DOCSLIB.ORG

Modified Expansion Sphincter Pharyngoplasty for Treatment of Children with Obstructive Sleep Apnea

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Modified Expansion Sphincter Pharyngoplasty for Treatment of Children with Obstructive Sleep Apnea Research Original Investigation Modified Expansion Sphincter Pharyngoplasty for Treatment of Children With Obstructive Sleep Apnea Seckin O. Ulualp, MD IMPORTANCE Lateral pharyngeal wall collapse has been implicated in the pathogenesis of obstructive sleep apnea (OSA). Modified expansion sphincter pharyngoplasty (ESP) is a simple procedure and can be considered in the surgical management of children with severe OSA. OBJECTIVE To describe a modified ESP addressing lateral pharyngeal muscle wall collapse in the treatment of children with OSA. DESIGN, SETTING, AND PARTICIPANTS Retrospective review of the medical records of children with OSA and lateral pharyngeal muscle wall collapse who underwent modified ESP and children who had tonsillectomy and adenoidectomy (TA) for OSA between 2008 and 2013 at a tertiary care children’s hospital. INTERVENTIONS Modified ESP. MAIN OUTCOMES AND MEASURES The primary outcome measure was the rate of cure, which was defined as an apnea-hypopnea index (AHI) lower than 1. Other outcomes were differences in preoperative and postoperative AHI, minimum saturation of peripheral oxygen, and percentage of total sleep study time with oxygen saturation less than 90%. RESULTS Twenty-five children who had modified ESP and 25 AHI-matched children who had TA for severe OSA were identified. The postoperative AHI was lower than the preoperative AHI in both groups. Preoperative AHI was similar between modified ESP and TA groups. The Author Affiliations: Department of Otolaryngology–Head and Neck mean (SD) postoperative AHI of the modified ESP group (2.4 [3.9]) was lower than that of the Surgery, University of Texas TA group (6.2 [6.0]) (P < .001). Cure rates for the modified ESP group (AHI <1, 64%; AHI <2, Southwestern Medical Center, Dallas; 72%; and AHI <5, 80%) were greater than those for the TA group (AHI <1, 8%; AHI <2, 44%; Division of Pediatric Otolaryngology, and AHI <5, 60%). Children’s Medical Center, Dallas, Texas. Corresponding Author: Seckin O. CONCLUSIONS AND RELEVANCE Modified ESP provided objective clinical improvement of OSA Ulualp, MD, Department of in children with severe OSA and lateral pharyngeal wall collapse and might serve as an Otolaryngology–Head and Neck effective alternative to TA for treatment of OSA. Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX JAMA Otolaryngol Head Neck Surg. 2014;140(9):817-822. doi:10.1001/jamaoto.2014.1329 75390-9035 Published online July 31, 2014. ([email protected]) . bstructive sleep apnea (OSA) occurs due to fixed and/or partial glossectomy, and genioglossus advancement have been dynamic upper airway obstruction caused by ana- used with varying results to cure OSA. Addition of new surgi- O tomical factors and abnormal upper airway motor cal techniques to the surgeon’s armamentarium potentially im- tone.1 Upper airway obstruction may be caused by collapse of proves the management of OSA in children. single or multiple structures such as the soft palate, uvula, pala- Lateral pharyngeal wall collapse has been documented in tine tonsils, lateral pharyngeal walls, base of the tongue, and adults and children with OSA.2,7,8 Lateral pharyngoplasty and epiglottis.2 Tonsillectomy and adenoidectomy (TA) is com- expansion sphincter pharyngoplasty (ESP) have been used to monly used as an initial procedure to treat OSA; however, TA address lateral pharyngeal wall collapse in adults with OSA.9-12 may not be curative in 21% to 75% of the children with OSA.3-6 The ESP procedure involves a combination of tonsillectomy, In children with Down syndrome or neurological impair- expansion pharyngoplasty, rotation of the palatopharyngeus ment, pillar closure, uvulopalatopharyngoplasty, lingual ton- muscle, a partial uvulectomy, and closure of the anterior and sillectomy, modified pharyngoplasty, lateral pharyngoplasty, posterior tonsillar pillars.10 Treatment with ESP prevents lat- jamaotolaryngology.com JAMA Otolaryngology–Head & Neck Surgery September 2014 Volume 140, Number 9 817 Copyright 2014 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 Research Original Investigation Pharyngoplasty for Pediatric Obstructive Sleep Apnea eral pharyngeal collapse and reduces apnea episodes in adults cautery (Figure 1A).13 The anterior fascicules of the palatopha- with OSA.10-12 Outcomes of ESP have not been studied in chil- ryngeus muscle were transected horizontally at the junction dren with OSA. The aim of the present study is to describe a of upper third and mid-third portions using a protected needle- modified ESP technique and compare outcomes of modified tip bovie (Figure 1B). Superficial fibers of the upper third por- ESP to those of TA in children with OSA. tion of the palatopharyngeus muscle were isolated, and deep fibers left with the muscle’s posterior surface attached to the pharyngeal constrictor muscles. Methods A blunt palate tunneling extending superolaterally from the arching fibers of the palatoglossus muscle into soft palate This study was approved by the University of Texas South- was created using a curved hemostatic forceps (Figure 1C). The western Medical Center institutional human research review isolated portion of palatopharyngeus muscle was pulled su- board, and informed consent was waived. peroanterolaterally into the palate tunnel while the lateral pha- ryngeal wall tension was observed. Then the isolated portion Evaluation of Study Participants of palatopharyngeus muscle was attached to the arching muscle The medical records were retrospectively reviewed for pa- fibers of soft palate with a single mattress stitch using Vicryl tients who underwent modified ESP and control subjects who 4-0 suture (Ethicon Inc) and a round-bodied needle (Figure 1D). had TA from September 2008 to September 2013. All patients The same steps were repeated on the opposite side (Figure 1E). in both the ESP and TA groups were younger than 21 years and In the modified ESP technique, increased distance is cre- underwent both preoperative and postoperative polysomnog- ated between, and tension within, the lateral pharyngeal walls. raphy for OSA assessment. The TA group included children In the present study, the modifications to previously de- whose apnea-hypopnea index (AHI) was matched to the chil- scribed ESP techniques included (1) transection of the palato- dren in the ESP group so as obtain similar levels of OSA sever- pharyngeal muscle at the upper third portion instead of the in- ity in both groups. No patients were excluded for craniofacial ferior end10,11; (2) transection of the superficial fibers of the anomalies, developmental delay, psychiatric illness, immu- palatopharyngeal muscle instead of full-thickness transec- nodeficiency, possible neoplasia, possible posttransplant lym- tion of the palatopharyngeal muscle11,12; (3) blunt palate tun- phoproliferative disorder, or other chronic conditions. All neling without mucosal incision10; (4) preservation of the uvula participants were identified using an electronic medical rec- instead of partial uvulectomy10; (5) no apposition of the en- ord system documenting surgical procedures performed by the tire anterior and posterior pillars10; and (6) lack of palate inci- author. sion for second intermediate suturing of flap.11 All participants underwent all-night, attended polysom- A microdebrider was used to remove the adenoid, and suc- nography by computerized polygraph performed in the dedi- tion electrocautery was used for hemostatic control of the ad- cated pediatric sleep laboratory at a tertiary care children’s hos- enoid bed. The tonsillar fossae and adenoid bed were exam- pital; sleep measurements were based on the criteria of the ined after oropharyngeal and gastric suctioning and before 2007 American Academy of Sleep Medicine guidelines. Poly- reversal of anesthesia. somnograms were scored by pediatric sleep medicine special- Postoperatively, overnight monitoring consisted of con- ists, and the AHI was calculated as the sum of obstructive ap- tinuous measurement of pulse oximetry, blood pressure, and neas and hypopneas per hour. Central apnea, central hypopnea, pulse rate. Analgesia was achieved by alternating between ac- and mixed apnea were not included in the AHI. The severity etaminophen and ibuprofen. For the next 2 weeks, adequate of OSA was categorized according to AHI as mild (AHI, 1-5); oral fluid intake for proper hydration and a soft blended diet moderate (AHI, 5-10); or severe (AHI >10).6 In the modified ESP were recommended. Parents were instructed to return to the group, drug-induced sleep endoscopy (DISE) was performed hospital for evaluation if they saw any volume of oropharyn- during induction of anesthesia by using the previously de- geal bleeding or