Malignant otitis externa.

OBJECTIVE: Malignant external otitis is a severe infection of the external auditory canal and skull base, which most often affects elderly patients with diabetes mellitus. This disease is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. Malignant otitis externa requires urgent diagnosis and treatment. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic and debridement necrotic tissue; sometimes, aggressive surgical management is done. We present our 5-year institutional experience in the management of this disease. The aim of this study was to present our experience with the management of malignant otitis externa. METHODS: All patients' records with malignant otitis externa during the last 5 years (2007-2012) were retrieved and reviewed. Diabetes mellitus profile, erythrocyte sedimentation rate, ear swab for culture and sensitivity, computed tomography, and scintigraphy using technetium 99 and gallium 67 were investigated for all patients. RESULTS: During the last 5 years (2007-2012), 10 patients with the diagnosis of malignant otitis externa were admitted to our clinic for investigation and treatment. There were 7 men and 3 women, all between 64 and 83 years of age, with severe persistent otalgia, purulent otorrhea, granulation tissue in the external auditory canal, and diffuse external otitis, and there were 4 patients with facial nerve palsy. Nine patients were confirmed to have a diabetes, and 4 of these 9 cases just had chronic renal failure and underwent dialysis; the remainder 1 case had no diabetes mellitus, but with chronic renal failure on dialysis. Ear swabs for culture and sensitivity usually revealed Pseudomonas aeruginosa. Local debridement and local and systemic antibiotic treatment were sufficient to control the disease. Facial nerve decompression was done in facial paralysis. Hyperbaric oxygen therapy was performed in facial nervy palsy cases. CONCLUSIONS: Malignant otitis externa is still a serious disease associated with cranial nerve complications and high morbidity-mortality rate. The most effective treatment is to control the diabetes and to fight infection with the proper antibiotic, debridement necrotic tissue, and sometimes aggressive surgical management. Monitoring of therapy response is done through normalization of erythrocyte sedimentation rate, control of diabetes mellitus, and improvement of computed tomography and radioisotope scanning.

Encephalomalacia in the frontal lobe: complication of the endoscopic sinus surgery.

Encephalomalacia is the softening or loss of brain tissue after cerebral infarction, cerebral ischemia, infection, craniocerebral trauma, or other injury. The term is usually used during gross pathologic inspection to describe blurred cortical margins and decreased consistency of brain tissue after infarction. Multicystic encephalomalacia refers to the formation of multiple cystic cavities of various sizes in the cerebral cortex of neonates and infants after injury, most notably perinatal hypoxic-ischemic events. Chronic sinusitis has become one of the most common diseases in otolaryngology practice. Many of these patients can be managed successfully with medical therapy. Those who fail intensive medical therapy may be candidates for functional endoscopic sinus surgery (ESS). This procedure has variable complication rates and can have some serious consequences. Serious complications of functional ESS are very rare, but cerebrospinal fluid leak, meningitis, hemorrhage, infection, or vision loss has been reported in a few cases. In this study, we present a 57-year-old man with encephalomalacia after a penetrating brain injury incurred during ESS.

A purely intracanalicular cochlear schwannoma presenting with progressive hearing loss.

Schwannomas arising from the cochlear nerve and confined to the internal auditory canal are rare. Clinically, a cochlear schwannoma can cause a progressive hearing loss. We report the case of a 56-year-old woman with a cochlear schwannoma that manifested as a slowly progressive hearing loss. The lesion was diagnosed by gadolinium-enhanced 3-Tesla magnetic resonance imaging.

The effect of lidocaine, bupivacaine and ropivacaine in nasal packs on pain and hemorrhage after septoplasty.

