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Salivary Gland Embryology, Physiology, and Stem Cell Complexity

Introduction Salivary glands play an essential role in maintaining oral homeostasis by secreting saliva under unstimulated (resting) and stimulated (neuronal-regulated) conditions. For example, saliva functions as a barrier for bacterial infestations due to its antibacterial composition. It also plays the essential roles of oral lubricant, protecting tooth enamel, providing enzymes for digestion of food, and is an indicator of overall health. Unfortunately, cancer treatments (radiation and/or…

Salivary Gland Anatomy

Introduction The major salivary glands: parotid, submandibular, and sublingual glands, are paired and symmetric. In the oral cavity 700–900 minor salivary glands are found, the majority of which are located at the junction of the hard and soft palates. In this chapter, anatomic relations of the main salivary glands are shown in a layered fashion. Parotid Gland Location The face ( Fig. 1.1 ) is divided…

Innovations in Surgical Treatment of OSA

The aim of this chapter is not necessarily to provide the reader with information about the newest device, as it will be explored somewhere else in this book, but rather to provide a brief overview of one perspective in the process of innovating medical technologies and how it has been and could be applied in the future to the management of obstructive sleep apnea (OSA). 1…

Prevention and Correction of Pediatric SDB/OSA and Post-T&A Relapse: A Non-Surgical Orthodontic/Dentofacial Orthopedic Approach

1 Introduction Sleep-disordered breathing (SDB) comprises a wide spectrum of sleep-related breathing abnormalities; those related to increased upper airway resistance include snoring, upper airway resistance syndrome (UARS), and obstructive sleep apnea/hypopnea syndrome (OSAHS). First identified in 1976, Christian Guilleminault diagnosed children with a sleep apnea syndrome similar to that seen in adults by means of polysomnography. He found that excessive daytime sleepiness, a decrease in school…

Drug-Induced Sleep Endoscopy in Children

1 Introduction Over the past decade there has been an evolution in the care for children with obstructive sleep apnea (OSA). Although adenotonsillectomy (T&A) has been regarded as typically successful in treating pediatric OSA, recent publications raise questions regarding its efficacy. Depending on the outcome measure selected, success can be as low as 27% (Apnea/Hypopnea Index [AHI] <1) or as high as 78% (AHI <5). A…

Laryngomalacia

1 Introduction Laryngomalacia is the term most widely used to describe the “inward collapse of supraglottic structures during inspiration,” as originated by Jackson and Jackson in 1942. The inward collapse of the epiglottis or arytenoids results in stridor that is typically inspiratory and high pitched. Laryngomalacia is often cited as the most common congenital laryngeal anomaly and most frequent cause of stridor in infants. The stridor…

Intracapsular Microdebrider-Assisted and Coblation Tonsillectomy

1 Introduction Tonsillectomy remains one of the most common surgical procedures performed on children. In contrast to several decades ago when infectious indications were common, the reason most children undergo tonsillectomy today is to relieve upper airway obstruction. Traditional “extracapsular” tonsillectomy remains a fairly morbid procedure. Children routinely require several days off from school, and parents are often forced to take time off from work. Despite…

Current Techniques of Adenoidectomy

1 Introduction The clinical significance of adenoid hypertrophy was not truly appreciated until the mid-19th century. This was due to the adenoids' relatively inaccessible location given the technology available at that time. Once discovered, various techniques for the removal of the adenoids were developed. Some of these basic techniques have remained with us since that time. Although commonly known for causing chronic sinonasal symptoms or influencing…

Evaluation and Management of Persistent Pediatric Obstructive Sleep Apnea

1 Introduction According to a 2009 meta-analysis, 35% to 40% of children who undergo adenotonsillectomy (T&A) for obstructive sleep apnea (OSA) have persistent disease after surgery. Our discussion will briefly outline techniques currently used to identify sites of obstruction in these patients and will subsequently describe current medical and surgical management options for persistent OSA. 2 Identification of Sites of Obstruction For children with persistent OSA,…

Management of Sleep-Related Breathing Disorders in Children

1 Introduction Sleep-related breathing disorders (SRBDs) span varying degrees of airway obstruction during sleep and contribute to significant epidemiologic burden, especially in developed countries. The first report of SRBD appeared in 1976, when Guilleminault described eight children with sleep apnea syndrome , confirmed by polygraphic monitoring. These children exhibited loud snoring, excessive daytime sleepiness, decrease in school performance, morning headaches, and nocturnal enuresis—all of which were…

