putative cause-effect relationship has been strengthened by more recent evidence, the body of evidence on causation, diagnosis, and treatment of these increasingly diagnosed disorders is still evolving. A variety of symptoms, functional and structural abnormalities involving the larynx, and other contiguous structures positioned proximal to the esophagus constitute the spectrum of these disorders (see the list below). Various terms such as supraesophageal gastroesophageal reflux disease (GERD), atypical GERD, laryngopharyngeal reflux (LPR), and extraesophageal complications of GERD have been used to describe this group of symptoms and signs.'
- Jeegar Jailwala and Reza Shaker reviews the theory and literature regarding laryngopharyngeal reflux at emedicine.com.

Top 10 reasons for sore throat

Throats are Easy Targets for Irritation
There are many causes of irritating, scratchy and painful sore throats, making it difficult at times to swallow, eat and talk. According to Lisa Chavis, R.Ph., pharmacist consultant to Cepacol® sore throat products, "Viruses and bacterial infections are frequently to blame, but are not always the culprit." Here is a breakdown of the top 10 reasons throats get sore: