Covid-19 Nasopharyngeal Swab Related CSF Rhinorrhoea: A case report.

With the onset of the COVID-19 pandemic, the number of nasopharyngeal swab samples has increased significantly. In this case report, the treatment of a patient who developed unilateral rhinorrhea after nasopharyngeal swab sample is presented. It is aimed to draw attention to the fact that this complication can be prevented with the appropriate technique during nasopharyngeal swab sampling.

Endoscopic Lateral Osteotomy in Rhinoplasty.

OBJECTIVES: The purpose of this study was to investigate the advantages of endoscopic lateral osteotomy, to evaluate the effects of the periosteal elevation on ecchymosis and to search the reasons for the ecchymosis and the intranasal mucosal tears. METHODS: On a randomly chosen side a subperiosteal tunnel was elevated, on the other side a subperiosteal tunnel was not elevated. Bilateral lateral osteotomies were performed. Internal nasal packing was not used. The post-operative care was similar for all patients. The patients were evaluated on the third post-operative day. The intranasal mucosal tears, the lateral osteotomy cut on the periosteal elevation side were examined using endoscopes. The degree of ecchymosis was determined by 2 other surgeons, who were unaware of the elevated side, using the grading system adapted from Hoffman et al. RESULTS: The intranasal mucosal injury was seen in 16 of non-elevated side whereas it was 14 on the periosteal elevated side. Endoscopy showed the perforating arteries and elevation of the periosteum caused rupture and oozing from these arteries which might be a cause for ecchymosis. Ecchymosis was more severe on the side with subperiosteal tunnel in 6 patients; whereas only in 2 patients it was more severe on the side with no subperiosteal tunnel elevation while in 12 patients the degree of ecchymosis was the same on both sides. CONCLUSION: Endoscopy gives a great opportunity to visualize the lateral osteotomy site. Besides the lateral osteotomy cut, the arteries and the intranasal mucosal injury can be visualized. Periost elevation increases the severity of ecchymosis due to the rupture of the perforating arteries, not due to the trauma of the angular artery. Intramucosal tears do not increase the severity of the ecchymosis.

Results of coblation midline glossectomy for obstructive sleep apnea.

OBJECTIVE: The aim of this study is to determine the effectiveness of coblation midline glossectomy for obstructive sleep apnea (OSA) when used as an isolated procedure. We also aim to compare the effect of this surgical procedure on supine and non-supine apnea. MATERIALS AND METHODS: The medical records of patients who underwent isolated tongue base surgery as a part of step-wise surgeries between January 2014 and February 2019 are retrospectively reviewed. Pre-operative and post-operative Epworth sleepiness score (ESS), body mass index (BMI), and polysomnographic data, including the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), supine AHI, and non-supine AHI of the patients were compared. RESULTS: The study included 29 patients (26 male and 3 female). AHI improved significantly, decreasing from 34.9 ± 20.9 to 25.8 ± 17.6. Supine AHI decreased from 62.55 ± 28.23 to 55.18 ± 31.67 post-operatively, but this decrease was not significant. Non-supine AHI decreased significantly from 22.49 ± 24.02 to 14.08 ± 17.46. ESS and ODI also improved significantly. CONCLUSION: Coblation midline glossectomy is an effective surgical procedure when applied solely, with a success rate of 52%. Non-supine apnea benefits to a greater degree than supine apnea from this surgical procedure.

Real-life assessment of chronic rhinosinusitis patients using mobile technology: The mySinusitisCoach project by EUFOREA.

BACKGROUND: Chronic rhinosinusitis (CRS) is a chronic inflammatory disease associated with a substantial personal and socioeconomic burden. Monitoring of patient-reported outcomes by mobile technology offers the possibility to better understand real-life burden of CRS. METHODS: This study reports on the cross-sectional evaluation of data of 626 users of mySinusitisCoach (mSC), a mobile application for CRS patients. Patient characteristics of mSC users were analysed as well as the level of disease control based on VAS global rhinosinusitis symptom score and adapted EPOS criteria. RESULTS: The mSC cohort represents a heterogeneous group of CRS patients with a diverse pattern of major symptoms. Approximately half of patients reported nasal polyps. 47.3% of all CRS patients were uncontrolled based on evaluation of VAS global rhinosinusitis symptom score compared to 40.9% based on adapted EPOS criteria. The impact of CRS on sleep quality and daily life activities was significantly higher in uncontrolled versus well-controlled patients. Half of patients had a history of FESS (functional endoscopic sinus surgery) and reported lower symptom severity compared to patients without a history of FESS, except for patients with a history of more than 3 procedures. Patients with a history of FESS reported higher VAS levels for impaired smell. CONCLUSION: Real-life data confirm the high disease burden in uncontrolled CRS patients, clearly impacting quality of life. Sinus surgery improves patient-reported outcomes, but not in patients with a history of more than 3 procedures. Mobile technology opens a new era of real-life monitoring, supporting the evolution of care towards precision medicine.