Revision Uvulopala­topharyngoplasty (UPPP) by Z-palatoplasty (ZPP)

1 Introduction Uvulopalatopharyngoplasty (UPPP) is the single most common surgical procedure performed for the correction of retropalatal obstruction causing or contributing to obstructive sleep apnea/hypopnea syndrome (OSAHS). Although its success rate has been reported at only 40% (when objective success is defined as a 50% reduction in the Apnea/Hypopnea Index [AHI] with a postoperative AHI of less than 20), when appropriate patient selection criteria are applied,…

Salvage of Failed Palate Procedures for Sleep-Disordered Breathing

1 Introduction Surgical procedures designed to shorten or otherwise modify the palate may provide relief of upper airway collapse at the palatal level in patients with sleep-disordered breathing (SDB). For patients who fail to obtain relief or suffer a relapse after an initial surgical success, salvage surgical techniques may be appropriate. Although the principles of these salvage techniques are similar to the commonly performed primary surgical…

Uvulopalatopharyn­goplasty: Analysis of Failure

1 Introduction Sleep-disordered breathing (SDB) encompasses a spectrum of conditions, including socially unacceptable snoring (SUS) and obstructive sleep apnea syndrome (OSAS). Whereas SUS is mostly debilitating in social circumstances, OSAS and its complications pose a major health problem for society. Increased awareness has led to the development of various treatment modalities to combat both these diseases, of which uvulopalatopharyngoplasty (UPPP) is, without a doubt, the most…

Current Techniques for the Treatment of Velopharyngeal Insufficiency

1 Introduction Velopharyngeal insufficiency (VPI) is a significant speech disorder hypernasal resonance. This can result in difficulty with speech intelligibility and swallowing, which can have a major impact on a patient's quality of life. Although most VPI occurs in the cleft palate population, it has also been identified after sleep surgery. In adults, VPI is more commonly seen after sleep surgery targeting the soft palate as…

Multimodality Management of Nasopharyngeal Stenosis After Uvulopalatopha­ryngoplasty

1 Introduction Nasopharyngeal stenosis (NPS) after uvulopalatopharyngoplasty (UPPP) is a serious problem. More palatal procedures are being performed, leading to an increased incidence of NPS, but little has been written about this severe complication and its management. Historically, adult NPS was a consequence of maxillofacial trauma or severe infection such as syphilis. Now NPS is seen as a complication of surgery such as tonsillectomy and adenoidectomy…

The Perioperative Management of Patients With Obstructive Sleep Apnea

1 Introduction The incidence of obstructive sleep apnea (OSA) has increased dramatically in the past two decades due to the increased incidence of obesity. Many continue to quote a 4% incidence of OSA in the adult population based on a 1994 report. A more recent study using data from the Wisconsin Sleep Cohort Study demonstrated an increased prevalence of OSA based on age, sex, and body…

Speech-Ready, Long-Term Tube-Free Tracheostomy for Obstructive Sleep Apnea

1 Introduction Obstructive sleep apnea (OSA) is caused by obstacles to the free flow of air through the upper airway from the lips or nasal tip to the larynx and therefore is within the otolaryngologist's sphere of responsibility. Management can involve weight loss, treatment of nasal obstruction, surgery of the pharynx, or the use of various ventilatory assist devices such as continuous positive airway pressure (CPAP).…

Distraction Osteogenesis Maxillary Expansion (DOME) for Adult Obstructive Sleep Apnea Patients

1 Introduction Maxillary morphology plays an important role in the pathophysiology of obstructive sleep apnea (OSA). Guilleminault et al. reported the presence of high and narrow hard palate differentiating OSA between relatives. Maxillary morphology studies have shown greater palatal heights in OSA subjects. Transverse maxillary hypoplasia with a high, arched palate in OSA is associated with increased nasal airflow resistance and inferior-posterior resting tongue position that results…

Modified Maxillomandibular Advancement Technique

1 Introduction Orthognathic surgery has been used to treat obstructive sleep apnea (OSA) since the mid-1980s. In the classical phase II surgery for OSA described by Riley et al., 10-mm advancement of the maxilla and mandible resulted in an impressive 97% cure rate in patients who had failed phase I surgery and 91% in patients treated solely by phase II surgery. Other studies on bimaxillary advancement techniques…