epistaxis during the postoperative period. scribed protocol.2 Data Collection and Statistical Analysis ESP Indications and Techniques Data pertaining to age, sex, medical history, surgical history, Indications for modified ESP included severe OSA and lateral comorbid conditions, body mass index (BMI), tonsil size,14 ad- pharyngeal wall collapse documented by DISE. At the time of enoid size,2 and findings of polysomnography were obtained surgery planning during the clinic visit, caregivers were of- from the charts. Centers for Disease Control and Prevention fered the option of modified ESP, in addition to TA, if the DISE growth standards were used to determine BMI percentiles. Chil- findings indicated lateral pharyngeal wall collapse. dren
Load more

Recommended publications
  • Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome
    Medical Policy Surgical Treatment of Snoring and Obstructive Sleep Apnea Syndrome Table of Contents Policy: Commercial Coding Information Information Pertaining to All Policies Policy: Medicare Description References Authorization Information Policy History Policy Number: 130 BCBSA Reference Number: 7.01.101 Related Policies None Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Medicare HMO BlueSM and Medicare PPO BlueSM Members Uvulopalatopharyngoplasty (UPPP) may be MEDICALLY NECESSARY for the treatment of clinically significant obstructive sleep apnea syndrome (OSAS) in appropriately selected adult patients who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance (OA). Clinically significant OSA is defined as those patients who have: Apnea/hypopnea Index (AHI) or Respiratory Disturbance Index (RDI) 15 or more events per hour, or AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke. Hyoid suspension, surgical modification of the tongue, and/or maxillofacial surgery, including mandibular- maxillary advancement (MMA), may be MEDICALLY NECESSARY in appropriately selected adult patients with clinically significant OSA and objective documentation of hypopharyngeal obstruction who have failed an adequate trial of continuous positive airway pressure (CPAP) or failed an adequate trial of an oral appliance (OA). Clinically significant OSA is defined as those patients who have: AHI or RDI 15 or more events per hour, or AHI or RDI 5 or more events and 14 or less events per hour with documented symptoms of excessive daytime sleepiness, impaired cognition, mood disorders or insomnia, or documented hypertension, ischemic heart disease, or history of stroke.
    [Show full text]
  • Upper Airway Surgery for Obstructive Sleep Apnea Aaron E
    Sleep Medicine Reviews, Vol. 6, No. 3, pp 195±212, 2002 doi:10.1053/smrv.2002.0242, available online at http://www.idealibrary.com on Upper airway surgery for obstructive sleep apnea Aaron E. Sher Capital Region Otolaryngology-Head and Neck Group, LLP, Medical Director, Capital Region Sleep Wake Disorders Center of St. Peter's Hospital, Associate Clinical Professor of Surgery, Division of Head and Neck Surgery, Albany Medical College, Albany, NY, USA KEYWORDS Summary Upper airway surgical treatments for obstructive sleep apnea syndrome Sleep apnea syndromes, (OSAS) attempt to modify dysfunctional pharyngeal anatomy or by-pass the pharynx. surgery, pharynx, Modi®cations of the pharynx diminish the bulk of soft tissue structures which abut the airway, soft tissue, air column, place them under tension, others alter their spatial inter-relationships. skeletal, palate, tongue, Surgical procedures are designed to modify the retropalatal pharynx, the retrolingual maxillomandibular, pharynx, or both. There is no single surgical procedure, short of tracheostomy, which tracheostomy, consistently results in complete elimination of OSAS. However, appropriate application of current surgical techniques (synchronously or sequentially) may achieve uvulopalatopharyngoplasty, cure in most patients without resort to tracheostomy. Patient selection, versatility in polysomnography varied surgical approaches, and willingness to utilize more than one procedure when necessary appear to be critical attributes of a successful surgical program. On the other hand, analysis of the ef®cacy of individual surgical interventions is thwarted by the frequent practice of reporting on the application of multiple procedures in combination with evaluation of the composite effect. Well designed, multi-center studies would help clarify the strengths and weaknesses of different treatment approaches.
