Objective:To develop and validate the Italian version of the Quebec Sleep Questionnaire (I-QSQ) for assessing quality of life (QoL) in patients with obstructive sleep apnoea (OSA). Methods:The questionnaire was translated, culturally adapted, and back-translated. Internal consistency and test-retest reliability were evaluated in patients with moderate OSA. Normative values were obtained in healthy subjects. Construct and criterion validity were assessed by comparing scores of patients and controls, and by correlating I-QSQ with the Epworth Sleepiness Scale. Responsiveness was examined in patients undergoing sleep surgery. Results:One hundred-six patients and 173 control subjects completed the I-QSQ without assistance. Internal consistency was acceptable to excellent across domains (Cronbach's α = 0.71-0.9), and test-retest reliability was high (ICC = 0.88-0.96). Patients scored significantly lower than controls in all domains (p < 0.001). A negative correlation was observed between I-QSQ and Epworth Sleepiness Scale scores (r = -0.54). Post-surgical patients showed significant improvement in I-QSQ total score. Conclusions:I-QSQ is a reliable, valid, and responsive tool for evaluating QoL in Italian-speaking patients with sleep apnoea and can be effectively used in clinical practice and research.

PURPOSE:To evaluate, in Obstructive sleep apnea (OSA) patients, the use of pre-treatment drug-induced sleep endoscopy (DISE) as a patient selection tool, that could improve the outcomes of mandibular advancement device (MAD) therapy. A multicenter retrospective case-control study has been performed. METHODS:A multicenter case-control study with two parallel arms was conducted to compare functional outcomes in patients undergoing MAD therapy. Group A (n = 118) received MAD therapy based solely on static clinical assessments, including dentoskeletal features, oropharyngeal anatomy, and upper airway endoscopy. Group B (n = 87) underwent pre-treatment DISE to dynamically evaluate the site, type, and pattern of upper airway collapse, thereby guiding patient selection for MAD therapy. RESULTS:In Group A, the mean pre-treatment apnea-hypopnea index (AHI) was 28.1, decreasing significantly to 12.4 post-treatment (p = 0.0001). In Group B, the mean AHI decreased from 31.3 to 9.5 (p = 0.0001). The Delta apnea-hypopnea index (ΔAHI) was significantly greater in Group B (-21.7) than in Group A (-16.6; p = 0.04). Similarly, the Delta Oxigen desaturation index (ΔODI) was -18.6 in Group B versus -14.1 in Group A (p = 0.04). The therapeutic success rate was significantly higher in Group B (82.7 %) compared to Group A (60.1 %) (p = 0.001). CONCLUSION:In OSA patients, a pre-treatment DISE evaluation, improves the selection of appropriate candidates for MAD therapy by enabling dynamic assessment of upper airway collapsibility during a pharmacologically induced sleep. This targeted selection results in significantly better therapeutic outcomes for MAD therapy for the OSA treatment.

The Berlin questionnaire (BQ), with its ten questions, stands out as one of the simplest and most widely implemented non-invasive screening tools for detecting individuals at a high risk of Obstructive Sleep Apnea (OSA), a still underdiagnosed syndrome characterized by the partial or complete obstruction of the upper airways during sleep. The main aim of this study was to enhance the diagnostic accuracy of the BQ through Machine Learning (ML) techniques. A ML classifier (hereafter, ML-10) was trained using the ten questions of the standard BQ. Another ML model (ML-2) was trained using a simplified variant of the BQ, BQ-2, which comprises only two questions out of the total ten. A 10-fold cross validation scheme was employed. Ground truth was provided by the Apnea–Hypopnea Index (AHI) measured by Home Sleep Apnea Testing. The model performance was determined by comparing ML-10 and ML-2 with the standard BQ in the Receiver Operating Characteristic (ROC) space and using metrics such as the Area Under the Curve (AUC), sensitivity, specificity, and accuracy. Both ML-10 and ML-2 demonstrated superior performance in predicting the risk of OSA compared to the standard BQ and were also capable of classifying OSA with two different AHI thresholds (AHI ≥ 15, AHI ≥ 30) that are typically used in clinical practice. This study underscores the importance of integrating ML techniques for early OSA detection, suggesting a direction for future research to improve diagnostic processes and patient outcomes in sleep medicine with minimal effort.

