Tonsil-derived mesenchymal stem cells exert immunosuppressive effects on T cells.

AIM: To assess the immunomodulatory effect of tonsil-derived mesenchymal stem cells (MSCs) on T-lymphocyte proliferation and cytokine production. METHODS: Tonsils were obtained from children aged 3 to 12 years (n=15) who underwent tonsillectomy for obstructive sleep apnea from April 2012-October 2014 at the Merkur University Hospital, Zagreb. Tonsil-derived MSCs were co-cultured with peripheral blood mononuclear cells (PBMCs) and phytohemagglutinin as a mitogen. PBMCs were induced to differentiate into T helper 1 or T helper 2 cells in the presence or absence of tonsil-derived MSCs, after which the production of interferon-gamma in T helper 1 and interleukin-4 in T helper 2 cells was assessed. RESULTS: Tonsil-derived MSC suppressed phytohemagglutinin-induced proliferation of PBMCs. Compared with controls, tonsil-derived MSC co-culture significantly decreased interferon-gamma production (P<0.001) and increased interleukin-4 production (P<0.001). CONCLUSION: Tonsil-derived MSCs exert immunomodulatory effects on T lymphocyte proliferation and T helper 1- and T helper 2-specific cytokine production.

Complications of endoscopic CO2 laser surgery for laryngeal cancer and concepts of their management.

Endoscopic CO2 laser surgery (ELS) is a widely accepted treatment modality for early laryngeal cancer. Commonly reported advantages of ELS are good oncologic results with low incidence of complications. Although less common if compared with open procedures, complications following ELS can be very serious, even with lethal outcome. They can range from intraoperative endotracheal tube fire accidents to early and late postoperative sequels that require intensive medical treatment, blood transfusion, or revision surgery. We present our institutional experience, discuss the possible complications of ELS for laryngeal cancer, and outline the concepts of their treatment, with comprehensive literature review. Complications are more frequent following the treatment of supraglottic as compared to glottic cancer. If compared with open surgery, ELS for laryngeal cancer is associated with a lower incidence of complications. Every surgeon performing ELS should comply with particular strategies to avoid complications in the first place, and have a clear concept of their management if they occur.

[Parathyroid hormone values in thyroid gland surgeries by harmonic scalpel and by conventional methods]. / Usporedba vrijednosti paratiroidnog hormona pri operacijama stitne zlijezde ultrazvucnim rezacem i konvencionalnim metodama.

We have examined if there are any differences in intraoperative and early postoperative concentrations of parathyroid hormone between the first group of patients, who had thyroidectomy surgery performed by harmonic scalpel, and the second group of patients operated on by standard techniqes with the use of electrocoagulation and ligature as primary hemostatic procedures. All the patients having total thyroidectomy had their blood taken in four measurement points; immediately after the induction anesthesia, 10 minutes after the first thyroid gland lobe removal, 10 minutes after total thyroid gland removal and 24 hours after the surgery. The blood samples were used to determine concentrations of the parathyroid hormone by an immunoradiometric test. The concentration comparison of parathyroid hormone between the first and the second group has not shown statistically significant difference for any of the four measurement points. The concentration comparison of parathyroid hormone within the same groups in relation to preoperational values (the first measurement point) has shown that in both groups the parathyroid hormone concentration, in all three post-incision measurement points, has been significantly lower in relation to the concentration measured before the surgery (p < 0.0005).

Cardiac metastases and a sudden death as a complication of advanced stage of head and neck squamous cell carcinoma.

In head and neck squamous cell carcinoma distant metastases are rare and metastases to the heart are extremely rare. In this report we present a patient with a sublingual and laryngeal carcinoma with metastases to lung and heart. Cardiac metastases present with non-specific symptoms that depends on the size and location of the metastases. The ideal tools for diagnosing cardiac metastases are echocardiography and cardiac MRI. CT scan could be used as a screening method of distant metastases in head and neck cancer. The treatment of cardiac metastases is generally ineffective.

Thyroid metastasis from breast carcinoma resembling medullary thyroid carcinoma.