    [Show full text]
  • Core Curriculum for Surgical Technology Sixth Edition
    Core Curriculum for Surgical Technology Sixth Edition Core Curriculum 6.indd 1 11/17/10 11:51 PM TABLE OF CONTENTS I. Healthcare sciences A. Anatomy and physiology 7 B. Pharmacology and anesthesia 37 C. Medical terminology 49 D. Microbiology 63 E. Pathophysiology 71 II. Technological sciences A. Electricity 85 B. Information technology 86 C. Robotics 88 III. Patient care concepts A. Biopsychosocial needs of the patient 91 B. Death and dying 92 IV. Surgical technology A. Preoperative 1. Non-sterile a. Attire 97 b. Preoperative physical preparation of the patient 98 c. tneitaP noitacifitnedi 99 d. Transportation 100 e. Review of the chart 101 f. Surgical consent 102 g. refsnarT 104 h. Positioning 105 i. Urinary catheterization 106 j. Skin preparation 108 k. Equipment 110 l. Instrumentation 112 2. Sterile a. Asepsis and sterile technique 113 b. Hand hygiene and surgical scrub 115 c. Gowning and gloving 116 d. Surgical counts 117 e. Draping 118 B. Intraoperative: Sterile 1. Specimen care 119 2. Abdominal incisions 121 3. Hemostasis 122 4. Exposure 123 5. Catheters and drains 124 6. Wound closure 128 7. Surgical dressings 137 8. Wound healing 140 1 c. Light regulation d. Photoreceptors e. Macula lutea f. Fovea centralis g. Optic disc h. Brain pathways C. Ear 1. Anatomy a. External ear (1) Auricle (pinna) (2) Tragus b. Middle ear (1) Ossicles (a) Malleus (b) Incus (c) Stapes (2) Oval window (3) Round window (4) Mastoid sinus (5) Eustachian tube c. Internal ear (1) Labyrinth (2) Cochlea 2. Physiology of hearing a. Sound wave reception b. Bone conduction c.
    [Show full text]
  • Surgical Treatments for Obstructive Sleep Apnea (OSA) Policy Number: PG0056 ADVANTAGE | ELITE | HMO Last Review: 06/01/2021
    Surgical Treatments for Obstructive Sleep Apnea (OSA) Policy Number: PG0056 ADVANTAGE | ELITE | HMO Last Review: 06/01/2021 INDIVIDUAL MARKETPLACE | PROMEDICA MEDICARE PLAN | PPO GUIDELINES This policy does not certify benefits or authorization of benefits, which is designated by each individual policyholder terms, conditions, exclusions and limitations contract. It does not constitute a contract or guarantee regarding coverage or reimbursement/payment. Self-Insured group specific policy will supersede this general policy when group supplementary plan document or individual plan decision directs otherwise. Paramount applies coding edits to all medical claims through coding logic software to evaluate the accuracy and adherence to accepted national standards. This medical policy is solely for guiding medical necessity and explaining correct procedure reporting used to assist in making coverage decisions and administering benefits. SCOPE X Professional _ Facility DESCRIPTION Sleep apnea is a disorder where breathing nearly or completely stops for periods of time during sleep. In obstructive sleep apnea (OSA), the brain sends the message to breathe, but there is a blockage to air flowing into the chest. It is a condition in which repetitive episodes of upper airway obstruction occur during sleep. The obstruction may be localized to one or two areas, or may encompass the entire upper airway passages to include the nasal cavity (nose), oropharynx (palate, tonsils, tonsillar pillars) and hypopharynx (tongue base). The hallmark symptom of OSA is excessive daytime sleepiness, and the typical clinical sign of OSA is snoring, which can abruptly cease and be followed by gasping associated with a brief arousal from sleep. The snoring resumes when the patient falls back to sleep, and the cycle of snoring/apnea/arousal may be repeated as frequently as every minute throughout the night.
    [Show full text]
  • 32 Surgical Treatment of Sleep-Related Breathing Disorders Donald M
    32 Surgical Treatment of Sleep-Related Breathing Disorders Donald M. Sesso Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center, Stanford, California, U.S.A. Nelson B. Powell and Robert W. Riley Department of Otolaryngology/Head and Neck Surgery, Stanford University Medical Center and Department of Behavioral Sciences, Division of Sleep Medicine, Stanford University School of Medicine, Stanford, California, U.S.A. INTRODUCTION Snoring, upper airway resistance syndrome (UARS), obstructive sleep apnea (OSA), and obstructive sleep apnea-hypopnea syndrome (OSAHS) are collectively referred to as sleep- related breathing disorders (SRBD). These terms describe a partial or complete obstruction of the upper airway during sleep. Patency of the pharyngeal airway is maintained by two opposing forces: negative intraluminal pressure and the activity of the upper airway musculature. Anatomical or central neural abnormalities can disrupt this delicate balance and result in compromise of the upper airway. This reduction of airway caliber may cause sleep fragmentation and subsequent behavioral derangements, such as excessive daytime sleepiness (EDS) (1–3). The goal of medical and surgical therapy is to alleviate this obstruction and increase airway patency. The first therapeutic modality employed to treat SRBD was surgery. Kuhlo described placement of a tracheotomy tube in an attempt to bypass upper airway obstruction in Pickwickian patients (4). Although effective, tracheotomy does not address the specific sites of pharyngeal collapse and is not readily accepted by most patients. These sites include the nasal cavity/nasopharynx, oropharynx, and hypopharynx. Often, multilevel obstruction is present. Consequently, the surgical armamentarium has evolved to create techniques that correct the specific anatomical sites of obstruction.
