High-Resolution Computed Tomography in Middle Ear Cholesteatoma: How Much Do We Need It?

Background and Objectives: The diagnosis of cholesteatoma is usually clinic, and the only efficient treatment is surgical. High-resolution computed tomography (HRCT) is not considered absolutely necessary for the management of an uncomplicated cholesteatoma, but unsuspected situations from a clinical point of view can be discovered using the scans, warning the surgeon. Our objective is to compare HRCT scan information with intraoperative findings in patients with cholesteatoma and analyze the usefulness of a preoperative HRCT scan from a surgical point of view. Materials and Methods: This is a prospective descriptive study conducted in the Department of Otolaryngology, Victor Babes University of Medicine and Pharmacy Timisoara, Romania, from May 2021 to April 2022. It was carried out on 46 patients with a clinical diagnosis of cholesteatoma who were consequently operated on in our department. All patients received full clinical and audiological examinations. In all cases, an HRCT scan was performed preoperatively as a mandatory investigation. Preoperative HRCT scans were analyzed, and their findings were compared to the intraoperative notes. The two sets of observations were analyzed using standard statistical methods. Results: Extensive cholesteatoma was the most common type of disease, involving 46% of the patients, followed by pars flaccida cholesteatoma (35%) and pars tensa cholesteatoma (19%). Eroded scutum was the most frequent lesion involving 70% of the patients, followed by incus erosion (67%). Comparison of the HRCT and intraoperative findings revealed a very good correlation for tegmen tympani erosion, sigmoid plate erosion, scutum and malleus erosion, and a moderate-to-good correlation for lateral semicircular canal erosion, incus and stapes erosion, and fallopian canal erosion. Conclusions: HRCT is a valuable tool in the preoperative assessment of cholesteatoma, helping in making surgical decisions. It can accurately predict the extent of disease and is helpful for detecting unapparent dangerous situations. However, it is not very accurate in detecting fallopian canal and stapes erosion.

Novel Triterpenic Acid-Benzotriazole Esters Act as Pro-Apoptotic Antimelanoma Agents.

Pentacyclic triterpenes, such as betulinic, ursolic, and oleanolic acids are efficient and selective anticancer agents whose underlying mechanisms of action have been widely investigated. The introduction of N-bearing heterocycles (e.g., triazoles) into the structures of natural compounds (particularly pentacyclic triterpenes) has yielded semisynthetic derivatives with increased antiproliferative potential as opposed to unmodified starting compounds. In this work, we report the synthesis and biological assessment of benzotriazole esters of betulinic acid (BA), oleanolic acid (OA), and ursolic acid (UA) (compounds 1-3). The esters were obtained in moderate yields (28-42%). All three compounds showed dose-dependent reductions in cell viability against A375 melanoma cells and no cytotoxic effects against healthy human keratinocytes. The morphology analysis of treated cells showed characteristic apoptotic changes consisting of nuclear shrinkage, condensation, fragmentation, and cellular membrane disruption. rtPCR analysis reinforced the proapoptotic evidence, showing a reduction in anti-apoptotic Bcl-2 expression and upregulation of the pro-apoptotic Bax. High-resolution respirometry studies showed that all three compounds were able to significantly inhibit mitochondrial function. Molecular docking showed that compounds 1-3 showed an increase in binding affinity against Bcl-2 as opposed to BA, OA, and UA and similar binding patterns compared to known Bcl-2 inhibitors.

Additional factors to corelate with a more than 30% NIHSS score improvement in patients 7 days after fibrinolytic and/or endovascular treatment for ischemic stroke.

BACKGROUND: Our objective was to find which additional factors can influence the favorable result in stroke patients after receiving fibrinolytic and/or endovascular treatment, quantified as a more than 30% improvement of the NIHSS score at 7 days. METHODS: This is a retrospective study to find factors that could influence a favorable evolution of patients with stroke that underwent fibrinolytic and or thrombectomy using the NIHSS score changes. At the admission in the hospital, blood glucose, blood count, coagulation time, INR, aPTT, PT, platelet count, NIHSS questionnaire and ASPECTS score were collected. NIHSS was assessed at the admission, after 1 h, after 2 h, after 24 h and after 7 days. RESULTS: As compared to the initial evaluation, at 7 days after admission 59% (72) of patients have improved with more than 30% the NIHSS. Higher levels of systolic blood pressure, glycemia and lower ASPECTS score at admission were observed in non-achievers. The value of INR contributed to model: for every unit increase of INR, the chance of better outcome decreases by 90,1%. High glycemia has also a negative impact: for every unit increase, the chance of better outcome decreases by 24%. Higher initial ASPECTS score is associated with better outcomes: each point increase of ASPECTS score at initial evaluation, increases the chance of better outcome by 154.2%. CONCLUSION: Males, older age, diabetes, and hyperglycemia correlate with a worse outcome after cerebral stroke regardless of the benefit yielded fibrinolytic and/or thrombectomy therapy. In this study, patients with the above-mentioned factors did not improve more than 30% of baseline NIHSS score from admission to the 7th day.

