Postoperative Audiometric Results of Patients with Otosclerosis in relation with High-resolution Computed Tomography and Intraoperative Macroscopic Findings.

OBJECTIVE: To analyse postoperative audiological findings in fenestral otosclerosis patients treated with stapedotomy, focal location-extensiveness findings on temporal high-resolution computed tomography (HRCT), and intraoperative macroscopic stapes footplate findings. Moreover, preoperative audiological findings were compared with HRCT and intraoperative macroscopic findings. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Otorhinolaryngology, University of Health Sciences, Ankara Numune Training and Research Hospital, Turkey from January 2015 to January 2018. METHODOLOGY: Patients were classified according to the temporal bone HRCT findings into three groups based on otosclerotic focus location and extensiveness. Macroscopic classification was based on the intraoperative findings of blue and white footplate. Patients with obliterative otosclerosis were not included in the study. Preoperative and postoperative audiological findings as well as surgical success were investigated. Findings were compared with HRCT and macroscopic classification groups. RESULTS: Postoperative air bone gap (ABG) increased as HRCT class increased from 0 to 3, meaning a more extensive otosclerotic focus (p=0.002). The comparison of the audiological outcomes, in accordance with the intraoperative findings, revealed that the postoperative air conduction pure-tone averages (AC PTA), ABG and ABG difference were higher in the white footplate group, with statistically significant differences compared to blue footplate group (p = 0.039, p = 0.001 and p=0.029, respectively). CONCLUSION: Postoperative audiological findings were found to be correlated with intraoperative and HRCT findings. A white footplate seen at surgery or a more extensive otosclerotic focus on temporal HRCT indicates a suboptimal audiological outcome. HRCT findings should be taken into account when planning the surgery. Key Words: Otosclerosis, Temporal bone HRCT, Footplate color, Stapedotomy, Audiometry.

Does inferior turbinate outfracture provide additional benefit when combined with inferior turbinate radiofrequency ablation?

PURPOSE: To evaluate, both subjectively and objectively, whether turbinate outfracture provides any additional benefit in the treatment of inferior turbinate hypertrophy when combined with radiofrequency ablation. METHODS: The study was conducted on 58 patients diagnosed with inferior turbinate hypertrophy. The patients were randomly divided into two groups according to the treatment they receive. Group A consisted of patients undergoing radiofrequency ablation and Group B included patients undergoing turbinate outfracture in combination with radiofrequency ablation. For the purposes of objective evaluation, all patients underwent acoustic rhinometry and anterior rhinomanometry preoperatively and at 6 months postoperatively. In addition, for subjective evaluation, the patients completed the Nasal Obstruction Symptom Evaluation (NOSE) questionnaire. Postoperative changes in objective and subjective parameters in both groups versus the preoperative period and their differences were compared statistically. RESULTS: In Group A, mean postoperative minimal cross-sectional area (MCA) and nasal volume (NV) values and NOSE scores were significantly greater compared to those obtained in the preoperative period. Similarly, Group B showed significantly greater mean postoperative MCA, NV and NOSE score values compared to the preoperative period. In Group A and B, mean postoperative total nasal resistance (TNR) value was significantly lower in comparison to the preoperative period. The differences in mean preoperative and postoperative MCA, NV, TNR and NOSE scores were significantly greater in Group B versus Group A. CONCLUSION: The addition of turbinate outfracture to inferior turbinate radiofrequency ablation treatment provides both objective and subjective benefits in the resolution of nasal obstruction.

[A rare cause of headache: Rhinolit]. / Bas agrisinda nadir bir neden: Rinolit.

The rhinolith is massed in a mineral nugget in the nasal cavity, which is the result of the accumulation of salts around the nidus. The nidus may be endogenous or exogenous. Long-term and unilateral nasal obstruction, nasal discharge, pain and malodor are major complaints. However, sometimes, they may not show any signs for years and maybe detected incidentally during a routine examination. In this study, we present a case of giant rhinolith with headache and nasal obstruction complaints.

The Voice Performance After Septoplasty With Surgical Efficacy Demonstrated Through Acoustic Rhinometry and Rhinomanometry.