    [Show full text]
  • Ear Pain in Patients with Oropharynx Carcinoma: Karlt.Beer Peter Vock How MRI Contributes to the Explanation Richard H
    Eur Radiol (2004) 14:2206–2211 DOI 10.1007/s00330-004-2340-2 HEAD AND NECK Harriet C. Thoeny Ear pain in patients with oropharynx carcinoma: KarlT.Beer Peter Vock how MRI contributes to the explanation Richard H. Greiner of a prognostic and predictive symptom Received: 22 October 2003 Abstract Reflex otalgia is a predic- glossus muscle, stylopharyngeus Revised: 11 March 2004 tive and prognostic parameter for lo- muscle, hyoglossus muscle and pre- Accepted: 5 April 2004 cal control in patients with orophar- epiglottic space. No difference was Published online: 1 May 2004 ynx carcinoma. Can a morphologic found for the muscles of mastication, © Springer-Verlag 2004 correlate of this important symptom levator and tensor veli palatini mus- be detected by MRI? Thirty-six pa- cles, styloglossus muscle, genioglos- tients were prospectively evaluated sus muscle, intrinsic muscles of the by MRI before radical radiotherapy. tongue, digastric muscles, mucosal Sixteen patients had reflex otalgia; surface of the lateral and posterior 20 did not. The oropharynx and adja- pharyngeal wall, uvula, valleculae, cent regions were analyzed. Alter- parapharyngeal space and larynx. An ation was defined as effacement of alteration of structures innervated by H. C. Thoeny (✉) · P. Vock anatomical structures, signal alter- the glossopharyngeal nerve was vi- Department of Diagnostic Radiology, ation or enhancement after contrast sualized on MRI significantly more Inselspital, χ2 University of Bern, medium administration. The -test often when reflex otalgia was pres- Freiburgstrasse 10, 3010 Bern, Switzerland was used to compare categorical pa- ent. Involvement of structures inner- e-mail: [email protected], rameters. In patients with reflex vated by other cranial nerves did not [email protected] otalgia, alteration of the following show the same association with ear Tel.: +41-31-6322939 structures innervated by the glosso- pain.
    [Show full text]
  • Volume 1: the Upper Extremity
    Volume 1: The Upper Extremity 1.1 The Shoulder 01.00 - 38.20 (37.20) 1.1.1 Introduction to shoulder section 0.01.00 0.01.28 0.28 1.1.2 Bones, joints, and ligaments 1 Clavicle, scapula 0.01.29 0.05.40 4.11 1.1.3 Bones, joints, and ligaments 2 Movements of scapula 0.05.41 0.06.37 0.56 1.1.4 Bones, joints, and ligaments 3 Proximal humerus 0.06.38 0.08.19 1.41 Shoulder joint (glenohumeral joint) Movements of shoulder joint 1.1.5 Review of bones, joints, and ligaments 0.08.20 0.09.41 1.21 1.1.6 Introduction to muscles 0.09.42 0.10.03 0.21 1.1.7 Muscles 1 Long tendons of biceps, triceps 0.10.04 0.13.52 3.48 Rotator cuff muscles Subscapularis Supraspinatus Infraspinatus Teres minor Teres major Coracobrachialis 1.1.8 Muscles 2 Serratus anterior 0.13.53 0.17.49 3.56 Levator scapulae Rhomboid minor and major Trapezius Pectoralis minor Subclavius, omohyoid 1.1.9 Muscles 3 Pectoralis major 0.17.50 0.20.35 2.45 Latissimus dorsi Deltoid 1.1.10 Review of muscles 0.20.36 0.21.51 1.15 1.1.11 Vessels and nerves: key structures First rib 0.22.09 0.24.38 2.29 Cervical vertebrae Scalene muscles 1.1.12 Blood vessels 1 Veins of the shoulder region 0.24.39 0.27.47 3.08 1.1.13 Blood vessels 2 Arteries of the shoulder region 0.27.48 0.30.22 2.34 1.1.14 Nerves The brachial plexus and its branches 0.30.23 0.35.55 5.32 1.1.15 Review of vessels and nerves 0.35.56 0.38.20 2.24 1.2.
