The Muller maneuver is a forced inspiration with both the nose pinched and mouth closed, after a forced expiration, so as to simulate the colapse of pharyngeal walls, similar to what happens at night during deep sleep (atonia of the pharyngeal muscles during REM sleep). When diagnosing patients with obstructive sleep apnea syndrome (OSAS) the nasofibroscopy-assisted Muller maneuver (NMM) is indispensable to identifying the site of obstruction[1] and thus properly establishing the surgical indication [2]. This patient was overweight (BMI of 29.4) and had documented severe OSAS with 4 channel ambulatory polygraphy and the apnea-hypopnea index (AHI) of 83.7 events\hour. Objective E.N.T. assessment shown Mallampati 3 with moderate-severe (Brodsky 3+) palatine tonsil hypertrophy. The images show (clockwise) the initial aspect ("helicopter view") of the oropharynx as seen from the rhinopharynx, the beginning of the Muller maneuver and the total closure of the oropharynx during the maneuver. Thus the patient was classified in the Fujita I class of OSAS, and was later operated, by way of tonsillectomy and modified uvulo-palatal-pharyngoplasty (UPPP) with expansion-sphincter construction. The NMM is a easy-to-use technique that provides valuable information in patients with OSAS and thus help establish the proper surgical indication.
Nasopharyngeal carcinoma has a tipically insidious presentation, with often neglected signs and symptoms, thus more than 99% of patients are symptomatic on diagnostic 1. There are 5 types of presentation models: the rhinologic type (nasal obstruction, epistaxis, rhinorrhea), the otologic type (otorrhea, conductive hearing loss), the lymphatic type (bulky cervical neck masses), the neurologic type (headache, cranial nerve palsy) and the opthalmic type (diplopia due to cranial nerve involvement - III, IV and VI). These presentation models are usually singular but will become associated as the disease progresses and the tumor extends, encompassing the skull base. We present the case of a 51 y.o. male with bilateral neck massess which appeared approximatively 6 months ago, recurrent epistaxis after sneezing, unilateral (right) hearing loss and otorrhea, right side hypogeusia (partial loss of taste sense) of the tongue and hypoesthesia of the right hemiface, involving the mandible and cheek. Naso-pharyngeal endoscopy showed a tumor involving the right lateral wall of the rhinopharynx as well as the posterior and superior walls and extending to the sphenoid sinuses and downward to the oropharynx. The tumor encompassed the Eustachian tube orifice - and the patient had otomastoiditis with persistent suppuration, consistent with otoscopy findings. Contrast CT scans showed skull base involvement, thus explaining cranial nerve involvement (mandibular branch of V). The diagnosis was locally advanced disease (stage IV) and a biopsy was performed, followed by a multi-modal radiation and chemotherapy protocol. Case particularity: late-onset presentation with rhinologic, neurologic, otic and lymphatic signs.
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