Nasal polyposis from cystic fibrosis in children - the experience of a single center.

BACKGROUND: Cystic fibrosis (CF) is the most common monogenic disease, characterized by clinically notable polymorphism. Respiratory disease is the main factor that influences the disease outcome and prognosis of the patient with CF, bacterial infections being responsible for severe exacerbations and rhinosinusitis a difficult complication, besides lung disease. AIM: The aim of the paper was to present a case series of CF-associated nasal polyposis and our management experience, providing new data for nasal and sinus complications. PATIENTS, MATERIALS AND METHODS: Patients attending the National Cystic Fibrosis Center, Timisoara, Romania, were evaluated for nasal polyposis. Besides clinical examination, endoscopy, and computed tomography (CT) was performed for comprehensive evaluation. Patients with persistent symptoms or with complicated sinusitis underwent surgical approach. RESULTS: Fourteen (18.18%) children were diagnosed with nasal polyposis and had surgery, with positive outcomes. One patient received Omalizumab for an associated, uncontrolled asthma with a subsequent substantial effect with the significant polyp reduction and lack of recurrence. CONCLUSIONS: Even if extremely difficult to manage, complicated nasal polyposis CF related might have an improved outcome and better life quality.

UVA/UVB Irradiation Exerts a Distinct Phototoxic Effect on Human Keratinocytes Compared to Human Malignant Melanoma Cells.

Solar ultraviolet radiation (UVR) is responsible for the development of many skin diseases, including malignant melanoma (MM). This study assessed the phototoxic effects of UVA, and UVB radiations on healthy and pathologic skin cells by evaluating the behavior of human keratinocytes (HaCaT) and MM cells (A375) at 24 h post-irradiation. The main results showed that UVA 10 J/cm2 exerted no cytotoxicity on HaCaT and A375 cells, while UVB 0.5 J/cm2 significantly reduced cell viability and confluence, induced cell shrinkage and rounding, generated nuclear and F-actin condensation, and induced apoptosis by modulating the expressions of Bax and Bcl-2. The association of UVA 10 J/cm2 with UVB 0.5 J/cm2 (UVA/UVB) induced the highest cytotoxicity in both cell lines (viability < 40%). However, the morphological changes were different-HaCaT cells showed signs of necrosis, while in A375 nuclear polarization and expulsion from the cells were observed, features that indicate enucleation. By unraveling the impact of different UVR treatments on the behavior of normal and cancer skin cells and describing enucleation as a novel process involved in the cytotoxicity of UVA/UVB irradiation, these findings bridge the gap between the current and the future status of research in the field.

HPV and Other Risk Factors Involved in Pharyngeal Neoplasm-Clinical and Morphopathological Correlations in the Southwestern Region of Romania.

Oropharyngeal squamous cell carcinoma (OPSCC) development is strongly associated with risk factors like smoking, chronic alcohol consumption, and the living environment, but also chronic human papilloma virus (HPV) infection, which can trigger cascade cellular changes leading to a neoplastic transformation. The prevalence of these factors differs among different world regions, and the prevention, diagnosis, and prognosis of OPSCC are highly dependent on them. We performed a retrospective study on 406 patients diagnosed with OPSCC in our region that were classified according to the tumor type, localization and diagnosis stage, demographic characteristics, risk factors, and histological and immunohistochemical features. We found that most of the patients were men from urban areas with a smoking habit, while most of the women in our study were diagnosed with tonsillar OPSCC and had a history of chronic alcoholism. During the immunohistochemical study, we analyzed the tumor immunoreactivity against anti-p16 and anti-HPV antibodies as markers of HPV involvement in tumor progression, as well as the correlation with the percentage of intratumoral nuclei immunomarked with the anti-Ki 67 antibody in serial samples. We observed that the percentage of Ki67-positive nuclei increased proportionally with the presence of intratumoral HPV; thus, active HPV infection leads to an increase in the rate of tumor progression. Our results support the implementation of strategies for OPSCC prevention and early diagnosis and can be a starting point for future studies aiming at adapting surgical and oncological treatment according to the HPV stage for better therapeutic results.

