Posterior Soft Palate Research Articles

State-Dependent Biomechanical Behavior of Oropharyngeal Structures in Apneic and Control Subjects: A Proof-of-Concept Study.

Rationale: Apneic individuals have reduced airway caliber during sleep. The biomechanical changes in upper airway anatomy contributing to this airway narrowing are largely unknown. Objectives: We sought to investigate the state-dependent (wake vs. sleep) biomechanical behavior of the upper airway soft-tissue and craniofacial structures. Methods: Upper airway magnetic resonance imaging was performed in 15 sleep-deprived control subjects (apnea-hypopnea index, <5; 0.3 ± 0.5 events per hour) and 12 sleep-deprived apneic subjects (apnea-hypopnea index, ⩾5; 35.2 ± 18.1 events per hour) during wake and sleep and analyzed for airway measures and soft-tissue/mandibular movement. Results: In the retropalatal region, control subjects showed sleep-dependent reductions (P ⩽ 0.037) in average cross-sectional airway area (CSA), minimum CSA, and anteroposterior and lateral dimensions. Apneic subjects showed sleep-dependent reductions (P ⩽ 0.002) in average CSA, minimum CSA, and anteroposterior and lateral dimensions. In the retroglossal region, control subjects had no sleep-dependent airway reductions. However, apneic subjects had sleep-dependent reductions in minimal CSA (P = 0.001) and lateral dimensions (P = 0.014). Control subjects only showed sleep-dependent posterior movement of the anterior-inferior tongue octant (P = 0.039), whereas apneic subjects showed posterior movement of the soft palate (P = 0.006) and all tongue octants (P ⩽ 0.012). Sleep-dependent medial movement of the lateral walls was seen at the retropalatal minimum level (P = 0.013) in control subjects and at the retropalatal and retroglossal minimum levels (P ⩽ 0.017) in apneic subjects. There was posterior movement of the mandible in apneic subjects (P ⩽ 0.017). Conclusions: During sleep, control and apneic subjects showed reductions in retropalatal airway caliber, but only the apneic subjects showed retroglossal airway narrowing. Reductions in anteroposterior and lateral airway dimensions were primarily due to posterior soft palate, tongue and mandibular movement and to medial lateral wall movement. These data provide important initial insights into obstructive sleep apnea pathogenesis.

Upper Airway Characteristics and Morphological Changes by Different MADs in OSA Adult Subjects Assessed by CBCT 3D Imaging.

This study aimed to analyse the effectiveness of four different designs of the Mandibular Advancement Device (MAD) and the morphological changes on upper airway characteristics of Obstructive Sleep Apnea (OSA) patients inducted by each of them, detected by Cone Beam Computer Tomography (CBCT) 3D imaging. Twenty-two patients were recruited after an OSA diagnosis with PSG. Four different customised and titratable MADs were used and an initial CBCT scan was obtained for each patient. Six months after the end of the MAD titration phase, all the subjects performed a second PSG with the MAD in situ; the second PSG showed an Apnoea-Hypopnoea Index (AHI) of <5 or a decrease of 50% in AHI when compared with the initial AHI. Moreover, a second CBCT scan with the MAD in situ was performed. DICOM files were imported into the airway analysis software programme and the pharyngeal area around the oropharynx was highlighted. The area and volume of the oropharynx with and without the device was evaluated. A considerable improvement of the airway was observed (+33.76%), and a significant difference in the enlargement ratio between the posterior soft palate (+32.41%) and the posterior tongue (+36.96%) region was also found. The greatest increase in airway volume was achieved in patients treated with the MAD Forward and TAP (+42.77% and +41.63%, respectively). MAD therapy is effective to treat moderate to severe OSA with an increased upper airway volume. The design of the MAD can influence the effectiveness of the treatment.