We aimed to investigate the effects of local anesthetics soaked in Merocel nasal packs on hemorrhage and pain after septoplasty. The methodology includes a prospective double-blind study that was conducted in patients undergoing septoplasty because of nasal septal deviation. The study included 143 patients. The patients were divided into four groups. Each group received 1% lidocaine + 0.000625% adrenalin, 0.375% ropivacaine, 0.25% bupivacaine as study groups or 0.9% sodium chloride as a control group in their Merocel packs postoperatively. The local anesthetics or sodium chloride were reapplied at the eighth postoperative hour. Each patient was given a questionnaire where verbal analog score and amount of postoperative hemorrhage was noted. The statistical analysis was performed using two sided t test on each patient group at each time point. The results included the patients in the control group needing rescue drug most often. There was no statistically significant difference between bupivacaine and lidocaine plus adrenalin in the patients who requested rescue drug. The patients in the ropivacaine group requested rescue drug more frequently than the bupivacaine and lidocaine plus adrenalin groups. Bupivacaine group had significantly better pain scores versus control group at all intervals except for the first postoperative hour.The bupivacaine group had better pain scores versus ropivacaine and lidocaine plus adrenalin groups in the 4th, 8th and the 24th hours. The bupivacaine group had better pain scores versus lidocaine plus adrenalin in the 12th, 16th and the 20th hours. The ropivacaine group had significantly better pain scores versus control group in the 8th, 12th, 16th, 20th and 24th postoperative hours. The ropivacaine group scored better than lidocaine plus adrenalin group just in the 16th hour. The lidocaine plus adrenalin group had significantly better pain scores versus control group in 4th and 12th hours. There was no statistically significant difference between the study groups in terms of postoperative hemorrhage. We concluded that bupivacaine use in nasal surgery provides better analgesia at least in the first 8 h period and does not cause more bleeding. Topical bupivacaine application to nasal packs should be considered after septoplasty.

Genetic alterations of the LKB1 gene in head and neck cancer.

The genetic alterations associated with head and neck cancer (HNC) are numerous and include a variety of different pathways. It has also been shown that numerous tumor suppressor genes are involved in HNC. The LKB1 gene has been defined as a tumor suppressor gene, and somatic mutations of this gene have been identified in many different neoplasms. The aim of this study was to investigate the LKB1 gene in HNC. Nine exons of the LKB1 gene were analyzed by direct sequencing. We detected a novel missense mutation in the nuclear localization signal coding region of the LKB1 gene in 10 tumor samples from patients with HNC. Six different single-nucleotide substitutions were also observed in the introns. In two patients, a 7 bp duplication was detected in intron 3. These results indicate that the LKB1 gene may play a role in the etiology of HNC.

Inflammatory pseudotumor of the lymph nodes in the neck.

Inflammatory pseudotumor is a tumor-like lesion with histopathologic characteristics of inflammation. A 63-year-old woman, who presented with complaints of 2 neck masses on the right side of the neck with waxing and waning course in whom excisional biopsy was performed revealing inflammatory pseudotumor of the lymph node in the neck, is presented, and this rare clinical entity is discussed together with relevant literature.

Management of jugular paragangliomas in otolaryngology practice.

Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity and should be considered in the evaluation of all lateral neck masses. The aim of this study was to review an institutional experience in the management of jugular paragangliomas. Thirteen jugular paragangliomas (Fisch classifications C and D glomus jugulare) were treated in our institution during a period of 5 years (2003-2008). All patients with adequate follow-up and complete records (13 cases) were reviewed with emphasis on the results of surgical management and the factors influencing them. Coupled with the residual tumors in 2 patients, the surgical control achieved was 82%. No recurrence was seen. All patients were subjected to digital subtraction angiography to define the vascular supply of the tumor. Microcoil embolization of 11 jugular paragangliomas (all [100%] of the patients who accepted the operation) was performed during the initial digital subtraction angiography. There was no perioperative mortality. There was one case of perioperative cerebrospinal fluid leak, which was repaired during the surgery. The facial nerve was preserved in all of the patients. The overall preservation rate of lower cranial nerves was 54% (7 of 13). Two patients with residual jugular paraganglioma were posttreated with irradiation (gamma knife) owing to skull base extension with significant symptomatic relief. Two patients who refused the surgical treatment were managed by stereotactic radiosurgery. The primary therapeutic option for jugular paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. The combined therapeutic approach with preoperative selective embolization followed by surgical resection is the safe and effective method for complete excision of tumors with a reduced morbidity rate. Irradiation (gamma knife) is an effective therapy method for residual jugular paraganglioma.