Kaposi's sarcoma of the larynx: case series.

Kaposi's sarcoma (KS) represents a type of cancer that usually arises on the skin and very rarely in other organs. KS-associated herpesvirus (KSHV), also known as human herpesvirus-8 (HHV-8) commonly arises in patients with acquired immunodeficiency syndrome (AIDS). Laryngeal involvement of KS is very rare. Our study comprised of three cases with laryngeal KS. All cases were solved through surgical excision of the tumor. Histopathological and immunohistochemistry examinations revealed laryngeal KS. Laryngeal KS should be managed through surgical resection, followed by oncological treatment.

Benign tumors of the superficial lobe of the parotid gland.

Tumors of the parotid gland are a rare occurrence among head and neck tumors (only 3-8%), and the vast majority are benign. Most benign tumors of the parotid gland are pleomorphic adenoma (PA), followed by Warthin's tumor (WT) and they occur in the superficial lobe. The only reasonable treatment is considered to be total tumor removal, but the appropriate surgical approach remains a matter of controversy. Over time, it went from enucleation to superficial parotidectomy (SP) and then to extracapsular dissection (ECD). SP is often considered to be the "gold standard"; however, the risk of intraoperative damage to the facial nerve (FN) cannot be ignored. Lately, ECD - which does not expose the main trunk of the FN - has been regarded as a safe technique for the treatment of small benign parotid tumors. PATIENTS, MATERIALS AND METHODS: The study retrospectively reviewed all parotidectomies for benign parotid tumors of the superficial lobe performed in the Department of ENT, Municipal Emergency Clinical Hospital, Timisoara, Romania, between January 2014 and December 2018. The following patient data were collected: age; sex; follow-up duration; extension of the resection; use of FN monitoring and lesion features, including position, pathology, and size. Preoperative investigation protocol included a computed tomography (CT) scan to assess the size and location of the tumor helping the treatment planning. The same surgical team performed both standard SP and ECD for the treatment of these tumors. All cases were confirmed as benign parotid tumors. Recurrences of any kind and tumors involving the deep lobe of the gland were excluded from the study. All patients underwent a macroscopically complete resection of the tumor. The main outcome was the postoperative complications in the two groups. Data regarding these complications were recorded on follow-up visits at one, six, 12 and 24 months. RESULTS: Ninety-five patients with benign parotid tumors were operated by the same surgical team at the Department of ENT, Municipal Emergency Clinical Hospital, Timisoara, between January 2014 and December 2018 but only 89 (38 men and 51 women) met the follow-up criteria and were included in the study. Sixteen (18%) patients underwent ECD, and 73 (82%) patients underwent SP as a primary intervention. The mean lesion size for ECD group was 2.0±0.9 cm and 4.2±1.7 cm in the SP group, and it was statistically significant (p<0.05). As expected, the most common type of tumor was PA but the distribution between the groups was different: in the SP group, PA represents 83% (61∕73) of cases but only 44% (7∕16) of cases in the ECD group. Median follow-up time was comparable in the two groups - 33±8 months for the ECD group and 39±11 months for the SP group. There were also differences between the two groups regarding the postoperative complication rate. There were significantly more transient and permanent FN paralysis, transient and permanent great auricular nerve (GAN) dysfunctions and Frey's syndrome (FS) in the SP group. CONCLUSIONS: A comparison between ECD and SP as surgical procedures for the treatment of benign tumors of the parotid seems inappropriate as their indications do not overlap. ECD showed similar effectiveness and fewer side effects than SP and can be considered the treatment of choice for small, superficial and/or marginal tumors located in the lateral lobe of the parotid gland.

Allergic rhinitis associated with nasal polyps and rhinosinusitis - histopathological and immunohistochemical study.