OBJECTIVE: To demonstrate the surgical efficacy of septoplasty using acoustic rhinometry (AR) and anterior rhinomanometry (ARM) and to evaluate the effect of septoplasty on voice performance through subjective voice analysis methods. MATERIALS AND METHODS: This prospective study enrolled a total of 62 patients who underwent septoplasty with the diagnosis of deviated nasal septum. Thirteen patients with no postoperative improvement versus preoperative period as shown by AR and/or ARM tests and three patients with postoperative complications and four patients who were lost to follow-up were excluded. As a result, a total of 42 patients were included in the study. Objective tests including AR, ARM, acoustic voice analysis and spectrographic analysis were performed before the surgery and at 1 month and 3 months after the surgery. Subjective measures included the Nasal Obstruction Symptom Evaluation questionnaire to evaluate surgical success and Voice Handicap Index-30 tool for assessment of voice performance postoperatively, both completed by all study patients. RESULTS: Among acoustic voice analysis parameters, F0, jitter, Harmonics-to-Noise Ratio values as well as formant frequency (F1-F2-F3-F4) values did not show significant differences postoperatively in comparison to the preoperative period (P > 0.05). Only the shimmer value was statistically significantly reduced at 1 month (P < 0.05) and 3 months postoperatively (P < 0.05) versus baseline. Statistically significant reductions in Voice Handicap Index-30 scores were observed at postoperative 1 month (P < 0.001) and 3 months (P < 0.001) compared to the preoperative period and between postoperative 1 month and 3 months (P < 0.05). CONCLUSION: In this study, first operative success of septoplasty was demonstrated through objective tests and then objective voice analyses were performed to better evaluate the overall effect of septoplasty on voice performance. Shimmer value was found to be improved in the early and late postoperative periods.

Is Adenotonsillar Size a Significant Factor on Voice in Children Undergoing Adenotonsillectomy?

OBJECTIVE: To determine whether adenotonsillar size is a significant determinant of voice in children who have undergone adenotonsillectomy. STUDY DESIGN: Prospective cohort study. PLACE AND DURATION OF STUDY: Ear Nose Throat Clinic, Ankara Numune Training and Research Hospital, Ankara, Turkey, from July 2017 to June 2018. METHODOLOGY: A total of 57 patients, who have been diagnosed with chronic adenotonsillitis and operated for obstruction or infection, were included in the study. Patients were divided into two groups according to their palatine tonsil sizes. Each patient performed voice analysis preoperatively and one month postoperatively, recruiting both objective and subjective methods. F0, jitter % and shimmer % values were assessed with objective methods; while subjective methods evaluated pediatric voice handicap index (pVHI) scores. Pre- and post-operative F0, jitter % and shimmer % values and pVHI scores from each study group were compared. RESULTS: In each study group, pre- and post-operative F0, jitter % and shimmer % values were found to be similar. In Group A, postoperative pVHI scores were found to be significantly reduced (p<0.001). In Group B, however, pre- and postoperatively assessed pVHI scores were similar. CONCLUSION: Adenotonsillar hypertrophy in children, who underwent adenotonsillectomy, seems to be an important and positively effecting factor on the subjective, but not the objective, parameters of voice.

Relation of otosclerosis and osteoporosis: A bone mineral density study.

OBJECTIVE: Otosclerosis and osteoporosis are metabolic bone diseases. In this paper, we investigated presence of osteoporosis with bone mineral density test in patients who had surgery for otosclerosis. METHODS: We included 27 patients who had conductive hearing loss and diagnosed with otosclerosis during an exploratory tympanotomy, and 30 healthy controls into this study. Bone mineral densitometry test was used for analysis of osteoporosis. T-scores of the patients and the controls obtained from L1-L4 vertebrae and femur neck were compared. In addition, the relations of duration of the disease, air and bone conduction thresholds, and air-bone gap in the operated ear with 25(OH)D3 levels, T-scores obtained from L1-L4 vertebrae and femur neck were investigated in the otosclerosis group. RESULTS: T-score obtained from L1-L4 region was -1.14±1.05 in the otosclerosis group, and was -0.56±1.10 in the control group; the difference was statistically significant (p=0.045). The T-scores obtained from the femur neck were -0.59±0.82 and 0.03±0.74 in the otosclerosis and the control groups respectively, with a statistically significant difference in between (p=0.004). As the air and bone conduction thresholds and the air-bone gaps of the patients with otosclerosis increased, 25(OH)D3 levels and T-scores decreased, but the differences were not statistically significant. CONCLUSION: The relation between otosclerosis and osteoporosis was shown with bone mineral density test in our study. T-scores of the otosclerosis patients were found smaller than the normal population.