Composite cartilage island grafts in type 1 tympanoplasty: audiological and otological outcomes.

Tympanoplasty is a surgical procedure used for eradicating chronic middle ear infection and for reconstructing hearing in infected ears. Independent from the graft placing technique, the atrophy and the insufficiency of the graft material would be seen.For cases at high risk for failure, such as recurrent perforations, total perforations, and severely atelectatic tympanic membranes, many surgeons have used cartilage as a grafting material because of its increased stability and resistance to negative middle ear pressure. Various cartilage grafting techniques have been described, including the palisade, cartilage island, and cartilage shield.In our study, we investigated audiological and otological outcomes of tympanoplasty type 1 with composite cartilage island grafts. Between 2004 and 2008, 100 cases of composite cartilage island tympanoplasty were identified. A total of 74 patients were attended to in this study. Graft take was evaluated in all patients, and postoperative complications were noted. Hearing results were analyzed by comparing the preoperative and postoperative pure-tone average air-bone gap. Graft take was accomplished in 72 patients (97.29%). There was no graft lateralization or displacement in the middle ear. The mean postoperative pure-tone average air-bone gap improvement was 20.2 dB at 500 Hz, 23.58 dB at 1000 Hz, 22.23 dB at 2000 Hz, and 24.79 at 4000 Hz.Our study indicates that composite cartilage island tympanoplasty has a high degree of reliability and excellent hearing improvement especially in patients at high risk for graft failure.

Schwannoma of the hard palate.

About half of all neurogenic tumors are seen in the head and neck region. The types of neurogenic tumors must be distinguished. Schwannomas originate from Schwann cells of the neural sheath and are solitary, well-encapsulated, slow-growing adjacent to the parental nerve but extrinsic to the nerve fascicles.Approximately 25% to 45% of all schwannomas are seen in the head and neck region and are found rarely in the oral cavity. Most of the intraoral schwannomas are located in the tongue. Other less common locations are the buccal mucosa, palate, base of the mouth, gingiva, and lips.In this study, we report a rare case of schwannoma of the hard palate, which was excised intraorally.

Follicular dendritic cell sarcoma of the parotid gland recurring 6 times within 12 years.

Follicular dendritic cell sarcoma is a rare neoplasm of low to intermediate malignant potential. It can occur in any location where follicular dendritic cells reside, and nearly all the cases reported in clinical notes have occurred as primary lymph node tumors. Carcinosarcoma or true malignant mixed tumor of the salivary gland is a tumor composed of both carcinomatous and sarcomatous elements. It is an exceedingly rare tumor of the salivary glands, and only approximately 60 clinical notes have been reported. In this report, we describe a recurrent carcinosarcoma of the parotid gland that contained an unusual mesenchymal component (follicular dendritic cell sarcoma) in a 42-year-old woman with cytohistologic and immunohistochemical findings. The predominant sarcomatous component made the diagnosis in the current report difficult because only one clinical note on follicular dendritic cell sarcoma in the parotid gland has been previously reported in the English literature. During the 12-year follow-up period, 6 local recurrences were also detected.

Oropharyngeal flora changes after tonsillectomy.

OBJECTIVE: We aimed to investigate the effect of tonsillectomy on oropharyngeal flora in children who underwent tonsillectomy for chronic recurrent tonsillitis. STUDY DESIGN AND SETTING: A prospective study was performed comprising patients with chronic recurrent tonsillitis who underwent tonsillectomy at the Department of Otolaryngology, Cerrahpasa Medical School. Incisional core biopsies of excised tonsils were also performed. Swabs and core biopsy specimens were transferred and maintained in Stuart's medium and sent to the Department of Microbiology and Clinical Microbiology at Cerrahpasa Medical School for microbiologic evaluation. SUBJECTS AND METHODS: Oropharyngeal swabs and tonsillar core biopsy specimens from 31 patients operated on for recurrent tonsillitis were cultured. Follow-up oropharyngeal swabs were cultured one month after tonsillectomy. RESULTS: There was no significant difference between the preoperative and postoperative isolation rate of the potentially pathogenic bacteria. Normal aerobic flora did not change significantly. However, the isolation rate of the Neisseria species dropped (P = 0.097) but did not reach statistical significance. Among anaerobes, Bacteroides fragilis, one of the major anaerobic bacteria, dropped significantly (P = 0.007). The Propionibacterium acnes isolation rate increased significantly (P = 0.009). CONCLUSION: Oropharyngeal anaerobic bacterial flora decreases after tonsillectomy in recurrent tonsillitis patients. The isolation rate for bacteria of the normal flora and potentially pathogenic bacteria does not change. Tonsils with recurrent infections may become a nidus for anaerobic bacteria. In patients with chronic recurrent tonsillitis, tonsillectomy may help change anaerobic bacterial oropharyngeal flora to the normal flora found in healthy individuals.