The serum leptin level in non-obese patients with obstructive sleep apnea.

OBJECTIVE: This study aimed to determine the association between the severity of obstructive sleep apnea (OSA) and the serum leptin level in non-obese OSA patients. METHODS: This prospective case-control study included non-obese OSA patients that presented with sleep-related disturbances and underwent polysomnography (PSG) between April 2015 and June 2016. The serum leptin level was measured and its relationship to PSG parameters was investigated. RESULTS: The study included 73 OSA patients (20 female and 53 male) with a mean age of 41.1±11.5 years and mean body-mass index (BMI) of 26.4±2.7kgm-2. The serum leptin level in 44 patients with moderate/severe OSA (AHI ≥15) was 3.4±2.6ngmL-1, versus 4.5±3.8ngmL-1 in 29 patients with snoring/mild OSA (AHI <15) (P=0.20). There were not any correlations between any of the PSG parameters and the serum leptin level, but there was a significant correlation between the leptin level and BMI (r=0.345, P<0.01). CONCLUSION: The serum leptin level does not differ significantly between non-obese OSA patients with moderate/severe and snoring/mild OSA. Obesity is the primary factor associated with the serum leptin level.

The status of the middle turbinate and the risk of sinusitis after endoscopic transnasal sphenoidotomy.

The objectives of this study are to evaluate the occurrence of postoperative middle turbinate lateralization and the relationship between this lateralization and the risk of iatrogenic sinusitis after endoscopic transnasal sphenoidotomy procedure. Patients who undergone endoscopic transnasal sphenoidotomy and came under the surveillance of our otorhinolaryngology department between the January of 2010 and the December of 2015 were retrospectively scanned. Among them, the patients who were evaluated with paranasal sinus computed tomography (CT) postoperatively were included in the study. The amount of middle turbinate lateralization in each patient was evaluated by comparing their routine preoperative CT image with the postoperative CT image. The air-fluid levels or soft tissue opacifications in the sinuses or obstruction of the ostiomeatal complex were accepted as the evidence of sinusitis on the images. The patients were asked questions regarding their symptoms of sinusitis on a phone interview for the statistical evaluation of their preoperative and postoperative Visual Analog Scale scores of complaints of sinusitis. The difference between preoperative and postoperative measurements was found to be statistically significant (p < 0.001, 95% CI). The middle turbinate position was lateralized in 31 patients (81.6%), medialized in four patients (10.5%), and remained unchanged in three patients (7.9%). Overall, the sinus opacification and mucosal thickening rates did not change significantly which suggested the operation did not pose patients at increased risk of sinusitis. Mean VAS scores of complaints of sinusitis did not change significantly except for sensation of facial pressure, which showed a minor but statistically significant decrease (p < 0.001). This study revealed the lateralization of the middle turbinate after transnasal sphenoidotomy. However, it seemed that this lateralization did not create a predisposing factor for the development of acute and chronic sinusitis.

Sole effect of genioglossus advancement on apnea hypopnea index of patients with obstructive sleep apnea.

CONCLUSION: Selected patients might have benefited from genioglossus advancement (GA), even it was applied solely. GA provided significant reduction on the apnea hypopnea index (AHI), with a 53% surgical success. OBJECTIVES: The aim of this study was to evaluate the impact of GA on AHI of patients with obstructive sleep apnea (OSA). METHOD: From January 2008 to April 2014 patients who underwent a genioglossus advancement procedure alone were included into the study and records of these cases were analyzed retrospectively. Pre-operative and post-operative values of body mass index (BMI), Epworth Sleepiness Scale (ESS), nocturnal polysomnographic data including AHI, mean, and minimum oxygen saturation were compared. RESULTS: There were 16 males and one female patient with the mean age of 46 years. The AHI showed a significant reduction from 27.5 ± 8 pre-operatively to 17.3 ± 12.6 post-operatively. The pre-operative and post-operative mean O2 saturation value improved from 92.1 ± 2.4% to 93.4 ± 1.7%. Pre-operative ESS scores decreased significantly from 7.7 ± 1.6 to 4.8 ± 1.9. There were no significant difference between pre- and post-operative values of BMI and minimum O2 saturation. The success rate was found to be 53%, which was based on success criteria as an AHI of <20 with at least 50% reduction.