New Predictive Parameters of Bell's Palsy: Neutrophil to Lymphocyte Ratio and Platelet to Lymphocyte Ratio.

BACKGROUND: Bell's palsy is the most frequent cause of unilateral facial paralysis. Inflammation is thought to play an important role in the pathogenesis of Bell's palsy. AIMS: Neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR) are simple and inexpensive tests which are indicative of inflammation and can be calculated by all physicians. The aim of this study was to reveal correlations of Bell's palsy and degree of paralysis with NLR and PLR. STUDY DESIGN: Case-control study. METHODS: The retrospective study was performed January 2010 and December 2013. Ninety-nine patients diagnosed as Bell's palsy were included in the Bell's palsy group and ninety-nine healthy individuals with the same demographic characteristics as the Bell's palsy group were included in the control group. As a result of analyses, NLR and PLR were calculated. RESULTS: The mean NLR was 4.37 in the Bell's palsy group and 1.89 in the control group with a statistically significant difference (p<0.001). The mean PLR was 137.5 in the Bell's palsy group and 113.75 in the control group with a statistically significant difference (p=0.008). No statistically significant relation was detected between the degree of facial paralysis and NLR and PLR. CONCLUSION: The NLR and the PLR were significantly higher in patients with Bell's palsy. This is the first study to reveal a relation between Bell's palsy and PLR. NLR and PLR can be used as auxiliary parameters in the diagnosis of Bell's palsy.

[New predictive parameters of nasal polyposis: neutrophil to lymphocyte ratio and platelet to lymphocyte ratio]. / Nazal polipte yeni öngörücü parametreler: Nötrofil lenfosit orani ve trombosit lenfosit orani.

OBJECTIVES: This study aims to investigate the correlations between nasal polyposis (NP) and NP density with neutrophil to lymphocyte ratio (NLR) and platelet to lymphocyte ratio (PLR). PATIENTS AND METHODS: The study included 105 patients (72 males, 33 females; mean age 41.33±12.85 years; range 16 to 63 years) diagnosed as NP (NP group) and 83 healthy individuals (54 males, 29 females; mean age 44.01±8.50 years; range 18 to 62 years) (control group). Nasal polyposis density score was calculated with preoperative Lund-Mackay computed tomography grading system. Neutrophil to lymphocyte and PLR ratio values of NP and control groups were calculated and statistically compared. Neutrophil to lymphocyte and PLR values were statistically compared in terms of NP density in the NP group. RESULTS: Mean NLR value was 2.26 in the NP group and 1.75 in the control group with a statistically significant difference (p=0.001). Mean PLR value was 120.79 in the NP group and 109.84 in the control group with a statistically insignificant difference (p=0.073). CONCLUSION: Neutrophil to lymphocyte ratio value may be used as a novel marker that is easily administered in patients with nasal polyps and obtained with low-cost tests. New studies with larger patient series are needed for the value of PLR.

Evaluation of autoinflammatory disease genes in nasal polyposis.

BACKGROUND/AIM: To investigate cold-induced autoinflammatory syndrome 1 (CIAS 1) gene polymorphisms that cause autoinflammatory diseases in patients with nasal polyposis (NP). MATERIALS AND METHODS: The study included 30 patients diagnosed with NP and 30 healthy age-matched individuals as a control group. CIAS1 polymorphisms were assessed by DNA sequence analysis. Patients with nasal polyps and the control group were compared in terms of gene polymorphisms. Each of the 8 polymorphisms of the CIAS1 gene was analyzed separately in the patient group. RESULTS: The most frequently observed polymorphisms in the patient group were c.732G > A in 83%, c.663C > T in 23%, and c.1308C > A in 23% of the patients. c.732G > A polymorphism was evaluated separately. Guanine was transformed to adenine at the 732nd nucleotide position of the CIAS1 gene in the cDNA of chromosome 1. CONCLUSION: The CIAS1 gene c.732G > A polymorphism was thought to be responsible for an increase in disease susceptibility. The frequency of the "A" allele is higher in the patient group compared to the control group. Autoinflammatory diseases seem like a candidate to be one of these factors. This is the first report to define the role of autoinflammatory diseases among these factors.