OBJECTIVES:To investigate through an international survey the actual clinical application of drug-induced sleep endoscopy (DISE) in pediatric patients with obstructive sleep apnea (OSA) and to clarify the use, application, clinical indications, and protocol of pediatric DISE. METHODS:A specific survey about pediatric DISE was initially developed by five international otolaryngologists with expertise in pediatric sleep apnea and drug-induced sleep endoscopy and was later spread to experts in the field of sleep apnea, members of different OSA-related associations. RESULTS:A total of 101 participants who answered all the survey questions were considered in the study. Sixty-four sleep apnea experts, equivalent to 63.4% of interviewed experts, declared they would perform DISE in pediatric OSA patients. A total of 81.9% of responders agreed to consider the DISE as the first diagnostic step in children with persistent OSA after adenotonsillectomy surgery, whereas 55.4% disagreed with performing DISE at the same time of scheduled adenotonsillectomy surgery to identify other possible sites of collapse. In the case of young patients with residual OSA and only pharyngeal collapse during DISE, 51.8% of experts agreed with performing a velopharyngeal surgery. In this case, 27.7% disagreed and 21.4% were neutral. CONCLUSION:Pediatric DISE is internationally considered to be a safe and effective procedure for identifying sites of obstruction and collapse after adenotonsillectomy in children with residual OSA. This is also useful in cases of patients with craniofacial malformations, small tonsils, laryngomalacia or Down syndrome to identify the actual site(s) of collapse. Despite this evidence, our survey highlighted that pediatric DISE is not used in different sleep centers.

Upper airway (UA) surgery is commonly employed in the treatment of patients with obstructive sleep apnea (OSA). The intricate pathophysiology of OSA, variability in sites and patterns of UA collapse, and the interaction between anatomical and non-anatomical factors in individual patients may contribute to possible surgical failures. This clinical consensus statement aims to identify areas of agreement among a development group comprising international experts in OSA surgery, regarding the appropriate definition, predictive factors in patients, and management of surgical failure in OSA treatment. A clinical consensus statement (CCS) was developed using the Delphi method by a panel of 35 contributors from various countries. A systematic literature review adhering to PRISMA guidelines was conducted. A survey consisting of 60 statements was then formulated and presented to the experts. Following two rounds of the Delphi process, consensus or strong consensus was achieved on 36 items, while 24 items remained without consensus. Specifically, 5 out of 10 statements reached consensus regarding on the 'Definition of Surgical Success/Failure after OSA Surgery'. Regarding the 'Predictive Factors of Surgical Failure in OSA Surgery', consensus was reached on 10 out of 13 statements. In the context of the 'Diagnostic Workup in OSA Surgery', consensus was achieved on 9 out of 13 statements. Lastly, in 'Treatment in Surgical Failure Cases', consensus was reached on 12 out of 24 statements. The management of OSA after surgical failure presents a significant clinical challenge for sleep specialists. This CCS provides valuable guidance for defining, preventing, and addressing surgical failures in the treatment of OSA syndrome.

PurposeThis systematic review aims to compare the efficacy and safety of multilevel and single level surgery, including barbed pharyngoplasties, in the treatment of obstructive sleep apnea (OSA).MethodsThe study followed PRISMA guidelines and searched PubMed/MEDLINE, Google Scholar, and Ovid databases for studies evaluating the effect of barbed pharyngoplasties on adults with OSA. Prospective and retrospective cohort studies were included with pre- and post-treatment comparisons of sleep tests and self-reported clinical outcomes. Exclusion criteria were non-English studies, case reports, reviews, conference abstracts, letters, and pediatric studies. Successful surgery was classified using Sher's criteria.ResultsThe study selected a total of 1014 patients from 26 studies, 24 of which were longitudinal studies with 10 retrospective trials and 14 prospective studies. The average age of the patients was 46.9 years, with an average Body Mass Index (BMI) of 25.6 kg/m(2). Most of the patients were male (84.6%). The study included only palatal surgical techniques with barbed sutures, and patients who underwent cardio-respiratory monitoring and Drug Induced Sleep Endoscopy (DISE) before surgery. Mean Apnea Hypopnea Index (AHI) preoperative was 32.9/h, AHI postoperative was 11.9/h, and mean reduction of AHI was 62.3%. The most commonly adopted palatoplasty was Barbed Repositioning Pharyngoplasty (BRP) in 16 out of 26 studies, followed by its subsequent modifications in 3 studies.ConclusionsBarbed pharyngoplasties appear to be effective both on objective measurement and subjective scores. DISE represents a fundamental tool to assess uni-level or multilevel obstruction. When retro-palatal collapse is present, barbed pharyngoplasty appears to be effective. Barbed pharyngoplasties maintain their good results both in single level or multilevel surgery. Randomized clinical controlled trials with multi-center cooperation and long-term study are necessary.