S123 Maternal and Fetal Outcomes After IBD Surgery During Pregnancy

Background: Inflammatory bowel disease (IBD) incidence peaks in the reproductive years. Despite advances in medical treatment, approximately 20% of ulcerative colitis (UC) and 80% of Crohn’s disease (CD) patients require surgical intervention during their lifetime. Active disease during pregnancy increases the risk of negative pregnancy outcomes, such as spontaneous abortion, low birth weight, prematurity and deformities. Achieving remission prior to conception and maintaining it throughout the pregnancy remain of utmost importance. However, surgery during pregnancy may be required for medically refractory disease or for disease-related complications such as intraabdominal abscess, perforation, or toxic megacolon. Literature pertaining to the maternal and fetal outcomes after IBD surgery during pregnancy remains scarce. Methods: This is a case series of 3 patients who underwent surgery for IBD during pregnancy and subsequently delivered at our quaternary IBD referral center. Results: Case 1: A 34-year-old female with recently diagnosed indeterminate colitis presented with disease exacerbation during her fifth gestational week. Despite treatment with mesalamine, methylprednisolone, and infliximab, she had persistent hematochezia, abdominal pain, and distention. On 11w6d of pregnancy, she underwent an open subtotal colectomy with end ileostomy for severe colitis. Postoperative period was uncomplicated. She then underwent a C-section at 38w5d of gestation. Baby weighed 2.9 kg, Apgar scores 9-9. The newborn had a cleft in the posterior soft palate, micrognathia, tongue tie, and laryngomalacia resulting in dyspnea and dysphagia, which required operative intervention during infancy. The mother ultimately underwent completion proctectomy with IPAA and ileostomy closure at 5- and 7-months following delivery, respectively. Postoperative pouch function was normal. During routine follow-up, pouchoscopy revealed cuffitis, which responded to mesalamine suppository. Case 2: A 28-year-old female with an 8-year history of UC previously treated with prednisone and azathioprine developed disease exacerbation during her 11th gestational week. During 25th week of pregnancy, she underwent an open subtotal colectomy with end ileostomy for acute severe ulcerative colitis. Postoperative period was uncomplicated. She underwent C-section at 39th week of gestation. Baby weighed 3.7 kg, Apgar scores 3-3-8. The newborn developed dyspnea which was resolved following positive pressure ventilation in the NICU for 30 hours. The mother underwent completion proctectomy with IPAA and ileostomy closure 2 years after delivery. Four years following pouch creation, she developed pouchitis, which was controlled with vedolizumab. Case 3: A 20-year-old female with recently diagnosed Crohn’s disease had disease exacerbation at 4 weeks gestation despite treatment with adalimumab and prednisone. A pelvic abscess was identified via ultrasound requiring percutaneous drainage twice. During the ninth week of pregnancy, she underwent a laparoscopic converted to open ileocecectomy due to recurrent abscess and abdominal pain. Postoperative period was uncomplicated. The pregnancy was complicated by pre-eclampsia in the third trimester. The patient had a vaginal delivery at 37w6d of gestation. Baby weighed 2.7 kg, Apgar scores 8-9. The post-delivery course of the mother and infant was uncomplicated. Conclusions: IBD affects females during their childbearing ages. IBD surgery at times needs to be done urgently/emergently; acceptable maternal and fetal outcomes can be achieved.

Six-year post-surgical evaluation in the treatment protocols in the dental arches of children with oral cleft: longitudinal study.

Oral cleft surgical repairs are performed using different techniques worldwide. Objective To evaluate and compare the development of the dental arches of children with unilateral cleft lip and palate before and after the primary surgeries performed with different techniques at the first months and six years of life.Methodology This is a retrospective longitudinal study. The sample comprised 56 dental casts divided int the following groups: Group 1 (G1) – cheiloplasty (Millard technique) at three months and one-step palatoplasty (von Langenbeck technique) at 12 months; and Group 2 (G2) – cheiloplasty (Millard technique) and two-step palatoplasty: anterior hard palate closure (Hans Pichler technique) at three months and posterior soft palate closure (Sommerlad technique) at 12 months. The digitized dental casts were evaluated at three months – pre-surgical (T1) and six years of life– post-surgical (T2). The following linear measurements were analyzed: intercanine (C–C’), intertuberosity (T–T’) distances; anterior dental arch (I–CC’), anterior intersegment (I–C’), and total arch (I–TT’) lengths. The palate area was also measured. Parametric and non-parametric tests were applied (p<0.05).Results In G1, the intragroup comparison showed statistically significant smaller I–CC’ and I–C’ at T2 (p=0.001 and p<0.001, respectively), while T–T’, I–TT’, and area comparisons were significantly greater (p<0.001, p=0.002, and p<0.001, respectively). In G2, the intragroup comparison exhibited statistically significant smaller C–C’ and I–C’ at T2 (p=0.004, for both), whereas T–T’, I–TT’ and area comparisons were significantly greater (p<0.001, p=0.004, and p<0.001, respectively). At T2, the intergroup analysis revealed that G1 had a statistically significant smaller I–CC’ (p=0.014). The analysis of the intergroup differences (∆=T2–T1) showed that G1 had a statistically smaller I–CC’ (p=0.043).Conclusion The two-step palatoplasty showed a more favorable prognosis for the maxillary growth than one-step palatoplasty in children with oral clefts.