We are reporting a case of a 42-yr-old female with a history of right breast carcinoma. She was surgically treated (breast quadrantectomy with axillary dissection) and receiving a third cycle of adjuvant chemotherapy when a feeling of a constant pressure in the front of the neck and lack of air occurred. Subsequent work-up revealed a node in the right thyroid lobe with enlarged paratracheal bilateral and right mid and lower jugular lymph nodes. Fine-needle aspiration cytology, repeated within a 20 days window and analyzed by two different cytologists, showed a medullary thyroid carcinoma with a cervical lymph nodes metastasis so the patient underwent total thyroidectomy with selective and paratracheal neck dissection. Histology and immunohistochemistry revealed the specimen to be metastasis of breast carcinoma. During regular follow-up of our patient, eighteen months after initial diagnosis, no new metastases were found. To our best knowledge, this is the first described case of a thyroid metastasis of breast carcinoma that was cytologically misdiagnosed as a medullary thyroid carcinoma.

Synchronous multicentric bilateral sinonasal inverted papilloma and frontal sinus osteoma.

Inverted papilloma is generally considered a benign unilateral sinonasal tumor. Its synchronous bilateral multicentric occurrence is extremely rare. A 22-year-old male patient presented with stage III inverted papilloma involving both ethmoid sinuses, both frontal sinuses, and cribriform area. The patient also had a large osteoma emanating from the basal part of the frontal sinus septum, which completely obstructed both nasofrontal recesses, leaving no communication between the sinuses and the nasal cavity. The frontal sinus septum was intact, so there was no communication between the 2 sides either. Following the era of aggressive surgical approaches dominated by lateral rhinotomy and medial maxillectomy, the advent of endoscopic techniques has dramatically improved visualization of sinus chambers and nasal cavity, resulting in lower morbidity and similar results to those achieved with open surgical procedures. In our patient, the concomitant presence of a huge frontal sinus osteoma posed an unacceptable risk for endoscopic resection due to the possible residual disease in the nasofrontal recess regions. Surgical resection remains the mainstay treatment and should be tailored in accordance with the localization and spread of disease. The surgeon should be ready to use different surgical approaches and, if intraoperatively needed, to modify them accordingly.

Volumetric facelift: evaluation of rhytidectomy with alloplastic augmentation.

OBJECTIVES: Facial aging occurs as a result of soft tissue atrophy and resorption of the bony skeleton, which results in a loss of soft tissue volume and laxity of the overlying skin. Volumetric augmentation is a key component of facial rejuvenation surgery, and should be considered of equal importance to soft tissue lifting. Augmentation can be accomplished with synthetic fillers, autologous grafts, soft tissue repositioning techniques, and/or alloplastic implants. Only alloplastic implants, however, provide truly long-term volumetric correction. To date, there have been no large series dealing with the complications and results of implantation performed concurrently with rhytidectomy, which we have termed "volumetric rhytidectomy." We present our experience with 100 patients treated with a combination of malar and chin implants and rhytidectomy, compared to 200 patients who underwent rhytidectomy alone. METHODS: The authors performed a retrospective review of patients treated with a combination of silicone malar and chin augmentation with rhytidectomy versus patients treated with rhytidectomy alone. Both groups of patients underwent close postoperative evaluation at 3 days, 1 week, 2 weeks, and 1 month. All patients were surveyed at 6 months to assess aesthetic satisfaction. Complication rates were noted and tabulated. Statistical analysis was performed to evaluate for any differences in the two groups. RESULTS: Between 2002 and 2006, 100 patients underwent malar and chin implantation along with rhytidectomy; 200 patients underwent rhytidectomy alone. In the first group, there were a total of 6 cases in which implant removal was necessary, and 2 cases in which revision was required. There were no statistically significant differences (p < 0.05) observed between the two groups with respect to major or minor hematoma, seroma, infection, sensory nerve injury, facial nerve injury, hypertrophic scarring, dehiscence, skin sloughing, or revision. CONCLUSIONS: Volumetric rhytidectomy reliably augments the malar and mental areas, allows for subtle skeletal contouring, and results in successful rejuvenation. Rhytidectomy is relatively safe to perform concurrently with silicone augmentation, and does not result in an increased complication rate as compared to rhytidectomy alone.

Large intracranial intradural mucocele as a complication of frontal sinus osteoma.

Paranasal sinus osteomas are mostly asymptomatic; however, secondary mucocele can develop if they impede the natural sinus drainage. Such a mucocele can destroy the bone and extend into the adjacent structures. We report on an unusual case of frontal sinus osteoma in a 27-year-old patient, complicated by large secondary mucocele that eroded the bone and extended into the frontal lobe of the brain. Unexpectedly, the patient did not report any visual or other symptoms attributable to central nervous system deficit. The mucocele was completely resected through bifrontobasal osteoplastic craniotomy, whereas osteoma was evacuated in its entirety by both drilling and mobilizing. Open surgical approach remains the main treatment for complicated paranasal sinus osteoma, and radical removal of intracranial mucocele is mandatory to prevent the development of life-threatening infections. Although intradural extension of a secondary mucocele is extremely unusual, head and neck surgery specialists should take this severe complication in consideration.