Pharyngocutaneous fistula is one of the most common and serious complications associated with total laryngectomy. Numerous studies tried to evaluate causative and predisposing factors associated with this complication, but data are considerably variable and there is still no international consensus. Incidence rate varies considerably between studies, with reported rates from 3% to 65%. This 4K video presents our T‐shaped four‐step technique (FST) for closing the pharyngeal mucosa after total laryngectomy in a step‐by‐step manner. All sutures were performed by braided absorbable 3/0 26 mm 1/2c (Vicryl plus 3.0; Ethicon, Somerville, NJ, USA). Recordings were performed using a Karl Storz 4K 3D VITOM® exoscope (Karl Storz SE & Co. KG, Tuttlingen, Germany). We have been described this technique through a high‐definition video, showing each step, and tips from the authors. Our T‐shaped pharyngoplasty closure technique can be divided into four steps: 1. “Key Stitches”; 2. “Area Refinement Stitches”; 3. “Modified Connell Suture”; 4. “Modified Purse String Suture.” Our T‐shaped FST closure technique proved to be an effective and reproducible method, which we feel could be the preferred choice for primary pharyngoplasty closure.

Barbed snore surgery (BSS) was recently introduced for the management of obstructive sleep apnea (OSA) with optimistic clinical outcomes associated with a low complication rate. The purpose of the present study was to describe the surgical learning curve of the BSS to determine the effect of surgeon experience on surgical procedure time and complication rates. Patients who underwent tonsillectomy with barbed lateral pharyngoplasty were divided in two different groups based on surgeon experience. Operative time, intraoperative blood loss, intra- and post-operative complications, and hospitalization time were compared. A total of 144 consecutive patients (F: 27; mean age: 47.5 years, SD 9.7) were included. All procedures were successfully completed in 37.0 min (IQR 29.0–47.0). Senior surgeons completed the procedure in 33.0 min (IQR 27.0–41.0), while junior surgeons needed 52.0 min (IQR 36.5–64.5) (p < .05). No intra-operative complications were observed, and intra-operative blood loss was minimal in both groups. No difference was measured in terms of hospitalization time. Only one post-operative bleeding resolved with conservative treatment was detected in both groups. Junior surgeons showed a positive trend in the reduction of operative time (r = − 2.32, 95

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The introduction of sleep endoscopy in the diagnosis of sleep apnea-hypopnea syndrome (OSAHS) has led to the development of a customization in the surgical approach of patients refusing nocturnal ventilation.Sometimes follow up polysomnography can show a recurrence of OSAHS, even in patients with no changes in weight or head and neck anatomy.We report a case of a patient undergone uvulopalatopharyngoplasty and epiglottoplasty showing a worsening of OSAHS years after surgery.A 69-year-old man with moderate OSAHS refusing overnight ventilation underwent sleep endoscopy showing collpase of palate, tongue base and epiglottis.Uvulopalatopharyngoplasty and epiglottoplasty were then perfomed in addiction to application of mandibular advancement device (MAD), with normalization of parameters, as shown by the following polysomnographies.Over time, symptomes started to recur, and the patient underwent a new polysomnpography showing increase of apnea-hypopnoea index (AHI).A second sleep endoscopy was therefore performed, pointing out the role of the collapse of the residual epiglottis in developing apneas.Epiglottis stiffening operation was consequently perfomed with resolution of symptoms and reduction of AHI.Patients treated with surgery and MAD should always be monitored with follow up polysomnography.Worsening of symptoms should be evaluated by means of sleep endoscopy in order to identify and treat the new causes of obstruction.

D-glyceraldehyde stimulated insulin secretion from isolated rat pancreatic islets in static incubation and perifusion systems. At low concentrations (2-4 mM) D-glyceraldehyde was a more potent secretagogue than glucose. The insulinotropic action of 15 mM D-glyceraldehyde was not affected by D-mannoheptulose, was potentiated by cytochalasin B (5 mug/ml) and theophylline (4 mM), and was inhibited by both adrenalin (2 muM) and somatostatin (10 mug/ml). D-glyceraldehyde at a concentration of 1.5 mM produced a 10-fold increase of L-[4,5-3H]leucine incorporation into proinsulin and insulin without a significant increase into other islet proteins. Glucose at 1.5 mM did not stimulate proinsulin biosynthesis. D-Glyceraldehyde at concentrations higher than 1.5 mM, in marked contrast to glucose, progressively inhibited incorporation of labelled leucine into proinsulin + insulin and other islet proteins. D-Glyceraldehyde also inhibited the oxidation of glucose. L-Glyceraldehyde did not stimulate proinsulin biosynthesis and had less effect than the D-isomer on insulin release and glucose oxidation. The results strongly suggest that metabolites below D-glyceraldehyde-3-P are signals for insulin biosynthesis and release. Interaction of D-glyceraldehyde with a "membrane receptor" cannot, however, be excluded with certainty.