Effect of CT localization of upper airway obstruction site after inducing sleep on the value of obstructive sleep apnea hypopnea syndrome and the effect of surgery

Objective:To explore the value of CT location of the upper airway obstruction site after inducing sleep on the condition of obstructive sleep apnea（OSA） and its surgical efficacy. Methods:Forty patients with moderate-to-severe OSA diagnosed by polysomnography, first performed awake CT scan, then, the patient was slowly injected intravenously with dexmedetomidine to induce sleep, when the patient was apnea during sleep, CT scan of the corresponding part of the upper airway was performed. Compare and measure the cross-sectional area of the upper airway stenosis level in the two states, and evaluate the correlation between the cross-sectional area of the stenosis level after induction of sleep and the patient's AHI, blood oxygen saturation<90% of the time（CT90）. According to the change value of the cross-sectional area of each plane, it was divided into 2 groups, 22 cases in first group underwent hypothermia plasma uvulapalatopharyngoplasty, and 18 cases in second group underwent multi-plane combined surgery. After 12 months of follow-up, compare the post-long-term efficacy, changes in cross-sectional area values of various narrow planes before and after surgery, and changes in indicators related to sleep quality between the two groups. Results:Compared with the cross-sectional area of the nasopharyngeal area, posterior soft palate area, the posterior tongue area, and the epiglottis area measured by upper airway CT under awake breathing state, the cross-sectional area of each obstruction plane during sleep state decreased（P<0.01）. The minimum cross-sectional area of the upper airway plane sleep phase was negatively correlated with AHI and CT90, and the posterior soft palate and the posterior lingual base were highly correlated with AHI and CT90.12 months after treatment, the minimum cross-sectional area of each phase of the sleep phase in the experimental group 1 was significantly improved（P<0.01） compared with that before treatment, followed by the posterior tongue area（P<0.05）. There was no statistical difference between the nasopharyngeal area and the epiglottis area. The differences in nasopharyngeal area, posterior soft palate area, posterior tongue area, and epiglottis area in experimental group 2 after treatment were statistically significant（P<0.01 or P<0.05）, compared with that before treatment. The sleep-related indexes ESS, CT90, AHI, and LSaO₂ of the two groups were better than those before treatment after 12 months of treatment（P<0.01）. Comparison of experiment group 1 and 2, the effective rates were 72.72% and 95.23%（χ²=10.62, P<0.01）, the significant efficiency was 58.33% and 80.45%（χ²=8.62, P<0.01）, and the cure rates were 12.37% and 17.48%（x²=7.62, P<0.01）. Conclusion:CT examination of OSA patients after drug-induced sleep is safe and feasible, and it has important value for the accurate location of the upper airway obstruction site. 64-slice spiral CT upper airway scanning under induced sleep has guiding significance for the evaluation of OSA patients' condition and long-term surgical efficacy.

