Cephalometric analysis was carried out before nasal surgery with patients in upright and supine body positions, as has been described. The group of patients with normal cephalometry findings consisted of patients with a posterior airway space (ie, the minimal distance between the base of the tongue and the posterior pharyngeal wall [ph1-ph2]) of > 7.0 mm, and a perpendicular distance from the hyoid bone to the mandibular plain (H/MP) of < 23 mm.
Category Archives: Pulmonary Function : Part 3
Snoring Is Not Relieved by Nasal Surgery Despite Improvement in Nasal Resistance: Patients and Study Design
The study population consisted of 40 consecutive men who had been referred to the ENT Hospital at Helsinki University Central Hospital because of a snoring problem or suspicion of sleep apnea and were scheduled for surgical treatment of nasal ob-struction. Only one patient had undergone septoplasty earlier, but other upper airway surgery for SDB had not been performed. The evaluation for nasal surgery had been based on symptoms, and anterior rhinoscopy and anterior rhinomanometry (RMM) findings without strict criteria for nasal resistance. The mean age of the patients was 44.2 years (SD, 9.5 years; age range, 26 to 62 years), and the mean body mass index (BMI) was 27.9 kg/m2 (SD, 3.4 kg/m2; range, 22 to 37 kg/m2). The mean total nasal resistance (TNR) was 0.574 Pa/cm/s (SD, 0.597 Pa/cm/s) without decongestion and 0.355 Pa/cm/s (SD, 0.339 Pa/cm/s) after decongestion of the nasal mucosa. All patients were of Finnish origin. None of the patients used sedatives regularly.
A relationship between nasal obstruction and snoring or sleep-disordered breathing (SDB) has been found in several previous studies, suggesting that SDB can be worsened by nasal obstruction and can even result from it. Nasal resistance has been found to be higher in snorers when compared with nonsnorers, and in SDB when compared with primary snoring. However, a causal relationship between nasal obstruction and SDB has not been substantiated beyond controversy due to the lack of qualified prospective follow-up studies. Nocturnal nasal congestion has been shown to be a strong independent risk factor for habitual snoring. In subjects with long-term nasal congestion occurring always or almost always at night, the risk of habitual snoring increased from 3.6-fold to 4.9-fold when compared with subjects without nasal congestion in a 5-year follow-up, Here
Our series confirms the previous characterization of AIDS-related pneumothorax: simultaneous (1/6) or sequential (1/6) bilateral occurrence, resistance to simple chest tube drainage (3/3), poor prognostic sign as seen by the high mortality (2/6), high recurrence rate (2/5), and relation to low CD4 levels. The relative low incidence of previous aerosolized pentamidine administration (2/6) in our series shows that this is not the only predisposing factor. Pneumocystis carinii pneumonia-related pneumothorax can occur even in the absence of such therapy. This supports the statement of Sepkowitz and colleagues that the proven benefits of aerosolized pentamidine prophylaxis in AIDS patients outweigh the risk of developing atypical P-carinii pulmonary involvement. buy birth control
One might speculate that visceral pleural biopsy specimens would have yielded P-carinii. Further, in the series of Renzi et al of 5 pneumothoraces occurring in 48 AIDS patients receiving aerosolized pentamidine, only 1 of 5 had proved PCP recurrence on BAL. Perhaps videothoracoscopy combined with biopsy may have yielded a greater incidence of recurrence of active P-carinii disease. generic yaz
The poor distal penetration allows for ongoing peripheral infection and resultant lung destruction. Interestingly, in our series, patients suffered pneumothorax with or without prior pentamidine therapy.
Subpleural pneumatoceles, cysts, and emphysematous blebs are known sequelae of P-carinii infections. However, upper lobe cystic disease can have other causes such as intravenous drug abuse. These causes may be hard to separate but the presence of diffuse parenchymal consolidation and cysts, dispersed throughout the lung parenchyma rather than limited to the periphery of the lung, favors PCP as the more significant contributing cause of upper lobe cystic disease in most patients. In our one patient presenting with isolated apical bullous lesions and adhesions, previous irradiation or intravenous drug abuse may have been contributing causes. buy yaz online
In one of these patients with positive pleural biopsy specimens and brushing, previous and subsequent BALs did not reveal P carinii and CT scan revealed only moderate emphysematous destruction (case 2b). Thoracoscopy with talcage as initial therapy or after failure of simple chest tube drainage eventually resolved the pneumothorax in five of eight patients. Of these five patients, one required repeated thoracoscopy to resolve a persistent pneumothorax. Two required repeated thoracoscopy for recurrent pneumothorax, with one needing a second chest tube for complete resolution. In a sixth patient, the pneumothorax appeared to completely resolve posttalcage. However, the patient died of respiratory insufficiency due to overwhelming PCP on day 11 postoccurrence of pneumothorax. This was prior to chest tube removal, so definite resolution cannot be claimed. In two cases, talcage was clearly not successful. One patient died of cerebral toxoplasmosis on day 30, without full resolution of his pneumothorax. The second patient required surgery at day 35. The duration of hospitalization of the surviving patients was 30 to 112 days, averaging 70 days. The duration of chest tube drainage, either one or two chest tubes, was 9 to 47 days, averaging 29 days. read only
The thoracoscopic findings of these patients are summarized in Table 3. The most striking videothoracoscopic appearance in pneumothorax in AIDS patients with PCP was small to large white-yellow subpleural nodules dispersed throughout the lung surface (Fig 1). These were found in five of six lungs affected with PCP and pneumothorax. The lesions were more prominent in the upper lobes. The apex of the lung also contained multiple cysts in one patient (case 3b) and a larger bulla and small discrete subpleural blebs in another patient (case 5). In the latter patient, a large reddish nodule surrounded by several small whitish nodules was noted on the parietal pleura, facing nodules on the visceral pleura. Adhesions of the pleural cavity were found infrequently in patients with PCP (case 4). itat on
Biopsy specimens were taken with an optical biopsy forceps, using a 4-mm telescope (Panoview) for biopsies under direct vision in cases with a single point of entry for biopsy of the parietal pleura. In cases with a second entry point for visceral biopsy, spoon forceps with electrocautery were used and passed through a 5-mm insulated trocar (Richard Wolf, Knitlingen, Germany). Brushing was performed with a “microbiology brusher” (LTA Medicale, Montreuil, France).
The rate of acquired immunodeficiency syndrome (AIDS) related spontaneous pneumothorax, primarily due to Pneumocystis carinii pneumonia (PCP), is approximately 4 percent. This greatly exceeds the overall incidence of spontaneous pneumothorax, which is estimated to be about 6/100,000 per year.2 In patients with AIDS, the pneumothorax is often recurrent, refractory to chest tube drainage, and bilateral. The cause of pneumothorax is thought to be due to diffuse subpleural lung destruction in PCP, either pneumatoceles and emphysematous blebs as sequelae of remote P-carinii infections or necrosis and abcesses during active P-carinii disease.’ The subpleural localization of persistent or recurrent P-carinii infection is thought to be related to a lack of penetration of the aerosolized pentamidine, used as prophylaxis in many of these patients, to the more distal bronchioli and alveoli. In this study, we report the thoracoscopic findings in spontaneous pneumothorax in six patients with AIDS with eight separate episodes of pneumothorax. The diagnostic utility of biopsy and brushing of the visualized visceral and parietal nodules, the results of talcage during thoracoscopy, and the cause of this type of pneumothorax are discussed.