The effect of obstructive sleep apnea syndrome and continuous positive airway pressure treatment on voice performance.

OBJECTIVE: Obstructive sleep apnea syndrome (OSAS) may affect voice performance due to alterations that occur in the upper respiratory tract. The aim of the study was to assess the effect of OSAS and continuous positive airway pressure (CPAP) treatment on voice performance. MATERIALS AND METHODS: Twenty-seven patients with moderate to severe OSAS (apnea-hypopnea index ≥15/h) who underwent polysomnographic examination and 28 age- and gender-matched normal control subjects were enrolled in the study. The patients and the control subjects completed Voice Handicap Index (VHI) questionnaires, and their acoustic voice analyses were performed. Fundamental frequency (F0), jitter %, and shimmer % parameters were statistically compared. Acoustic analyses were performed again 1 month after regular CPAP use in OSAS patients, and the parameters before and after the treatment were compared. RESULTS: F0 was 160.82 Hz, jitter was 0.70%, shimmer was 1.05%, and VHI was 1.18 in the control group. In OSAS patients before CPAP treatment, F0 was 157.04 Hz, jitter was 0.82%, shimmer was 1.33%, and VHI was 13.11. These results showed that shimmer and VHI parameters were significantly worse in OSAS patients. After CPAP treatment, F0 was 169.19 Hz, jitter was 0.62%, shimmer was 0.93% and VHI was 5.00. The differences were statistically significant in all parameters. CONCLUSION: The acoustic parameters of OSAS patients differed from those of the normal control subjects. The patients' voice performance improved after a regular use of CPAP treatment for 1 month.

Prognostic effect of hyperbaric oxygen therapy starting time for sudden sensorineural hearing loss.

Sudden sensorineural hearing loss is one of the otological emergencies whose pathogenesis is uncertain and associated with total or partial loss of hearing function. The aim of this study was to investigate whether the hyperbaric oxygen therapy starting time affects the management of sudden sensorineural hearing loss. Fifty-nine patients with sudden sensorineural hearing loss admitted to our clinic between 2008 and 2012 were retrospectively included in this study. All patients received hyperbaric oxygen therapy. In addition, each patient received intravenous piracetam and 37 patients received steroid therapy. Hyperbaric oxygen therapy was initiated between 1 and 7 days with 20 patients determined as Group A, between 8 and 14 days with 25 patients determined as Group B and between 15 and 28 days with 14 patients determined as Group C. Hearing gains of these three groups were statistically evaluated. Each of them showed statistically significant improvement. Lowest hearing gain was observed in Group C and the gain of this group was statistically less than the other two groups. There was no significant difference between the hearing gains of the Group A and Group B. Starting hyperbaric oxygen therapy in patients with sudden sensorineural hearing loss within the first 14 days has positive effect on the prognosis of the disease.

Investigation of SCGB3A1 (UGRP2) gene arrays in patients with nasal polyposis.

The aim of the current study is to investigate the potential relationship between polymorphisms and nasal polyposis (NP) pathogenesis in the SCGB3A1 (UGRP2) gene, which is a member of the secretoglobin gene super family. Genotypic variations were studied by performing DNA sequencing in blood samples of 80 patients with NP and 70 healthy individuals to evaluate nucleotide changes and their positions that might be in the SCGB3A1 gene (promotor, splicing points, and exon distributions). In the SCGB3A1 gene, three single-nucleotide changes labeled IVS1-89 T>G, c. -183 G>T, IVS1-189 G>A were identified. IVS1-89 T>G and IVS1-189 G>A belong to the first intronic region of the gene, whereas c. -183 G>T was observed in the promoter region of the gene. The IVS1-89 T>G nucleotide change was observed in the patient and control groups, whereas c. -183 G>T and IVS1-189 G>A nucleotide changes were observed in the control group only. SCGB3A1 (IVS1-89) genotype frequencies between patients with NP and control group were not significantly different (p = 0.311). There was a statistically significant difference in the control group in comparison to patients with NP in terms of SCGB3A1 (c. -183 GT) and SCGB3A1 (IVS1-189 GA) frequency (p = 0.0045 and p = 0.009, respectively). The findings of the current study suggest that SCGB3A1-183 T and SCGB3A1 IVS1-189 A alleles might have a protective effect against NP, and that SCGB3A1 (-183 GT and IVS1-189 GA) genotypes should be studied in future population-based studies.