Clinical value of upper airway MSCT measurement in adult male patients with moderate to severe OSA

Objective:To investigate the pathogenesis of OSA-related through 128-slice spiral CT measurements of adult male patients with moderate to severe OSA at different respiratory phases, and to optimize treatment options for patients with OSA. Method:128-slice spiral CT was used to scan the upper airway in 52 adult male patients with moderate to severe OSA and 20 normal controls under two different breathing states: calm breathing and Müller maneuver. The plane diameter and length of each area of the upper airway were measured. Area size, soft palate length, thickness, airway volume, airway length, total thickness of the pharyngeal wall, and calculate the compliance of the pharyngeal cavity, including the compliance of the pharyngeal wall, the compliance of the anterior and posterior pharyngeal wall, and the total pharyngeal compliance. Comparison of measurement results and correlation analysis with related parameters.Result: In the OSA group, the length and area of the smallest plane of each airway area（except the posterior epiglottic area） during calm breathing are greater than Müller's movement, and the difference was statistically significant（P<0.05）. The soft palate length and thickness of the OSA group during calm breathing were significantly larger than those of the normal group, and the difference was statistically significant（P<0.01）, In the OSA group, the total thickness of the soft palate region and the posterior lingual area of the pharyngeal wall in the Müller group was significantly greater than the calm breathing state, and the difference was statistically significant（P<0.01）. The volume of the nasopharynx, posterior epiglottic area and airway length in the OSA group during calm breathing were significantly larger than those in the normal group, and the difference was statistically significant（P<0.01）. The compliance of the pharyngeal cavity in the OSA group was greater than that in the normal group, and the difference was statistically significant（P<0.05）. In the OSA group, the volume of the posterior soft palate, posterior tongue, and total airway volume during Müller movement were significantly smaller than those of calm breathing, and the differences were statistically significant（P<0.01）. In the OSA group, the compliance of the pharyngeal wall in the posterior region of the soft palate was greater than the compliance of the anterior and posterior wall of the pharynx, while the compliance of the posterior region of the pharynx in the posterior region of the pharynx was greater than the compliance of the pharynx. There was a significant positive correlation between BMI and AHI in OSA patients（P<0.05）, which was statistically significant. Conclusion:Through MSCT measurement of the upper airways of adult male patients with moderate to severe OSA, the morphological structure and compliance of the upper airways can be observed intuitively, and the degree and location of upper airway stenosis can be accurately assessed, and the measurement indicators and related parameters can be combined. The correlation can optimize the clinical treatment options for adult male patients with OSA.

The correlation of gagging threshold with intra-oral tactile and psychometric profiles in healthy subjects: A pilot study.

Excessive gag reflex could be problematic for adequate dental care. Although various factors may increase the susceptibility to gagging, its contributing factors have not been fully determined. This study aimed to determine whether gag reflex was associated with tactile sensitivity and psychological characteristics. Fifteen volunteers of healthy males and females each were recruited for this study. After completing a questionnaire describing the self-perceived gag reflex activity, a disposable saliva ejector was inserted along the palate into the mouth until gagging was evoked. The ratio of the insertion depth to the palatal length was used as an index for the gagging threshold. The two-point discrimination (TPD) and Semmes-Weinstein monofilament (SWM) tests were performed to assess the tactile sensitivity of the palatal regions (hard palate, anterior and posterior soft palate). The Symptom Checklist-90-Revised was used to investigate the relationship between the gagging threshold and the psychological status. Our findings showed that the gagging threshold had a significant positive correlation with the TPD and SWM thresholds on the hard palate. The psychological profiles of psychoticism and hostility score were also significantly correlated with the gagging threshold. However, there were no significant differences in the tactile and gagging thresholds, as well as the psychological profiles, between males and females. Our results suggested that the tactile sensitivity of the anterior palate is a determining factor for the gagging threshold and implied that the initial response of the oral entry site to stimulation may lead to the development of gag reflex.

Intravelar and Extravelar Portions of Soft Palate Muscles in Velic Constrictions: A Three-Dimensional Modeling Study.

Purpose This study predicts and simulates the function and relative contributions of the intravelar and extravelar portions of the levator veli palatini (LVP) and palatoglossus (PG) muscles in velic constrictions. Method A finite element-based model of the 3-dimensional upper airway structures (palate, pharynx, tongue, jaw, maxilla) was implemented, with LVP and PG divided into intravelar and extravelar portions. Simulations were run to investigate the contributions of these muscles in velopharyngeal port (VPP) closure and constriction of the oropharyngeal isthmus (OPI). Results Simulations reveal that the extravelar portion of LVP, though crucial for lifting the palate, is not sufficient to effect VPP closure. Specifically, the characteristic "bulge" appearing in the posterior soft palate during VPP closure ( Pigott, 1969 ; Serrurier & Badin, 2008 ) is found to result from activation of the intravelar portion of LVP. Likewise, the intravelar portion of posterior PG is crucial in bending the "veil" or "traverse" ( Gick, Francis, Klenin, Mizrahi, & Tom, 2013 ) of the velum anteriorly to produce uvular constrictions of the OPI ( Gick et al., 2014 ). Conclusions Simulations support the view that intravelar LVP and PG play significant roles in VPP and OPI constrictions.