Currently, allergic rhinitis (AR) is the most common allergic disease worldwide. AR is defined as immunoglobulin E (IgE)-mediated chronic inflammatory disease of the upper airways. It characterizes by symptoms like nasal obstruction, rhinorrhea, nasal itching, and sneezing. The immune system and genetic susceptibility in the interaction with the environment lead to the development of AR. Many cytokines, chemokines and cells maintain allergic inflammation. Studies show that 10% to 30% of the adult population are affected, and that prevalence rates are increasing world widely. AR, nasal polyps (NP), as well as chronic rhinosinusitis (CRS) are all associated with eosinophilic infiltration and large quantities of mast cells (MCs) within the mucosa. The diagnosis and management of chronic sinonasal diseases involves the analysis of eosinophilic infiltration, MCs, and their markers eosinophilic cationic protein (ECP) and tryptase. Regarding nasal cancer, nasal allergies were found to exhibit a dual function: immune surveillance may help in the defense against malignant cells, but an opposite effect is observed in tissues with chronic stimulation and inflammation. In the present paper, we studied a group of 70 patients diagnosed with AR and NP, rhinosinusitis or nasal cancer, admitted to the Ear, Nose & Throat (ENT) Clinic of the Emergency City Hospital, Timisoara, Romania, between January 2016 and December 2020, and we identified 37 (53%) patients diagnosed with AR and NP, 25 (36%) patients diagnosed with AR and rhinosinusitis, and eight (11%) patients diagnosed with AR and nasal cancer. The average age of the patients was 53 years old. Every patient included in the study was histopathologically and immunohistochemically diagnosed.

Cystic hygroma of the neck - case report.

Cystic hygromas (CHs) are benign congenital malformations of the lymphatic system mainly diagnosed in small children aged less than two years old. They may give a multitude of local, sometimes severe complications. The most used method of treatment is surgical removal. In this paper, we present the case of a CH of a 13-year-old boy, localized in the right lateral region of the neck, diagnosed through magnetic resonance imaging (MRI), with excellent results of the surgical treatment.

Clinical, ultrasound and histopathological correlation of clinically N0 neck nodes in patients with cancers of the pharynx and larynx.

BACKGROUND: The presence of metastatic cervical adenopathy is essential for treatment planning and prognosis assessment. Treatment of patients with head and neck cancer with clinically negative cervical lymphadenopathy (N0) remains controversial. Neck palpation, as the method used in tumor, node, metastasis (TNM) staging, has limitations and can provide false negative results in some cases. Lymph node metastases are associated with a reduced survival rate but at the same time, neck dissection for the patient with N0 neck is not without risks or complications. OBJECTIVES: In prospective study, we compared palpation, ultrasonography (US) examination of the neck and histopathological examination in patients with cancers of the pharynx and larynx. PATIENTS, MATERIALS AND METHODS: Forty-six patients with cancers of the pharynx and larynx that presented with a N0 neck were prospectively analyzed. They were divided in two groups: 23 patients operated with an external approach including the control of the lymph node areas, and a second group of 23 patients operated using endoscopy and carbon dioxide (CO2) laser, no neck dissection - "watchful waiting policy". All patients have had a flexible endoscopy of the pharynx and larynx, US of the neck and all received surgical treatment for their primary tumor. Imaging was performed in selected cases. All the removed lymph nodes were sent for histopathology. US was also used as a follow-up method. The US features of the examined lymph nodes were: diameters [longitudinal (L) and transverse (T)]; the ratio of the two diameters (L∕T); shape; lymph node area; central hypodensity; regular∕irregular margins; aspect (homogeneous or not). RESULTS: US has detected 25 lymph nodes in the open surgery group and intraoperatively, we excised 31 (sensitivity of 80.6%). Ten lymph nodes showed metastases, with 100% accuracy of US, which have been confirmed both pathologically and immunohistochemically. US in the second group - patients treated with CO2 laser - detected at four patients 10 cervical lymph nodes that did not presented any malignant features. At recurrence alone, the US confirmed 100% presence of nodes metastases. CONCLUSIONS: US was superior to palpation and this method can be recommended as a diagnostic tool in preoperative assessment of patients without palpable metastasis (N0).

Clinical features in toxic coma in children.

The purpose was to identify rapidly the etiology of toxic coma in children, to appreciate the severity of the coma, to detect elements of gravity based on associated clinical signs and symptoms and to evaluate the initial treatment. Toxic coma is a medical emergency, especially in a Pediatric Emergency Department, requiring rapid and precise evaluation. The key objectives in the evaluation and management of coma in children are: detecting severity characteristics, depth of coma, specific clinical signs and symptoms, etiological and differential diagnostic and also initializing supportive therapy and specific treatment. This is a retrospective study, where we analyzed all patients diagnosed with coma admitted to the 'Grigore Alexandrescu' Clinical Emergency Hospital for Children over a nine-year period from 2003 to 2011. We focused on toxic coma. A prospective component related to tracking certain signs and symptoms associated with toxic coma to diagnose and initiate appropriate therapy as early as possible was also included. In this nine-year study, 750 comatose patients were included. We found that toxicants represent the main cause of coma in children. There were 445 patients diagnosed with toxic coma, representing 59.3% and 305 cases of non-toxic coma, 40.7% of all coma cases presented in ER. The etiology of toxic coma in children is dominated by alcohol and abuse substances, followed by neurologic medication. Clinical manifestations were more frequent and more severe as the coma degree increases. Associating clinical manifestations in patients with altered neurologic status of toxic cause and toxicants has an important role in practice, because it helps us recognize the frequency of association of coma complications such as: aspiration syndrome, arrhythmias and seizures.