European position paper on the anatomical terminology of the internal nose and paranasal sinuses.

The advent of endoscopic sinus surgery led to a resurgence of interest in the detailed anatomy of the internal nose and paranasal sinuses. However, the official Terminologica Anatomica used by basic anatomists omits many of the structures of surgical importance. This led to numerous clinical anatomy papers and much discussion about the exact names and definitions for the structures of surgical relevance. This European Position Paper on the Anatomical Terminology of the Internal Nose and Paranasal Sinuses was conceived to re-evaluate the anatomical terms in common usage by endoscopic sinus surgeons and to compare this with the official Terminologica Anatomica. The text is a concise summary of all the structures encountered during routine endoscopic surgery in the nasal cavity, paranasal sinuses and at the interface with the orbit and skull base but does not provide a comprehensive text for advanced skull base surgery. It draws on a detailed review of the literature and provides a consensus where several options are available, defining the anatomical structure in simple terms and in English. It is recognised that this is an area of great variation and some indication of the frequency with which these variants are encountered is given in the text and table. All major anatomical points are illustrated, drawing on the expertise of the multi-national and multi-disciplinary contributors to this project.

Management of cerebrospinal fluid leak during endoscopic pituitary surgery.

OBJECTIVE: Dural opening and closures are major steps in endoscopic pituitary surgery. Restoring the normal anatomy at the end of the procedure creates a natural barrier between the intrasellar compartment and the sinonasal cavity. METHODS: In this study, we present a relatively simple dural opening and closure technique for endoscopic pituitary surgery. This technique provides a better alternative to the use of a more complex nasoseptal flap or the multilevel closure with artificial materials as it restores the normal anatomy after the tumor removal and provides a better physiological barrier between the sinonasal cavity and the intrasellar compartment. Incision is performed in circular or horseshoe fashion leaving a small peduncle, and then the dura is reflected. RESULTS: Of the 733 endoscopic transsphenoidal procedures in 667 patients conducted between January 2006 and May 2012, we used this described technique in 50 cases (7.4%). In these 50 cases with dural flap, there was no postoperative CSF leakage. Intraoperative CSF leakage was observed in 135 (20.2%) of the 667 patients. In 15 (11.1%) of these 135 patients we used the dural flap technique accompanied with fat and/or fascia lata support. There was no postoperative leakage in these patients. In the remaining 120 (89.9%) patients who had intraoperative CSF leakage, we used fat and/or fascia lata for the reconstruction of the sella floor. But we observed postoperative CSF leakage in 12 (10%) of the 120 patients without the dural flap which were reoperated. CONCLUSION: The dural flap technique we employ has several advantages. First of all, it allows optimal physiological reconstruction after the surgery. Secondly, the bridge between the flap and the main dura helps maintain the vascular supply, which in turn can radically shorten the healing time. Thirdly, this technique is obviously a better alternative to the time consuming and expensive multilevel closures with tissue sealants and artificial grafts.

Orbital chondrosarcoma arising from paranasal sinuses.

Orbital chondrosarcoma arising from paranasal sinuses or from the nasal cavity with orbital extension is highly unusual. The aim of this report is to describe our multidisciplinary experience in the treatment of three patients with extensive sino-orbital chondrosarcomas. The patients were aged 43, 75 and 63 years, and the tumors originated from the maxillary, sphenoidal, and ethmoidal sinuses, respectively. Magnetic resonance imaging studies showed homogeneously hypointense lesions on T1-weighted scans, which were hyperintense on T2-weighted images. Intranasal endoscopic surgery alone or in combination with other conventional surgical approaches was the main therapeutic choice. Two patients had recurrences treated with wider surgical removal. Fractionated stereotactic radiotherapy was used in two cases. Two patients had histopathological grade I tumor and one had grade III chondrosarcoma. No patient had regional spread or distant metastasis. All patients were disease-free at 4, 2, and 3 years, respectively, following their last therapeutic interventions. Endoscopic surgery results in lesser morbidity for chondrosarcomas arising from paranasal sinuses and extending into posterior parts of the orbit. However, because control of surgical margins may not be complete, recurrences may occur justifying more radical approaches.