Three-dimensional evaluation of upper airway in patients with obstructive sleep apnea syndrome during oral appliance therapy.

Obstructive sleep apnea syndrome (OSAS) represents a frequent and common respiratory disease characterized by repeated episodes of complete and/or partial obstruction of upper airways during sleep, normally associated with reduction of oxygen saturation in blood. The oral appliances (OAs) are considered to be an effective treatment modality thanks to the upper airway enlargement. Lateral cephalometry has been used for the 2-dimensional evaluation of upper airway form with several limits. We obtained an accurate 3-dimensional (3D) volume analyses with cone beam computed tomography (CBCT) scans to confirm the effects of OA on the upper airway in patients with OSAS. Ten Italian patients with moderate or severe OSA (3 males and 7 females, 53.4 ± 11.3 years of age, and BMI 24.5 ± 2.7), who cannot tolerate continuous positive air pressure therapy and rejected a surgical approach, were treated with non-adjustable customized OAs and evaluated with CBCT and polysomnography. Upper airway form was examined in the presence and absence of OA and the volume was measured and compared in 2 different areas. Specific planes have been considered to match the data and calculate the benefit obtained with therapy. Nine out of ten patients showed an improvement of total upper airway volume and an improvement in apnea-hypopnea index. Volume increased both in the posterior soft palate region and in the posterior tongue region. In the inferior area, we observed greater differences. 3D image reconstruction accurately confirmed morphological changes in the upper airway during OA therapy. The use of this 3D evaluation is expected to improve the results of OA therapy in the future.

Presentation of a nasopharyngeal palatal pleomorphic salivary adenoma causing airway obstruction in a patient with a Le Fort 1 fracture: a case report.

Introduction: A pleomorphic adenoma originating in the nasopharynx was acutely repositioned from the posterior soft palate to lie within the oral cavity following a road traffic accident (RTA) in which the patient sustained a le fort 1 fracture. Poster presentations for BAOMS Annual Scientific Meeting 2-4 July 2014, Edinburgh International Conference Centre, ScotlandBritish Journal of Oral and Maxillofacial SurgeryVol. 52Issue 8Preview Full-Text PDF

Effective three-dimensional evaluation analysis of upper airway form during oral appliance therapy in patients with obstructive sleep apnoea

The oral appliance (OA) is considered to be an effective treatment modality for obstructive sleep apnoea (OSA). Upper airway enlargement during OA therapy is critical, and lateral cephalometry has been used for the two-dimensional evaluation of upper airway form during this therapy. However, this method cannot provide an accurate three-dimensional (3D) view of upper airway form. To confirm the effects of OA on the upper airway in patients with OSAS, we performed CT in the presence and absence of OA in 15 Japanese patients (12 males, 3 females) who responded to OA therapy. CT in the presence and absence of OA was consecutively performed for each patient, and upper airway cross-sectional area in six arbitrary planes parallel to the palatal plane was measured. Next, 3D image reconstruction was performed; morphological changes in upper airway form were evaluated, and upper airway volume at three levels from the palatal plane to the deepest point of the epiglottis was measured. The cross-sectional area of two planes in the posterior soft palate region significantly increased in the presence of OA compared with that in the absence of OA. In the presence of OA, upper airway cross-sectional area and volume significantly increased in the posterior soft palate region compared with those in the posterior tongue region. 3D CT image reconstruction accurately confirmed morphological changes in the upper airway during OA therapy. Continued use of this 3D evaluation is expected to improve the results of OA therapy in the future.