[Acute lingual tonsillitis]. / Akutna upala jezicne tonzile.

Acute lingual tonsillitis is a rarely diagnosed cause of sore throat. The patient with acute lingual tonsillitis typically has severe sore throat, dysphagia and pain at the level of hyoid bone, and it is interesting that patients with previous palatine tonsillectomy can present with almost normal oral examination findings. The diagnosis of potentially fatal epiglottitis should be excluded. Because the base of the tongue can not be visualized by intraoral examination, diagnosis must be made by indirect or transnasal fiberoptic laryngoscopy.

A prospective observational study of 363 cases operated with three different harmonic scalpels.

The objective of this study is to evaluate the efficacy of the Harmonic ACE, Harmonic FOCUS and harmonic scalpel with 5-mm curved blade in head and neck surgery. During a 15-month period, we performed 295 thyroidectomies, 23 parotidectomies and 45 tonsillectomies using the harmonic scalpel. Control group consisted of 106 thyroidectomies, 9 parotidectomies and 30 tonsillectomies performed with the use of conventional hemostatic techniques. The use of both Harmonic ACE and Harmonic FOCUS scalpel reduced the time of thyroid and parotid surgery by 20-25%. The use of Harmonic ACE reduced the mean time of tonsillectomy, while the use of 5-mm curved blade had no significant effect. Postoperative pain and complication rate were comparable for both the groups. In conclusion, the use of both Harmonic ACE and Harmonic FOCUS devices significantly reduces operative time in the head and neck procedures and enables a smaller neck skin incision in thyroidectomy.

Endoscopic CO2 laser surgery for supraglottic cancer--ten years of experience.

We present our experience with primary CO2 laser surgery for planocellular supraglottic carcinoma. During a ten-year period, we performed 64 curative supraglottic laryngectomies. Twenty-nine patients presented with T1 and 35 with T2 carcinoma. There were 46 patients without regional and/or distant metastases (N0 neck), and 18 patients with N+ neck. Thirty-three (52%) patients were treated with surgery alone, and in 31 (48%) patients surgical procedure was combined with radiotherapy. Estimated overall 5-year survival for all patients was 89%. Local and regional tumor control as well as survival rate were comparable with the results of other therapeutic options, i.e. radiotherapy or open supraglottic laryngectomy. Functional results outline the advantages of endoscopic laser surgery for laryngeal carcinoma. Transoral endoscopic CO2 laser surgery is efficacious treatment for T1 and T2 supraglottic carcinoma, and can be combined with neck dissection and postoperative irradiation.

Mold-shaped, nanofiber scaffold-based cartilage engineering using human mesenchymal stem cells and bioreactor.

BACKGROUND: Mesenchymal stem cell (MSC)-based tissue engineering is a promising future alternative to autologous cartilage grafting. This study evaluates the potential of using MSCs, seeded into electrospun, biodegradable polymeric nanofibrous scaffolds, to engineer cartilage with defined dimensions and shape, similar to grafts used for subcutaneous implantation in plastic and reconstructive surgery. MATERIALS AND METHODS: Human bone marrow derived MSCs seeded onto nanofibrous scaffolds and placed in custom-designed molds were cultured for up to 42 days in bioreactors. Chondrogenesis was induced with either transforming growth factor-beta1 (TGF-beta1) alone or in combination with insulin-like growth factor-I (IGF-I). RESULTS: Constructs exhibited hyaline cartilage histology with desired thickness and shape as well as favorable tissue integrity and shape retention, suggesting the presence of elastic tissue. Time-dependent increase in cartilage matrix gene expression was seen in both types of culture: at Day 42, TGF-beta1/IGF-I treated cultures showed higher collagen Type 2 and aggrecan expression. Both culture conditions showed significant time-dependent increase in sulfated glycosaminoglycan and hydroxyproline contents. TGF-beta1/IGF-I-treated samples were significantly stiffer; with equilibrium compressive Young's modulus values reaching 17 kPa by Day 42. CONCLUSIONS: The successful ex vivo development of geometrically defined cartilaginous construct using customized molding suggests the potential of cell-based cartilage tissue for reconstructive surgery.