Caruncular late-onset junctional nevus: apropos of an anatomo-clinical observation.

Conjunctival nevi are benign tumors, most often located at the nasal or temporal limbus, and rarely in the fornix or tarsus. The vast majority of caruncular tumors are benign and only few are malignant. Most of the caruncular tumors (either benign or malignant) are nevi. We report a case of a 75-year-old female patient presenting caruncular atypical late-onset junctional nevus that clinically arose malignancy suspicion. Ophthalmologic macroscopic examination and slit lamp examination of the right eye were performed. Further blood tests were performed. Carunclectomy was performed two days after admission to hospital. Microscopy revealed the junctional localization, diffuse proliferation of the nevocytes. Immunoreactions with S100 and human melanoma black 45 (HMB45) antibodies were performed. Differential diagnosis of these lesions represents a great challenge. The greatest challenge represents the differential diagnosis between a benign tumor and a malignant life-threatening one, the malignant melanoma, especially with unusual presentation. The presence of a late-onset caruncular tumor with uncertain evolution requires excision biopsy to determine the diagnosis and to establish the best management.

The involvement of upper airway in Wegener's granulomatosis - about four cases.

The authors present four cases of Wegener's granulomatosis patients with multiorganic manifestation forms, but with a prevalent involvement in upper-airway. Granulomatosis diseases of the nose include bacterial infections (rhinoscleroma, tuberculosis, syphilis, lupus, and leprosy), fungal infections (rhinosporidiosis, aspergillosis, mucormycosis, candidosis, histoplasmosis, and blastomycosis) and diseases with unspecified etiology (Wegener's granulomatosis, mediofacial malignant granuloma, and sarcoidosis). We consider an interesting experience regarding Wegener's granulomatosis due to its rarity, being an autoimmune systemic disease, with continuous evolution and multiorganic involvement. The beginning of the disease is like upper airway affection, a kind of "persistent cold", being difficult to differentiate it from a common cold in the head, with a prolonged evolution. It is important to mention that we establish the diagnosis of Wegener's granulomatosis starting with Ear Nose and Throat (ENT) clinical exam, followed by other tests and investigations realized in our Clinic and completed with specialty tests (nephrology, internal medicine and dermatology), meaning that we need a close cooperation with these medical specialties. All the patients presented multiorganic involvement. Notably significant for our four cases is the prolonged evolution in a stable condition in one patient.

Juvenile nasopharyngeal angiofibroma: Timisoara ENT Department's experience.

UNLABELLED: Juvenile nasopharyngeal angiofibroma is a histologically benign, but very aggressive and destructive tumor found exclusively in young males. The management of juvenile nasopharyngeal angiofibroma has changed in recent years, but it still continues to be a challenge for the multidisciplinary head and neck surgical team. OBJECTIVE: The purpose of this study was to review a series of 30 patients describing the treatment approach used and studying the outcome of juvenile nasopharyngeal angiofibroma in the ENT Department Timisoara, Romania for a period of 30 years. METHODS: The patients were diagnosed and treated during the years 1981-2011. All patients were male. Tumors were classified using Radkowski's staging system. Computed tomography and magnetic resonance imaging allowed for accurate diagnosis and staging of the tumors. Biopsies were not performed. Surgery represented the gold standard for treatment of juvenine nasopharyngeal angiofibroma. All patients had the tumor removed by an external approach, endoscopic surgical approach not being employed in this series of patients. RESULTS: All patients were treated surgically. Surgical techniques performed were: Denker-Rouge technique in 13 cases (43.33%), paralateronasal technique in 7 cases (23.33%), retropalatine technique in 5 cases (16.66%) and transpalatine technique in 5 cases (16.66%). No preoperative tumor embolization was performed. The recurrence rate was 16.66%. The follow-up period ranged from 1 year to 12 years. CONCLUSIONS: Management of juvenile nasopharyngeal angiofibroma remains a surgical challenge. Clinical evaluation and surgical experience are very important in selecting the proper approach. A multidisciplinary team, with an experienced surgeon and good collaboration with the anesthesiologist are needed for successful surgical treatment.