Treatment of Obstructive Sleep Apnea-Hypopnea Syndrome With Combined Uvulopalatopharyngoplasty and Midline Glossectomy: Outcomes From a 5-Year Study

The aim of this retrospective long-term follow-up study was to assess 5-year outcomes after combined uvulopalatopharyngoplasty (UPPP) and midline glossectomy surgery for the treatment of obstructive sleep apnea-hypopnea syndrome (OSAHS). A total of 34 subjects with OSAHS with combinatory obstructions of posterior soft palate and posterior tongue area who underwent combined midline glossectomy and UPPP were successfully followed for 5 years to examine the therapeutic effect of treatment. All subjects were of Friedman stage II or III and had major stenoses at the base of the tongue. The apnea-hypopnea index (AHI), and mean lowest S(pO(2)) were measured preoperatively and postoperatively to assess therapeutic efficacy. The mean preoperative AHI was 56.0 ± 8.4 episodes/h, while the mean lowest S(pO(2)) was 62.1 ± 10.6%. AHI and mean lowest S(pO(2)) were significantly increased and decreased, respectively, from preoperative levels at each follow-up point after surgery, up to 5 years (P < .05). The average widened pharyngeal space after surgery was 42 mm(2). At 6 months, surgery was classified as being curative in 27/34 (79.41%) of subjects, and markedly effective or effective in the remaining subjects. At 5 years, surgery was classified as being curative in 7/34 (20.59%) subjects, markedly effective or effective in 25/34 (73.53%) subjects, and not effective in 2/34 (5.88%) subjects. Five years after surgery the average body mass index for the subjects who were not cured was slightly higher than those who were cured, but the difference was not statistically significant (31.3 ± 3.7 kg/m(2) vs 29.7 ± 3.6 kg/m(2), P = .29). Subjects who were cured had lower supine AHI values than those who were not cured (2-year postoperative AHI 36.8 ± 9.2 episodes/h vs 43.8 ± 6.9 episodes/h, P = .03, 5-year post-operation AHI 32.1 ± 7.6 episodes/h vs 41.7 ± 8.2 episodes/h, P = .006). These findings suggest that combined midline glossectomy and UPPP can be an effective treatment for subjects with Friedman stage II or III OSAHS and substantial stenosis around the base of the tongue.

Follicular Lymphoid Hyperplasia in Palate: A Case Report with Immunohistochemical Analysis and Review

Follicular lymphoid hyperplasia of the hard palate is a reactive lymphoid proliferation which closely simulates the palatal lymphomas, both clinically and histologically. It is therefore imperative that the pathologist be familiar with the features that separate these two conditions. It reported a case of FLH in a 70-year-old white woman, showing a nodular lesion in right posterior soft palate, reddish, soft, asymptomatic. Histopathological analysis revealed lymphoid aggregates with discrete lobular appearance in the lamina propria of connective tissue showing numerous lymphocytes in the periphery with scanty cytoplasm and homogeneously basophilic nuclei and central areas of germinal centers showing tingible-body macrophages and occasional mitotic figures. In order to distinguish Follicular Lymphoma (FL) from Follicular Hyperplasia (FH), immunohistochemical staining method for bcl-2 was used showing positivity in the mantle zone and absence of immunostaining in the cellular elements within the follicle centres.

Primary oropharyngeal tuberculosis causing destruction of uvula—A rare presentation

Despite the contact of pulmonary secretions and the mucous membranes of the upper respiratory tract with a high bacillary load, tuberculosis of the head and neck area, excluding laryngeal forms, is exceptional and constitutes only 2–6% of extra pulmonary tuberculosis and 0.1–1% of all forms of tuberculosis. Oral cavity tuberculosis is uncommon, out of which primary pharyngeal tuberculosis is extremely rare. We present a case of an ulcerative lesion in a 7-year-old female subsequently proven to be primary oropharyngeal tuberculosis. There was an erosion of uvula and posterior soft palate. There was also an ulcerated area on adjacent area of left tonsillar fossa with slough over posterior pharyngeal wall.

Regional regulation of palatal growth and patterning along the anterior-posterior axis in mice.