In vitro adipose tissue engineering using an electrospun nanofibrous scaffold.

Electrospun 3-dimensional nanofibrous scaffolds share morphologic similarities to collagen fibrils, and promote favorable biologic responses of seeded cells. In this study, we have fabricated a 3-dimensional nanofibrous scaffold made of poly L-lactic acid, and examined its ability to support and maintain the adipogenic differentiation of human bone marrow-derived mesenchymal stem cells in vitro. After a 21-day incubation, oil red O staining of constructs treated with adipogenic supplements revealed positive adipose-like staining, compared with lack of staining in untreated cultures. Semi-quantitative RT-PCR analysis of human bone marrow-derived mesenchymal stem cells cultured in adipogenic medium revealed highly elevated levels of adipogenesis-associated genes (1797-fold for lipoprotein lipase, and 5.6-fold for peroxisome proliferator-activated receptor gamma). Immunofluorescence staining of cellular constructs in adipogenic culture media showed the presence of lipoprotein lipase vesicles, a characteristic feature of adipose tissue. These results suggest that the poly L-lactic acid-based nanofibrous scaffold is a promising candidate for adult stem cell-based engineering of adipose tissue.

[The use of harmonic scalpel in head and neck surgery: a report on 161 patients]. / Ultrazvucni rezac u kirurgiji glave i vrata: nase iskustvo sa 161 bolesnikom.

The harmonic scalpel cuts and coagulates simultaneously using a mechanical vibration. The present article reports our experience in the use of this instrument. Over a period of 5 months, we performed 123 thyroidectomies, 13 parotidectomies and 25 tonsillectomies using the harmonic scalpel. 106 thyroidectomies, 9 parotidectomies and 30 tonsillectomies were performed with the use of conventional hemostatic techniques (electrocautery and knot tying). The use of harmonic scalpel shortened the duration of thyroid and parotid surgery by 20-30% as compared with the conventional techniques. The average incision length for those undergoing thyroidectomy with the harmonic scalpel was 1.5 cm shorter compared with the conventional thyroidectomy group. The use of harmonic scalpel shortened the average duration of tonsillectomy by 5.5 minutes. Postoperative pain and complication rate were comparable for both groups. The use of the harmonic scalpel reduces surgical time and intraoperative blood loss, and enables shorter incision length in thyroid surgery.

Does suture material and technique really matter? Lessons learned from 800 consecutive blepharoplasties.

OBJECTIVES: The purpose of this study was to evaluate established suture materials and techniques for blepharoplasty closure and evaluate for any differences in rates of complications between these groups. STUDY DESIGN AND METHODS: This was a prospective study of a large sequential series of patients undergoing upper blepharoplasty who were treated by the same senior author over a 5-year period. Patients were assigned one of four techniques for closure of the incision based on the senior author's experience. After 6 weeks, rates of complications and revisions were noted and addressed. Satisfaction rates were noted at 3 months. RESULTS: In the group whose incisions were closed with running subcuticular polypropylene (Prolene), 5 (2.5%) presented with milia, and 11 (5.5%) had a standing cone deformity (SCD). Use of running cutaneous locked Prolene resulted in 8 patients (17%) with milia and 2 patients (4.4%) requiring revision of a SCD. Use of a running 6-0 plain gut suture resulted in 12 patients (6.7%) with milia and 5 patients (2.8%) with unsightly scarring. In the group whose incisions were closed with running 6-0 fast-absorbing gut, 10 patients (2%) presented with milia, and there were no scar revisions. There were statistically significant differences between the groups with respect to formation of milia, scarring, and persistent erythema (P < .008). CONCLUSIONS: Blepharoplasty is a safe and effective procedure that can be performed successfully with several established techniques. In our experience, closure with two interrupted 6-0 Prolene sutures and a running 6-0 fast-absorbing gut resulted in the lowest rates of complications and revisions.

Tele-3-dimensional computer-assisted functional endoscopic sinus surgery: new dimension in the surgery of the nose and paranasal sinuses.