Management of paragangliomas in otolaryngology practice: review of a 7-year experience.

BACKGROUND AND AIMS: Paragangliomas of the head and neck are highly vascular lesions originating from paraganglionic tissue located at the carotid bifurcation (carotid body tumors), along the vagus nerve (vagal paragangliomas), and in the jugular fossa and tympanic cavity (jugulotympanic paragangliomas) and should be considered in the evaluation of all lateral neck masses. The aim of this study is to review an institutional experience in the management of these tumors. MATERIALS AND METHODS: Twenty-six patients with 27 paragangliomas were treated in our institution during a period of 7 years (2000-2007). There were 15 women (57.6%) and 11 men (42.4%) with a mean age of 33.5 years. A painless lateral neck mass was the main finding in 16 patients (61.5%). There was no evidence of a functional tumor. Carotid angiography was performed on all of our patients (100%) to define the vascular anatomy of the lesion. Twenty-two paragangliomas (of the 25 operated paragangliomas; 88%) underwent selective embolization of the major feeding arteries. We performed surgery on 24 (92.3%) patients. Two patients were treated with radiotherapy. RESULTS: Most lesions were paragangliomas of the carotid bifurcation (n = 14 [51.8%]), whereas 6 patients were diagnosed with jugular (22.2%), 1 with a vagal (3.7%), 1 with a tympanic paraganglioma (3.7%), 2 with jugulotympanic paraganglioma (7.4%), and 1 with laryngeal paraganglioma (3.7%). In 1 patient (3.8%), bilateral paragangliomas in the carotid bifurcation were detected. There was an evidence of malignancy in all cases (3.8%). Preoperative embolization has proven successful in reducing tumor vascularity in approximately 22 (of 25 who accepted surgery; 88%) paraganglioma patients. The common preoperative complication was vascular injury, which occurred in 6 (23%) of 26 patients; the main postoperative complication was transient cranial nerve deficit in 4 (15.3%) of 26 patients; and a permanent Horner syndrome was documented in 2 patients (7.6%). Cerebrospinal fluid leak occurred in 1 patient (3.7%). Postoperatively, stroke was occurred in 1 patient (3.7%). Two patients with jugular paraganglioma were treated with irradiation because of skull base extension with significant symptomatic relief. CONCLUSIONS: The primary therapeutic option for paragangliomas is complete excision of tumor with preservation of vital neurovascular structures. Combined therapeutic approach with preoperative selective embolization followed by surgical resection is the safe and the effective method for complete excision of the tumors with a reduced morbidity rate.

Carotid-cavernous fistula after functional endoscopic sinus surgery.

Carotid-cavernous fistulas (CCFs) are anomalous communications between the carotid arterial system and the venous cavernous sinus. They can arise because of spontaneous or trauma causes. Most caroticocavernous fistulas are of spontaneous origin and unknown etiology. Spontaneous CCF may also be associated with cavernous sinus pathology such as arteriosclerotic changes of the arterial wall, fibromuscular dysplasia, or Ehler-Danlos syndrome. Traumatic CCFs may occur after either blunt or penetrating head trauma. Their clinical presentation is related to their size and to the type of venous drainage, which can lead to a variety of symptoms, such as visual loss, proptosis, bruit, chemosis, cranial nerve impairment, intracranial hemorrhage (rare), and so on. Treatment by endovascular transarterial embolization with electrolytically detachable coils is a very effective method for CCF with good outcomes. Carotid-cavernous fistulas have been rarely reported after craniofacial surgery and are uncommon pathologies in otolaryngology practice. In this study, we report a 40-year-old woman with CCF secondary to blunt trauma of functional endoscopic sinus surgery.