Cleft palate is a congenital disorder arising from a failure in the multistep process of palate development. In its mildest form the cleft affects only the posterior soft palate. In more severe cases the cleft includes the soft (posterior) and hard (anterior) palate. In mice a number of genes show differential expression along the anterior-posterior axis of the palate. Mesenchymal heterogeneity is established early, as evident from Bmp4-mediated induction of Msx1 and cell proliferation exclusively in the anterior and Fgf8-specific induction of Pax9 in the posterior palate alone. In addition, the anterior palatal epithelium has the unique ability to induce Shox2 expression in the anterior mesenchyme in vivo and the posterior mesenchyme in vitro. Therefore, the induction and competence potentials of the epithelium and mesenchyme in the anterior are clearly distinct from those in the posterior. Defective growth in the anterior palate of Msx1-/- and Fgf10-/- mice leads to a complete cleft palate and supports the anterior-to-posterior direction of palatal closure. By contrast, the Shox2-/- mice exhibit incomplete clefts in the anterior presumptive hard palate with an intact posterior palate. This phenotype cannot be explained by the prevailing model of palatal closure. The ability of the posterior palate to fuse independent of the anterior palate in Shox2-/- mice underscores the intrinsic differences along the anterior-posterior axis of the palate. We must hitherto consider the heterogeneity of gene expression and function in the palate to understand better the aetiology and pathogenesis of non-syndromic cleft palate and the mechanics of normal palatogenesis.

Noradrenergic innervation of minor salivary glands in the uvula.

Sirs: In order to maintain homeostasis in living mammals, the sympathetic and parasympathetic nervous systems are usually antagonistic to each other. However, innervation of the salivary glands is one of the exceptions. Stimulation of the sympathetic nerve induces secretion of a proteinaceous fluid, while parasympathetic nerve stimulation causes copious secretion of an electrolyte-rich fluid [4, 6–8]. Sympathetic innervation differs between the major and minor salivary glands. The adrenergic innervation of minor salivary glands is virtually absent from the parenchyma, although it is present around the blood vessels in marked contrast to the dense parenchymal adrenergic innervation observed in the parotid and submandibular glands [3, 9]. The aim of our investigation was to define the sympathetic innervation of the minor salivary glands in the uvula (and posterior soft palate). Uvular specimens were obtained from 31 patients (19 men, 12 women; ages 32–48 years) who underwent uvulopalatopharyngeal plasty (UPPP) or laser-assisted uvula plasty (LAUP) as treatment for obstructive sleep apnea syndrome or snoring. The UPPP was performed under general anesthesia, while LAUP was done under local anesthesia. Excised tissues were examined for glyoxylic acid histofluorescence. The technique for glyoxylic acid histofluorescence was modified from the method of Torre and Surgeon [12]. In this technique glyoxalate reacts with norepinephrine to give a fluorescent product at an excitation wavelength of 370 nm and emission wavelength of 460 nm. Glyoxylic acid, sucrose and other reagents were obtained from Sigma Chemical (St. Louis, Mo., USA). Fresh specimens were cut into 100to 500 μm-thick slices using small surgical scissors or a vibratome. Each slice was then placed into 0.32 M sucrose containing 2% glyoxylic acid. The pH was adjusted to 7.4–8.4 with 3 N NaOH. After 30 min, specimens were removed and sectioned with a Leitz 1720 cryostat to approximately 6–10 μm in thickness. Sections were placed on a microscope slide, allowed to air-dry and then H.-W. Wang · S.-H. Wang · J.-Y. Wang

MEDICAL RECORD DOCUMENTATION OF ACUTE PHARYNGITIS

Name: Charles Whitcomb1 Birth date: May 3, 19762 Drug allergies: Hives with sulfonamides3 Immunizations: 5 DTP injections recorded4 Monday, September 24, 1990 CHIEF COMPLAINT: Sore throat. HISTORY: Throat started to hurt late Friday and has worsened gradually over the weekend. Hurts to swallow. Took temperature once: 100°F last night. Nose stuffy. Thinks he has swollen glands. PHYSICAL EXAMINATION: Fairly comfortable; complaining of throat pain. Temperature: 101°F orally. Tympanic membranes: clear. Nose: No discharge but sounds stuffy. Pharynx: Small tonsils; mildly erythematous; no exudate. Posterior soft palate and uvula mildly swollen; no petechiae. Neck: 1.0 cm mildly tender lymph node at each mandibular angle. A few smaller anterior and a number of 0.5 cm posterior cervical nodes. Neck fully supple.