    [Show full text]
  • Aadsm Annual Meeting San Antonio: June 7-919
    AADSM ANNUAL MEETING SAN ANTONIO: JUNE 7-919 FINAL PROGRAM WELCOME to the 2019 AADSM Annual Meeting 2 This year’s meeting features: • Three rooms of general sessions on Saturday and Sunday – Fundamentals, Clinical Applications and Advances in DSM; • Poster presentations, located just outside of the exhibit hall, including new “late-breaking abstracts;” • Lunch presentations from vendors during the industry product theatres on Saturday; • A lounge for Diplomates of the ABDSM and dental directors of AADSM-accredited facilities to network; and • Special sessions for dentists on faculty at dental schools, interested in performing clinical research, looking for information on getting more involved with the AADSM. Information about these opportunities can be found in the pages of this final program. I have no doubt that this year’s meeting will offer you the opportunity to renew and initiate relationships with colleagues from around the world while expanding your knowledge of dental sleep medicine. Enjoy, Sheri Katz, DDS Chair, Annual Meeting Committee AADSM ANNUAL MEETING SAN ANTONIO: JUNE 7-919 ON-SITE REGISTRATION HOURS EXHIBIT HALL HOURS Salon A- F Friday, June 7 6:30am – 5:30pm Saturday, June 8 7:00am – 5:00pm Friday, June 7 10:00am – 4:00pm Sunday, June 9 7:00am – 1:30pm Saturday, June 8 10:00am – 4:00pm Sunday, June 9 10:00am – 12:30pm The registration desk is located in the Salon Ballroom Foyer of the Marriott Rivercenter. Learn about the newest products and services in the field by visiting Your registration includes admission to: the exhibit hall! The AADSM Annual • General Sessions (Friday-Sunday) Meeting exhibit hall showcases oral appliance manufacturers, • President’s Reception dental laboratories, software • Industry Supported Events companies and more.
    [Show full text]
  • Stanford University
    STANFORD UNIVERSITY CURRICULUM VITAE Updated September 2019 NAME Stanley Yung-Chuan Liu, MD, DDS POSITION Assistant Professor of Otolaryngology Stanford University School of Medicine Co-Director, Sleep Surgery Fellowship EDUCATION Date Attended Institution Degree, Title Major 9/25/96 - 6/11/00 Stanford University B.S. Biology 8/28/02 - 6/17/07 University of California – San D.D.S. Dentistry Francisco (UCSF), School of Dentistry 9/12/07 - 6/10/11 University of California – San M.D. Medicine Francisco (UCSF), School of Medicine ACADEMIC APPOINTMENTS 6/2013 – 6/2014 Clinical Instructor Department of Otolaryngology, Stanford University School of Medicine Stanford, CA, USA 9/2014 – Present Assistant Professor (Medical Center Line) Department of Otolaryngology, Stanford University School of Medicine Stanford, CA, USA 9/2015 – Present Preceptor Department of Ophthalmology, Stanford University School of Medicine Stanford, CA, USA HOSPITAL APPOINTMENTS/AFFILIATIONS 6/2013 – Present Stanford Hospital and Clinics, Stanford, CA, USA 9/2015 – Present San Francisco Veterans Affairs Hospital, Palo Alto, CA, USA CERTIFICATION 4/2018 – Present Diplomate, American Board of Oral & Maxillofacial Surgery 4/2018 – Present Candidate, American College of Surgeons LICENSURE 2010 – Present California Dental License #59319 2012 – Present California Medical License # A122495 HONORS AND AWARDS 2004 Howard Hughes Medical Institute – NIH Research Scholarship (Cloister Program) 2009 Advanced Training Clinical Research Fellowship, UCSF School of Medicine, 2010 Lightowler
    [Show full text]
  • Functional Anatomy of the Soft Palate Applied to Wind Playing
    Review Functional Anatomy of the Soft Palate Applied to Wind Playing Alison Evans, MMus, Bronwen Ackermann, PhD, and Tim Driscoll, PhD Wind players must be able to sustain high intraoral pressures in dition occurs because of a structural deformity, such as with order to play their instruments. Prolonged exposure to these high cleft palate. It is also associated with some other speech dis- pressures may lead to the performance-related disorder velopharyn- orders. VPI occurs when the soft palate fails to completely geal insufficiency (VPI). This disorder occurs when the soft palate fails to completely close the air passage between the oral and nasal close the oronasal cavity while attempting to blow air through cavities in the upper respiratory cavity during blowing tasks, this clo- the mouth, resulting in air escaping from the nose.5 Without sure being necessary for optimum performance on a wind instru- a tight air seal, the air passes into the nasal cavity and can ment. VPI is potentially career threatening. Improving music teach- then escape out the nose. This has a disastrous effect on wind ers’ and students’ knowledge of the mechanism of velopharyngeal playing, as the power behind the wind musicians’ sound closure may assist in avoiding potentially catastrophic performance- related disorders arising from dysfunction of the soft palate. In the relies on enough controlled expired air through the mouth. functional anatomy of the soft palate as applied to wind playing, Understandably, this disorder may potentially end the musi- seven muscles of the soft palate involved in the velopharyngeal clo- cian’s career.6 sure mechanism are reviewed.