Complications of endoscopic surgery of the pituitary adenomas: analysis of 570 patients and review of the literature.

Endoscopic transsphenoidal surgery is emerging as a minimally invasive and maximally effective procedure for pituitary adenomas. In this report we analyzed the complications in 624 procedures of endonasal transsphenoidal endoscopic surgery in the treatment of 570 patients with pituitary adenomas. The leading author (MB) operated pituitary adenomas via pure endoscopic endonasal transsphenoidal surgery between January 2006 and August 2011 at the Hacettepe University, Department of Neurosurgery in Ankara. Complications were assessed in 624 surgical procedures under five groups; rhinological, CSF leaks, infection, vascular and endocrinologic complications. We observed a total of 76 complications (12.1%). Rhinological complications occurred in 8 patients (1.3%): 4 epistaxis (0.6%) and 4 hyposmia (0.6%). Postoperative CSF leaks occurred in 8 patients (1.3%), and infectious complications occurred in 8 patients: 3 cases of sphenoidal sinusitis (0.4%), 5 cases of meningitis (0.8%). Only 1 case of internal carotid aneurysm rupture during the opening of sellar floor (0.16%) was observed. Endocrinologic complications occurred in 51 (8.1%) patients: Anterior pituitary deficiency in 12 (1.9%), transient diabetes insipidus (DI) in 29 (4.6%), permanent DI in 3 (0.4%) and inappropriate antidiuretic hormone secretion syndrome occurred in 7 (1.1%). There was no mortality directly related to the surgical procedure. The complication rates observed in our study suggests that the endoscopic pituitary surgery is at least as safe as microscopic transphenoidal surgery. These rates were obtained with due experience and well-coordinated teamwork. To further improve these rates, new technological developments will be helpful.

Distribution of inflammatory cells, adhesion molecules, intermediate filaments, and chemokine receptors in subgroups of nasal polyp patients.

BACKGROUND: The pathogenesis of nasal polyps (NPs) is incompletely understood. The aim of this study was to investigate the distribution of inflammatory cells, adhesion molecules, intermediate filaments, and chemokine receptors in subgroups of NP patients. METHODS: In total, 35 patients were enrolled (group 1, 10 patients with Samter syndrome; group 2, 10 patients with diffuse polyposis without signs of Samter syndrome; group 3: 5 patients with solitary nasal polyps; group 4, 10 controls). Immunohistochemical staining was performed for CD105, CD106, CD62E, CD4, CD8, CXCR4, CD147, CD90, CD104, BF45, vimentin, pancytokeratin, and muscle-specific actin (MSA) in all patients' specimens. RESULTS: Expression of CD4, CD8, and CD106 were similar between the groups. Number of patients expressing CD4 in groups 1, 2, and 3 were higher than the controls. Number of patients expressing CD8 antigen were significantly higher in all three groups than in the control group. Expression of CD147 in groups 3 and 4 was significantly higher than in groups 1 and 2. CD98 expression was higher in groups 1, 2, and 3 than in group 4. The number of patients expressing vimentin in groups 1, 2, and 3 was significantly higher than in group 4. Immunostaining for pancytokeratin was positive in all patients. CONCLUSION: In conclusion, inflammatory cell, adhesion molecule, intermediate filament, and chemokine receptor profiles in nasal polyps differ among different patient groups and control subjects. Additional specific immunohistochemical studies are necessary for development of more specific immunotherapies.

European position paper on endoscopic management of tumours of the nose, paranasal sinuses and skull base.

Tumours affecting the nose, paranasal sinuses and adjacent skull base are fortunately rare. However, they pose significant problems of management due their late presentation and juxtaposition to important anatomical structures such eye and brain. The increasing application of endonasal endoscopic techniques to their excision offers potentially similar scales of resection but with reduced morbidity. The present document is intended to be a state-of-the art review for any specialist with an interest in this area 1. to update their knowledge of neoplasia affecting the nose, paranasal sinuses and adjacent skull base; 2. to provide an evidence-based review of the diagnostic methods; 3. to provide an evidence-based review of endoscopic techniques in the context of other available treatments; 4. to propose algorithms for the management of the disease; 5. to propose guidance for outcome measurements for research and encourage prospective collection of data. The importance of a multidisciplinary approach, adherence to oncologic principles with intent to cure and need for long-term follow-up is emphasised.