One of the main objectives of our 3-dimensional (3D) computer-assisted functional endoscopic sinus surgery was to design a computer-assisted 3D approach to the presurgical planning, intraoperative guidance, and postoperative analysis of the anatomic regions of the nose and paranasal sinuses. Such an extremely powerful approach should allow better insight into the operating field, thereby significantly increasing the safety of the procedure. The last step to implementing the technology in the operating room was to connect the computer workstations and video equipment to remote locations by using a high-speed, wide-bandwidth computer network. During patient preparation, the surgeon in the operating room consulted remote experienced and skillful surgeons by viewing CT images and 3D models on computer workstations. The surgeon and consultants used software for CT image previews and 3D model manipulations on top of collaboration tools to define the pathosis, produce an optimal path to the pathosis, and decide how to perform the real surgical procedure. With tele-flythrough or tele-virtual endoscopy rendered through the use of 3D models, both surgeons can preview all the characteristics of the region (ie, anatomy, pathosis) and so predict and determine the next steps of the operation. This ensures greater safety thanks to the operation guidance and reduces the possibility of intraoperative error. The duration of the teleconsultation is thus shortened, which may prove the greatest benefit of tele-3D computer-assisted surgery. If this method were used, clinical institutions would spend less money for telesurgical consultation.

Dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body for diagnostic and surgical purposes. [Case report of orbital injury with ethmoid bone involvement].

The main goal of our dynamic 3D computer-assisted reconstruction of a metallic retrobulbar foreign body following orbital injury with ethmoid bone involvement was to use 3D-information obtained from standard computed tomography (CT) data to explore and evaluate the nasal cavity, ethmoidal sinuses, retrobulbar region, and the foreign body itself by simulated dynamic computed visualization of the human head. A foreign body, 10 x 30 mm in size, partially protruded into the posterior ethmoidal cells and partially into the orbit, causing dislocation and compression of the medial rectus muscle and inferior rectus muscle. The other muscles and the optic nerve were intact. Various steps were taken to further the ultimate diagnosis and surgery. Thin CT sections of the nasal cavity, orbit and paranasal sinuses were made on a conventional CT device at a regional medical center, CT scans were transmitted via a computer network to different locations, and special views very similar to those seen on standard endoscopy were created. Special software for 3D modeling, specially designed and modified for 3D C-FESS purposes, was used, as well as a 3D-digitizer connected to the computer and multimedia navigation through the computer during 3D C-FESS. Our approach achieves the visualization of very delicate anatomical structures within the orbit in unconventional (non-standard) sections and angles of viewing, which cannot be obtained by standard endoscopy or 2D CT scanning. Finally, virtual endoscopy (VE) or a 'computed journey' through the anatomical spaces of the paranasal sinuses and orbit substantially improves the 3D C-FESS procedure by simulating the surgical procedure prior to real surgery.

Transoral removal of a large parapharyngeal space neurofibroma with the Harmonic Scalpel.

We report the case of a 19-year-old man with neurofibromatosis type 1 who presented for evaluation of odynophagia, left-sided hemiparesis, multiple café au lait spots all over his body, and numerous subcutaneous and cutaneous neurofibromas. Imaging revealed the presence of two large neurofibromas-a 60 × 50 × 35-mm tumor in the left parapharyngeal space and an intradural tumor measuring 25 mm in diameter. We removed the larger tumor via a transoral route with the Harmonic Scalpel. The size of this tumor far exceeded the size of any other reported tumor removed in this manner. Various approaches to the parapharyngeal space have been described in the literature. To the best of our knowledge, this case represents the first report of a transoral removal of a huge parapharyngeal space neurofibroma with a Harmonic Scalpel.

Composite platysmofascial flap in reconstruction following partial vertical laryngeal resections.

OBJECTIVES: The superficial layer of deep cervical fascia represents a valuable material for the reconstruction of defects secondary to partial vertical laryngeal resections. However, there are drawbacks to the use of this flap, which include possible weakness and subsequent instability of the laryngeal wall. METHODS: To overcome this problem, we included platysma along with the superficial layer of deep cervical fascia to form a composite soft tissue flap that will meet all reconstructive needs following partial vertical laryngeal resection. RESULTS: Inclusion of platysma yields more durable and adequately vascularized flap resistant to saliva, seroma formation, and infection. Because of segmental blood supply of strap muscles and their indirect perforating vessels, medially based horizontal composite flap is better supplied with blood in comparison with cranially based vertical flap. Medial insertion of the horizontal flap is much more convenient than lateral, due to ancillary blood supply from the contralateral side and easier pursuance of ipsilateral neck dissection. CONCLUSIONS: The method of our choice for laryngeal reconstruction after partial vertical laryngeal resections is paramedially based horizontal platysmofascial composite flap with the insertion opposite to the side of the primary laryngeal tumor.