    [Show full text]
  • DENTAL and ORAL SURGICAL PROCEDURES Policy Number: DENTAL 002.28 T2 Effective Date: March 1, 2017
    UnitedHealthcare® Oxford Administrative Policy DENTAL AND ORAL SURGICAL PROCEDURES Policy Number: DENTAL 002.28 T2 Effective Date: March 1, 2017 Table of Contents Page Related Policy INSTRUCTIONS FOR USE .......................................... 1 Temporomandibular Joint Disorders BENEFIT CONSIDERATIONS ...................................... 2 PURPOSE ................................................................ 2 POLICY ................................................................... 2 PROCEDURES AND RESPONSIBILITIES ....................... 2 APPLICABLE CODES ................................................. 3 REFERENCES ........................................................... 7 POLICY HISTORY/REVISION INFORMATION ................. 7 INSTRUCTIONS FOR USE The services described in Oxford policies are subject to the terms, conditions and limitations of the member's contract or certificate. Unless otherwise stated, Oxford policies do not apply to Medicare Advantage members. Oxford reserves the right, in its sole discretion, to modify policies as necessary without prior written notice unless otherwise required by Oxford's administrative procedures or applicable state law. The term Oxford includes Oxford Health Plans, LLC and all of its subsidiaries as appropriate for these policies. Certain policies may not be applicable to Self-Funded members and certain insured products. Refer to the member specific benefit plan document or Certificate of Coverage to determine whether coverage is provided or if there are any exclusions or benefit
    [Show full text]
  • Appendix B: Muscles of the Speech Production Mechanism
    Appendix B: Muscles of the Speech Production Mechanism I. MUSCLES OF RESPIRATION A. MUSCLES OF INHALATION (muscles that enlarge the thoracic cavity) 1. Diaphragm Attachments: The diaphragm originates in a number of places: the lower tip of the sternum; the first 3 or 4 lumbar vertebrae and the lower borders and inner surfaces of the cartilages of ribs 7 - 12. All fibers insert into a central tendon (aponeurosis of the diaphragm). Function: Contraction of the diaphragm draws the central tendon down and forward, which enlarges the thoracic cavity vertically. It can also elevate to some extent the lower ribs. The diaphragm separates the thoracic and the abdominal cavities. 2. External Intercostals Attachments: The external intercostals run from the lip on the lower border of each rib inferiorly and medially to the upper border of the rib immediately below. Function: These muscles may have several functions. They serve to strengthen the thoracic wall so that it doesn't bulge between the ribs. They provide a checking action to counteract relaxation pressure. Because of the direction of attachment of their fibers, the external intercostals can raise the thoracic cage for inhalation. 3. Pectoralis Major Attachments: This muscle attaches on the anterior surface of the medial half of the clavicle, the sternum and costal cartilages 1-6 or 7. All fibers come together and insert at the greater tubercle of the humerus. Function: Pectoralis major is primarily an abductor of the arm. It can, however, serve as a supplemental (or compensatory) muscle of inhalation, raising the rib cage and sternum. (In other words, breathing by raising and lowering the arms!) It is mentioned here chiefly because it is encountered in the dissection.
    [Show full text]