Overview of vascular complications of pituitary surgery with special emphasis on unexpected abnormality.

Arterial bleeding during transsphenoidal surgery for pituitary adenoma is known complication. This usually happens due to rupture of intracavernous carotid or delayed hemorrhage due to the carotico-cavernous fistula and/or pseudoaneurysm. There is also evidence that cavernous carotid aneurysms may occur with pituitary tumors, yet largest series failed to demonstrate any link between aneurysm formation and pituitary tumors. Usually such an aneurysm rupture results in formation of carotico-cavernous fistula. However, pituitary apoplexy and even epistaxis have been reported. In this paper we present a patient with recurrent pituitary adenoma and cavernous carotid artery aneurysm, which caused significant hemorrhage during the surgery. Although retrospective analysis of MRI disclosed that the patient had the aneurysm before the first surgery, it remained silent until the second operation. Therefore neurosurgeons should be very susceptive to any signal changes on preoperative MR images, especially in recurrent cases, where normal anatomical relations are disturbed by fibrotic tissue. Also, we reviewed the vascular complication of pituitary surgery based on the literature.

Craniocerebral injury resulting from pencil penetration.

Penetrating craniofacial trauma in pediatric age group is quite rare. A case is reported that presented with a pencil penetration injury entering from the anterior maxillary sinus through the orbital medial wall, and ethmoidal cells and septum, reaching the contralateral gyrus rectus of the frontal lobe. All the vital structures were preserved. The patient was first treated with manual extraction of the pencil, without any immediate complications; however, rhinorrhea followed the procedure 4 h later. Early endoscopic surgical intervention was performed and the rhinorrhea was successfully treated in this case. This report discusses radiological and surgical characteristics of this unusual penetrating craniofacial trauma.

Spontaneous involution of nasopharyngeal angiofibroma.

There are several studies addressing regression of residual nasopharyngeal angiofibroma after surgery, but spontaneous regression of this tumor has been reported in only 2 cases. We present a case of nasopharyngeal angiofibroma that has involuted spontaneously in the last 5 years. The tumor had been diagnosed at another institute. Computed tomography taken in 2002 had revealed the tumor occupying the entire sphenoid sinus and the pterygopalatine fossa, extending to the cavernous sinus and the infratemporal fossa on the right side. The vascularization of the tumor had been mainly from the internal maxillary artery on angiography. The internal maxillary artery had been occluded with a coil, but branches of internal carotid artery could not be embolized due to high risks of complications. In 2004 the patient was seen at our institute, and this time, repeated angiography revealed rich vascularization from the internal carotid artery. The patient did not accept any treatment and was put on follow-up. He had no complaint in January 2007. The tumor was seen to disappear completely, except a little remnant at the right pterygopalatine fossa on computed tomography. This is the third reported case in the literature with spontaneous regression of nasopharyngeal angiofibroma.

Nasal pepsin assay and pH monitoring in chronic rhinosinusitis.

OBJECTIVES/HYPOTHESIS: The primary objective of this study was to determine the relationship between chronic rhinosinusitis (CRS) and laryngopharyngeal reflux (LPR). We also investigated the diagnostic value of pepsin in nasal lavage by means of fluorometric assay as compared with 24-hour dual-probe pH monitoring. STUDY DESIGN AND METHODS: This is a controlled, prospective study from a retrospective dataset of 33 patients recruited for endoscopic sinus surgery between 2005 and 2006 in a tertiary care referral center (Hacettepe University Medical Center). All patients underwent 24-hour dual-probe pH monitoring and nasal lavage fluid investigation for pepsin. A fluorometric pepsin assay using casein-fluorescein isothiocyanate in nasal lavage fluid was used to detect LPR. The control group included 20 patients who were proven not to have sinusitis. RESULTS: A higher incidence of pharyngeal acid reflux events was found in patients with CRS (29 of 33, 88%) compared with the control patients (11 of 20, 55%). The difference was statistically significant (P = .01). The fluorometric pepsin assay was correlated to the results of 24-hour dual-probe monitoring for LPR diagnosis with a 100% sensitivity and 92.5% specificity. These data suggest that an association between CRS and LPR is present and that the detection of pepsin in nasal lavage fluid may provide a noninvasive and feasible method of LPR screening.