Background: Poorly differentiated sinonasal carcinomas (PDSNCs) are rare and aggressive malignancies, which include squamous cell carcinoma (SCC), sinonasal undifferentiated carcinoma (SNUC), and neuroendocrine carcinomas (NEC). Several epigenetic markers have been suggested to support the histopathological classification, predict prognosis, and guide therapeutic decision. Indeed, molecularly distinct subtypes of sinonasal carcinomas, including SMARCB1-INI1 or SMARCA4 deficient sinonasal carcinoma, isocitrate dehydrogenase (IDH)-mutant SNUC, ARID1A mutant PDSNCs, and NUT carcinomas, have recently been proposed as separate entities. Identification of aberrant DNA methylation levels associated with these specific epigenetic driver genes could be useful for prognostic and therapeutic purpose. Methods: Histopathological review and immunohistochemical study was performed on 53 PDSNCs. Molecular analysis included mutational profile by NGS, Sanger sequencing, and MLPA analyses, and global DNA methylation profile using LINE-1 bisulfite-PCR and pyrosequencing analysis. Results: Nine SWI/SNF complex defective cases and five IDH2 p.Arg172x cases were identified. A significant correlation between INI-1 or IDH2 defects and LINE-1 hypermethylation was observed (p = 0.002 and p = 0.032, respectively), which were associated with a worse prognosis (p = 0.007). Conclusions: Genetic and epigenetic characterization of PDSNCs should be performed to identify distinct prognostic entities, which deserved a tailored clinical treatment.

Objectives The primary aim of the present study was to report our multi-institutional experience in surgical salvage with open partial horizontal laryngectomies (OPHL) after failed radiotherapy (RT) for laryngeal squamous cell carcinoma (LSCC). Secondary aims were to analyze the prognostic meaning of the main clinical and pathological parameters in relation to the oncologic outcome and to compare our results with the available literature. Study Design A retrospective multicenter analysis of surgical oncological outcomes. Methods We retrospectively review the clinical charts of 70 recurrent LSCC patients after primary RT failure undergone salvage OPHL. Results At last follow-up, 46 patients (65%) were disease-free; six (9%) were alive with disease; nine (12%) died because of the disease; and nine (12%) died without evidence of disease. The final local control, overall survival, disease-specific survival, and laryngectomy-free survival were 87%, 75%, 87%, and 91%, respectively. Twelve patients (17%) experienced postoperative complications, whereas 18 patients (25%) experienced late sequelae. In five patients (7%), decannulation was not possible because of postoperative laryngeal stenosis. Conclusion In selected patients, when proper selection criteria for conservation laryngeal surgery are adopted, OPHL can be considered for salvage after RT failure. Level of Evidence 4 Laryngoscope, 130:431-436, 2020

SUMMARY Objective The aim of this study is to focus attention on obstructive sleep apnoea hypopnoea syndrome (OSHAS) as a sequela of non-surgical treatments of selected head and neck cancer (HNca), sharing our experience in drug-induced sleep endoscopy (DISE). To the best of our knowledge, this is the first study that documents dynamic anatomical and functional alterations during sleep in irradiated OSAHS patients by DISE. Methods A retrospective study of patients affected by OSAHS referring to our department from January 2018 to December 2019 was carried out. Inclusion criteria were: patients who underwent radiation or chemo-radiation for HNca affecting upper airways that presented sleep-related breathing disorders after treatment. Results 6 patients with moderate to severe OSAHS and a clinical story of previous non-surgical treatment for an HNca were enrolled. DISE showed in all patients typical anatomical alterations observed in irradiated individuals. Four patients were treated with continuous positive airway pressure, while 2 subjects were treated with tailored minimal invasive surgery without post-operative complications. Conclusions Our results suggest that minimal invasive surgical treatments can be a good therapeutic option in very selected patients with post-irradiation iatrogenic OSAHS.

BACKGROUND: Endoscopic endonasal anterior skull base malignant sinonasal tumor resection and reconstruction remains a challenge. We describe our septal flip flap (SFF) reconstruction, a new surgical technique for repairing anterior skull base defects and report our outcomes. METHODS: We retrospectively reviewed the clinical data of 24 patients who underwent skull base reconstruction using a SFF following endoscopic resection with transnasal craniectomy. We raise the SFF from the contralateral nasal septum based on the septal branches of the anterior and posterior ethmoidal arteries; the SFF is then rotated laterally for anterior skull base reconstruction after transnasal resection with craniectomy. RESULTS: The SFF was used for multiple tumor types including, most commonly, intestinal-type adenocarcinoma, followed by olfactory neuroblastoma, squamous cell carcinoma, sinonasal undifferentiated carcinoma, and other types. All of the cases had either preoperative or postoperative radiation therapy. All flaps remained viable postoperatively. Postoperatively, nasal crusting was significantly reduced with faster healing of the surgical cavity. CONCLUSIONS: The SFF adds to the clinical armamen-tarium the opportunity to provide vascularized mucosal coverage extending from the frontal recess hack to the planum sphenoidalis. The use of SFF requires careful consideration when dealing with paranasal sinus cancers so as not to infringe oncologic principles.