Intranasal angiofibrolipoma.

Angiofibrolipoma is a rarely seen histopathological variant of lipoma. It is seldom in the head and neck region. Clinically, it shows macroscopic similarity with lipoma. In this article, we report a 65-year-old male case who presented with left-sided nasal obstruction. After complete removal of the tumor, histopathological diagnosis was reported as angiofibrolipoma. To the best of our knowledge, this is the first case report of an angiofibrolipoma of the nose in the literature.

[Cervical lymphadenopathy: progressive transformation of germinal centers]. / Boyunda lenfadenopati: Germinal merkezlerin progresif transformasyonu.

Enlarged lymph node in the head and neck region is a common reason for referral to ear nose throat specialists. In the differential diagnosis of chronic lymphadenopathies, infection, lymphoproliferative disorders and progressive transformation of germinal centers should be considered. In this article, we report two cases of progressive transformation of germinal centers in the neck.

Impact of corrective rhinologic surgery on rhinogenic headache.

OBJECTIVE: In this study, the localization of the headache, mucosal contact points, sinonasal anatomic variations and the incidence of mucosal abnormalities were determined in patients with rhinogenic headache, and the efficacy of the corrective surgery on the severity of the headache and the rate of improvement on that localization were investigated. STUDY DESIGN: Conducted in a prospective manner. LEVEL OF EVIDENCE: Level 2b. METHODS: Sixty-five patients who were admitted with sinonasal symptoms and headache and had septoplasty, endoscopic sinus surgery, or surgical procedures involving the nasal turbinates were included in this study. The quality and the severity of the headache were investigated preoperatively as well as in the 3rd and 12th postoperative months. RESULTS: Headache was most frequently localized the frontal region. The mucosal contact points were most frequently localized between the nasal septum and the middle or inferior turbinates. Differences between preoperative headache and headache in postoperative 3rd month and postoperative 12th month were statistically significant (P < 0.05). Improvement in headache after surgery was statistically significant in cases with Haller cell and paradoxical middle turbinate and in patients with contact points between the nasal septum and the middle or inferior turbinates (P < 0.05). CONCLUSIONS: We have shown the importance of surgery in the treatment of rhinogenic headache. We have also shown the reliability of the decongestion test for determining the indication for surgery. We suggest that the rhinologic surgery may have a great contribution to the treatment of headache.

[Inconsistency of the Epworth sleepiness scale results with the polysomnography findings in patients with sleep-disordered breathing]. / Uykuda solunum bozuklugu olan hastalarda Epworth uykululuk skalasi sonuçlarinin polisomnografi bulgulari ile uyumsuzlugu.

OBJECTIVES: This study aims to investigate the consistency of Epworth sleepiness scale (ESS) results and polysomnography (PSG) findings in the patients with sleep-disordered breathing (SDB). PATIENTS AND METHODS: A total of 109 patients (68 males, 41 females; mean age 48.6 years; range 20 to 77 years) who were admitted with the complaints of apnea, witnessed apnea and daytime sleepiness were included. The correlation among age, body mass index (BMI), and ESS and PSG findings were assessed. RESULTS: There was a positive and statistically significant correlation between the age and apnea-hypopnea index (AHI) (p<0.01). We observed that AHI figures increased with increasing age. There was also a positive and statistically significant correlation between the BMI and AHI (p<0.05). We found that AHI increased in parallel with BMI increase. There was, no statistically significant correlation among the AHI results based on the ESS assessment, the percentage of sleep under 90% of saturation, and the Arousal index (AI). CONCLUSION: The responses to the questions in the ESS may vary from individual to individual, depending on the socio-cultural and economic status. We believe, therefore, that a new Turkey-based questionnaire considering the lifestyle of our population would offer more useful information about sleep disordered breathing.

Investigation of the cochlear effects of intratympanic steroids administered following acoustic trauma.