An animal study on cartilage healing using auricular cartilage as a model.

We investigated the effect of different surgical procedures on cartilage healing, using auricular cartilage as a model, which would be useful to create a rationale for septal cartilage surgery. Different kinds of manipulations were performed on the auricular cartilage of six female New Zealand white rabbits. Histopathological investigations were performed under light microscopy 4 months postoperatively. The autologous cartilage grafts survived well under the forehead skin regardless of the presence of the perichondrium. The response of perichondrium to either incomplete or complete trauma was not only new cartilage formation but also ossification. When incomplete incisions were made on the non-perichondrial side, new cartilage formation was stimulated whereas ossification was induced when there was perichondrium on the cartilage. If the cartilage with perichondrium was sliced into small pieces and planted back in its original place, many ossification areas occurred. The crushed cartilage was usually absorbed but sometimes replaced by bony plates. The traumatized cartilage with perichondrium undergoes ossification. This finding may be important clinically in that surgeons should not traumatize septal cartilage with perichondrium and work under the perichondrium. This ossification of traumatized cartilage may later result in thickening of the septal cartilage which we sometimes face in revision surgery.

Juvenile nasopharyngeal angiofibroma: a revised staging system.

OBJECTIVES: To discuss the shortcomings of current staging systems and to suggest modifications according to new surgical methods and data. STUDY DESIGN: A retrospective chart review. METHODS: The medical records of 36 patients, all of whom underwent resection of juvenile nasopharyngeal angiofibroma by external or endonasal approach between 1983 and 2002, were reviewed retrospectively. Follow-up period of patients ranged from 3 to 7 years (mean, 4.5 years). Tumour extent, sites and rate of persistent disease were analyzed and compared with the literature. RESULTS: Persistent or recurrent disease was found in 12 of the 36 patients (33%). The primary tumour of these 12 cases invaded one or more anatomic region beside nasopharynx: the base of the pterygoid process in 9 cases (75%), the infratemporal fossa in 4 (33%), the pterygomaxillar fossa in 4 (33%), and the sphenoid sinus in 2 cases (17%). Involvement of the pterygoid process base was observed in only 3 of the 24 patients without persistent disease, whereas it was found 10 out of 12 patients with persistent disease. CONCLUSIONS: Advances in radiographic imaging, embolization, and surgical methods of treating angiofibromas have changed the sites associated with a high risk for persistent disease or morbidity. These changes have made it necessary for the authors to devise more appropriate classifications and, subsequently, several new staging systems were gradually introduced. Recent technological advances, particularly angled endoscopes, have resulted in improved exposure. In the light of all these recent advances, data from our series, and the literature, we suggested a new classification for determining the risk of persistent disease, choosing the appropriate surgical method, and for maintaining uniformity.

Proliferation, angiogenesis and hormonal markers in juvenile nasopharyngeal angiofibroma.

OBJECTIVES: Juvenile nasopharyngeal angiofibroma (JNA) is a highly vascular and locally invasive tumor that exclusively affects male adolescents. Sex hormones are first discussed to clarify the etiology of JNA. Recently with the advances in the field of cell biology angiogenetic markers, proliferation markers and growth factors are investigated to identify the molecular basis of JNA as all neoplasm. In this study we tried to evaluate the expression of proliferation, angiogenesis and hormonal markers in JNA. METHODS: Immunohistochemical analysis were performed on paraffin-embedded 27 JNA samples which were obtained from the patients operated at University of Hacettepe Department of Otorhinolaryngology, a tertiary care center. Estrogen receptor (ER), progesterone receptor (PR), proliferating cell nuclear antigen (PCNA), vascular endothelial growth factor (VEGF) and transforming growth factor beta (TGF-beta) specific antibodies were used and evaluated by light microscopy RESULTS: Two of 27 cases were ER positive. Nine of 27 cases were positive for PR. All of the cases were stained with PCNA. Twenty-four of 27 cases stained with VEGF. TGF-beta was positive in 14 of 27 cases. All recurrent cases were stained with PCNA and VEGF; just three of them were stained with TGF-beta. CONCLUSIONS: Hormonal markers ER and PR did not seem to play a role in pathogenesis of JNA. PCNA, VEGF and TGF-beta may play a role in the pathogenesis of JNA by promoting angiogenesis and proliferation, but this role did not seem to have a relation with hormonal markers.