IMPORTANCE Many adults with obstructive sleep apnea (OSA) use device treatments inadequately and remain untreated. OBJECTIVE To determine whether combined palatal and tongue surgery to enlarge or stabilize the upper airway is an effective treatment for patients with OSA when conventional device treatment failed. DESIGN, SETTING, AND PARTICIPANTS Multicenter, parallel-group, open-label randomized clinical trial of upper airway surgery vs ongoing medical management. Adults with symptomatic moderate or severe OSA in whom conventional treatments had failed were enrolled between November 2014 and October 2017, with follow-up until August 2018. INTERVENTIONS Multilevel surgery (modified uvulopalatopharyngoplasty and minimally invasive tongue volume reduction; n = 51) or ongoing medical management (eg, advice on sleep positioning, weight loss; n = 51). MAIN OUTCOMES AND MEASURES Primary outcome measures were the apnea-hypopnea index (AHI; ie, the number of apnea and hypopnea events/h; 15-30 indicates moderate and >30 indicates severe OSA) and the Epworth Sleepiness Scale (ESS; range, 0-24; >10 indicates pathological sleepiness). Baseline-adjusted differences between groups at 6 months were assessed. Minimal clinically important differences are 15 events per hour for AHI and 2 units for ESS. RESULTS Among 102 participants who were randomized (mean [SD] age, 44.6 [12.8] years; 18 [18%] women), 91 (89%) completed the trial. The mean AHI was 47.9 at baseline and 20.8 at 6 months for the surgery group and 45.3 at baseline and 34.5 at 6 months for the medical management group (mean baseline-adjusted between-group difference at 6 mo, −17.6 events/h [95% CI, −26.8 to −8.4]; P < .001). The mean ESS was 12.4 at baseline and 5.3 at 6 months in the surgery group and 11.1 at baseline and 10.5 at 6 months in the medical management group (mean baseline-adjusted between-group difference at 6 mo, −6.7 [95% CI, −8.2 to −5.2]; P < .001). Two participants (4%) in the surgery group had serious adverse events (1 had a myocardial infarction on postoperative day 5 and 1 was hospitalized for observation following hematemesis of old blood). CONCLUSIONS AND RELEVANCE In this preliminary study of adults with moderate or severe OSA in whom conventional therapy had failed, combined palatal and tongue surgery, compared with medical management, reduced the number of apnea and hypopnea events and patient-reported sleepiness at 6 months. Further research is needed to confirm these findings in additional populations and to understand clinical utility, long-term efficacy, and safety of multilevel upper airway surgery for treatment of patients with OSA.

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We have shown NC for epistaxis to be an effective treatment. In our study, it was associated with a significantly reduced hospital admission, complication rate and with no re-presentations.

Oral squamous cell carcinoma (OSCC) is the 8th most common cancer globally with an incidence rate of 18 per 100 000 per annum in Australia. 1,2 Surgery forms the primary treatment of OSCC. 3 Risk stratification in deciding on the need for adjuvant therapy after resection of the primary OSCC is based on the presence of adverse histologic features such as extracapsular spread (ECS), close/involved margins, lymphovascular involvement (LVI), perineural involvement (PNI) and lymph node metastases. [4][5][6] Perineural invasion is defined when at least one of the two histologic features is present. Either tumour cells need to be present in any of the three layers of the nerve sheath or they need to encircle at least 33% of the circumference of a nerve. 7 Although PNI is generally acknowledged to be a negative prognostic factor, there is conflicting evidence in the literature regarding its association with recurrence and overall survival. [8][9][10][11][12][13][14][15][16] In the study by Crachiolo et al, 10 PNI-positive OSCC tumours were associated with decreased disease-specific survival (DSS) but not associated with differences in local or regional control rates. Liao et al 12 found that presence of PNI was not associated with decreased local control or overall survival.Currently, PNI is reported as being either absent or present, without any general consensus on classifying the type and extent of PNI.Evidence in the literature suggests that histopathologic subcategories