OBJECTIVES/HYPOTHESIS: To electrophysiologically and histomorphologically demonstrate the effects of intratympanic corticosteroids administered following an acoustic trauma on cochlear hair cells. METHODS: The trial was performed on 16 Wistar albino rats. The rats underwent distortion product otoacoustic emissions (DPOAE) measurement before the acoustic trauma, and subsequently rats were exposed to noise. Following acoustic trauma, the otoacoustic emission measurement was repeated. The rats were divided into two groups, a study group and a control group. The study rats were injected with methylprednisolone via the intratympanic route throughout the study. In the control group, the rats were injected daily with saline. After performing repeated otoacoustic emission measurements, one rat in each of the groups was sacrificed and their cochleae isolated. RESULTS: The histological investigation performed after the 1st week revealed a statistically significantly higher rate of apoptotic cells in the inner and particularly the outer hair cells of the rat cochleae in the control group compared to the study group. Early measurement of DPOAE within the 1st week demonstrated significantly better amplitudes in the study group compared to controls. The otoacoustic emission assessment performed on the 14th day demonstrated statistically similar DPOAE values between the two groups. CONCLUSIONS: Intratympanic methylprednisolone injection administered following an acoustic trauma appears to reduce cochlear outer hair cell loss. The impact on hearing loss is less certain. Early measurement of DPOAE within the 1st week shows significantly better amplitudes in the study group compared to controls. However at 2 weeks, there is no statistically significant difference in DPOAE amplitudes between the study and control group.

Analysis of lower airway inflammation in a rabbit model of acute rhinosinusitis.

This study aimed to investigate the association of inflammatory changes of upper and lower airways in a rabbit model of acute rhinosinusitis. The study included six adult albino rabbits. The sinuses of one animal were injected with saline solution and the animal was served as sham control. Other animals were implanted with intranasal S. aureus soaked-absorbable gelatin sponge. Acute rhinosinusitis was induced and subjects were sacrificed at the end of the second week. Tissue samples from all levels of the airway were obtained. They were evaluated for the presence of inflammatory changes histologically. A scoring system for airway inflammation was used for quantitative assessment of the degree of inflammation. Structural changes in the epithelial and stromal layers of the upper and lower airway structures were analyzed, as well. The animal of which the sinuses were injected with saline solution developed neither acute rhinosinusitis nor lower airway inflammation. In contrast, the animals in which acute rhinosinusitis was induced demonstrated significant upper and lower airway inflammation histologically. Inflammatory changes ranged from engorgement of blood vessels and polymorphonuclear cell proliferation within the capillaries, in the perivascular tissue of the epithelium or in the lamina propria and to epithelial disruption. Nasal airway inflammation scores (2.86 ± 1.81) were significantly higher than lower airway scores (1.36 ± 0.77), (P < 0.01). We obtained a generalized mucosal inflammatory response against localized bacterial inflammation in a rabbit model of acute rhinosinusitis, confirming the suggestion of 'one airway--one disease' from a bacterial infection point of view.

[Revision surgery for chronic otitis media: evaluation of indications and results]. / Kronik otitis media düzeltme ameliyatlari: Endikasyon ve sonuçlarinin degerlendirilmesi.

OBJECTIVES: In patients who underwent primary and revision surgery for chronic otitis media, the types of revision surgery, most frequently observed regions of cholesteatoma, hearing results and the status of graft membrane were evaluated. PATIENTS AND METHODS: Forty-three of 495 patients (21 males, 22 females; mean age 38.4+/-15.2 years; range 15 to 76 years) with chronic otitis media who underwent revision surgery in our clinic between May 2003 and March 2009 were evaluated retrospectively. Indications for revision surgery were recurrence of the disease in 32 patients (74.4%) and reconstruction of hearing in 11 patients (25.6%). Forty patients (93.0%) underwent revision surgery once and three patients (7.0%) underwent revision twice. Over an average of 3.2 (range 1 to 6) years follow-up after primary and revision surgery, the types of revision surgery, the most frequently observed regions of cholesteatoma, hearing results and the status of graft membrane were assessed. RESULTS: Recurrence of cholesteatoma in revision surgery was seen in 28 patients (65.1%). Out of 27 patients, 23 patients (85.1%) showed intact graft membranes and four patients (14.8%) showed perforated graft membranes. CONCLUSION: In revision surgery, the first goal is to eliminate the disease. The management of chronic otitis media with cholesteatoma is surgery. Because of high postoperative recurrence rates, long-term follow-up is necessary.