Thermal effects of mobile phones on facial nerves and surrounding soft tissue.

OBJECTIVE: To investigate the possible thermal effects of microwaves from mobile phones on facial nerves (FN) and surrounding soft tissue. STUDY DESIGN: A prospective study. METHODS: We studied FN conduction rate and compound muscle action potentials (CMAP) on 12 rabbits before exposure to radiofrequency radiation (RFR) emitted from a mobile phone. Also, the temperature change in the soft tissues around the FN was investigated by a four channel Luxtron fiber optic system. A mobile phone with 1900 MHz frequency was placed over the ipsilateral ear of the rabbit for 25 minutes, and FN and surrounding tissues were exposed to a 1.5 watts pulse modulated (217 packets/s) electromagnetic field. During exposure to RFR, immediately after turning off the mobile phone, and 25 minutes after the exposure temperature change in the surrounding tissue of the FN was recorded and compared to preexposure values. Additionally, another recording regarding the FN functions was done and the data were compared to preexposure values. RESULTS: The average temperature of the surrounding soft tissues was 0.39 K higher than the preexposure values during the exposure and immediately after turning off the mobile phone, and decreased to normal levels 25 minutes after the exposure, which was statistically significant. The amplitudes of FN CMAP after radiofrequency radiation exposure were significantly smaller than the preexposure amplitudes and the amplitudes were normal in the 25 minute measurement. CONCLUSION: The RFR emitted from a mobile phone can cause temporary FN dysfunction that can be due to temporary temperature increase in the soft tissue around the FN.

Detection of HHV-8 and HPV in laryngeal carcinoma.

OBJECTIVE: In this study we aimed to investigate the presence of human herpesvirus 8 (HHV-8) and human papillomavirus (HPV) in laryngeal carcinoma. MATERIALS AND METHODS: Fifty patients operated on because of laryngeal carcinoma were included in the study. Forty-seven had squamous cell carcinoma (SCC) whereas three had verrucous carcinoma. Fresh tumoral tissues, or tumoral tissues obtained from archival paraffin-embedded blocks, were examined. HHV-8 DNA and HPV DNA were detected using polymerase chain reaction (PCR) and viral genotypes of HPV were determined via the hybrid capture method. The presence of HHV-8 DNA and HPV DNA were also investigated in normal appearing laryngeal tissue collected from 50 cadavers at autopsy. RESULTS: HPV DNA was detected in seven patients (7/50; 14%) (5 out of 47 patients with SCC (5/47; 10.6%) and two out of three patients with verrucous carcinoma). HHV-8 DNA was detected in five patients and they all had SCC (5/47; 10.6%). One case had both HHV-8 and HPV DNA. None of the control samples from cadavers harbored HHV-8 DNA, or HPV DNA. There was a statistically significant correlation between HHV-8 DNA and HPV DNA positivity and laryngeal SCC (Fisher exact test; p=0.023 for each). No statistically significant correlations were found between the presence of HHV-8 and/or HPV and age, gender, tumor stage, differentiation, the site of the tumor, smoking and alcohol use. CONCLUSIONS: The findings of the present study suggest that beside HPV, HHV-8 might have a role in laryngeal carcinogenesis. Further investigations are necessary to clarify the exact role of these viruses in laryngeal carcinoma.

Unilateral sudden hearing loss as the first sign of chronic myeloid leukemia.

Chronic myeloid leukemia (CML) is one of the etiologic causes of sudden hearing loss and vertigo. However, deafness in association with vestibular symptoms rarely occurs in CML as the first sign. In this article, a 50-year-old male with CML whose first signs and symptoms were unilateral sudden hearing loss and tinnitus in the right ear, vertigo and nausea was presented. Aetiopathogenetic mechanisms, clinical and radiological aspects and therapeutic options for CML with deafness and vertigo were discussed reviewing the literature.