Gains in Quality of Life in Chronic Otitis Media Patients After Surgery, Adjusted for Placebo Bias.

OBJECTIVE: Using a short-form specific questionnaire, we sought to quantify specific and generic benefits of surgery for chronic otitis media (COM) while adjusting for expectancy (placebo) bias. STUDY DESIGN: A prospective observational pretreatment/posttreatment study. SETTING: A national tertiary referral center. PATIENTS: Consecutive adult COM patients were enrolled for 1 year. Of 246 patients, 205 were recommended for surgery, and 167 were operated on the (more) affected ear. INTERVENTIONS: All patients filled out two questionnaires, one specific (Chronic Otitis Media Questionaire-12) and one generic (Short Form-36) at baseline, and then again 6 and 12 months after surgery. MAIN OUTCOME MEASURES: Factor-based scores of questionnaires, standardized response means (SRMs) for treatment effects, with multiple linear regression for implementing bias adjustment. RESULTS: All but one (generic Short Form-36 "mental" scale) of the seven considered measures gave very highly significant ( p < 0.001) improvements. Unadjusted SRMs were large (1.0-2.0 standard deviation units) for audiometry, symptoms of ear discharge, reported hearing, and aggregate specific quality of life, but only moderate for the less specific activity/healthcare. The proposed bias adjustment reduced SRM magnitudes for most measures by about a third, for activity/healthcare and ear discharge by only a tenth to a fifth, and for audiometry not at all. CONCLUSION: Most scores of the specific questionnaire displayed definite placebo-like biases; this demands caution in interpreting improvement after COM surgery. With bias adjustments, credible and worthwhile magnitudes of improvements remained for Chronic Otitis Media Questionnaire-12 total and subscores (0.5-1.09 standard deviation SRM), but not for generic quality of life.

Non-coding RNA and cholesteatoma.

OBJECTIVE: Cholesteatoma is a challenging chronic pathology of the middle ear for which pharmacologic therapies have not been developed yet. Cholesteatoma occurrence depends on the interplay between genetic and environmental factors while master regulators orchestrating disease progression are still unknown. Therefore, in this review, we will discuss the diagnostic and therapeutic potential of non-coding RNAs (ncRNA) as a new class of regulatory molecules. METHODS: We have comprehensively reviewed all articles investigating ncRNAs, specifically micro RNAs (miRNAs) and long ncRNAs (lncRNA/circRNA) in cholesteatoma tissue. RESULTS: Candidate miRNA approaches indicated that miR-21 and let-7a are the major miRNAs involved in cholesteatoma growth, migration, proliferation, bone destruction, and apoptosis. Regulatory potential for the same biological processes was also observed for miR-203a. The NF-kB/miR-802/PTEN regulatory network was in relation to observed miR-21 activity in cholesteatoma as well. High throughput approaches revealed additional ncRNAs implicated in cholesteatoma pathology. Competitive endogenous RNA (ceRNA) analysis highlighted lncRNA/circRNA that could be "endogenous sponge" for miR-21 and let-7a based on the hypothesis that RNA transcripts can communicate with and regulate each other by using shared miRNA response elements. CONCLUSION: In this review, we summarize the discoveries and role of ncRNA in major pathways in cholesteatoma and highlight the potential of miRNA-based therapeutics in the treatment of cholesteatoma.Level of Evidence: NA.

Malignant Otitis Externa: Causes for Various Treatment Responses.

OBJECTIVES: Malignant (necrotizing) otitis externa (MOE) is an aggressive form of skin inflammation of the external ear with a tendency to spread infection to the temporal bone. The study aimed to evaluate a causal relationship between treatment responses and clinical features in patients with MOE. MATERIALS AND METHODS: In a retrospective, descriptive section study, the database was analyzed between January 2008 and December 2018 in our department, all patients with diagnosed MOE were identified. RESULTS: A total of 30 patients were evaluated, of which 27 men and 3 women. The youngest patient was 52 years old while he was eldest 88 years, (mean-71 years old). As the most common comorbidity, diabetes mellitus was found in 23 (76%) subjects. Median duration of symptoms was about 3 months. The most common isolated pathogen was Pseudomonas aeruginosa (47%). Patients with facial nerve palsy and erosion of temporal bone find on computerized tomography affect prolonged stationary treatment (Mean, SD 29.2±8.5 and 26,7±11.6 days), while 80% of patients with facial nerve palsy had recurrence of disease (p=0.005) with mean duration of clinical remission of 60±17.3 days. Overall length of treatment is also increased in the presence of comorbidities as well as in patients with cranial nerve involvement. CONCLUSION: Patients with cranial nerve involvement, erosion of temporal bone and presence of comorbidities affect prolonged treatment and adverse prognosis. Early diagnosis and initiation of aggressive therapy are essential for stopping the further spread of the disease and prevention of serious complications.

Perimatrix of middle ear cholesteatoma: A granulation tissue with a specific transcriptomic signature.

OBJECTIVES/HYPOTHESIS: To establish comprehensive transcriptomic profiles of cholesteatoma perimatrix tissue and granulation tissue from chronic otitis media (COM) that did not develop cholesteatoma, which can indicate molecular pathways involved in the cholesteatoma perimatrix pathology and invasiveness. STUDY DESIGN: Retrospective Case Series. METHODS: Transcriptome data were obtained from cholesteatoma perimatrix tissue and COM granulation tissue by an Illumina iScan microarray. Differentially expressed genes (DEGs) were subsequently analyzed using both bioinformatical functional annotation and network analysis. Expression of candidate genes (MMP9 and LCN2) was validated by quantitative reverse transcription-polymerase chain reaction (qRT-PCR) on a larger group of samples. RESULTS: Analysis of the transcriptome led to the identification of 169 differentially expressed genes between investigated tissues. Bioinformatic analysis suggested that most significant biological processes involving DEGs were previously described in cholesteatoma pathology. Network analysis identified ERBB2, TFAP2A, and TP63 as major hubs of the DEGs molecular network. Furthermore, it was observed that the cellular component most significantly enriched in DEGs was extracellular space containing 47 DEGs. Using qRT-PCR, it was confirmed that mRNA levels of the major extracellular hub (MMP9) are increased, whereas its interacting molecule (LCN2) mRNA levels were decreased in cholesteatoma perimatrix tissue compared to COM granulation tissue. CONCLUSIONS: The current study approach offers an overall look at molecular mechanisms that describe the cholesteatoma entity by focusing exclusively on the perimatrix processes in comparison to COM granulation tissue. The observed differences in gene expression between cholesteatoma perimatrix and COM granulation tissue could suggest novel markers potentially influenced by the perimatrix-matrix molecular interplay, which is not present in COM without cholesteatoma. LEVEL OF EVIDENCE: NA Laryngoscope, 130:E220-E227, 2020.

The Allele 2 of the VNTR Polymorphism in the Gene That Encodes a Natural Inhibitor of IL-1ß, IL-1RA Is Favorably Associated With Chronic Otitis Media.

OBJECTIVES: Chronic otitis media (COM) is followed by irreversible tissue damage and destruction of the middle ear structures, with the possibility of complications under the maintenance of inflammation. Inflammatory mediators such as cytokines play a crucial role in the initial stage of inflammation. The aim of this study was to evaluate the association of the polymorphisms in two innate immunity/inflammation cascade genes from interleukin-1 (IL-1) gene cluster with COM with regard to cholesteatoma. METHODS: In the cross-sectional case-control study, DNA samples were collected from 189 patients with COM and 119 controls from a population of Serbia. The +3953 C/T (rs1143634), TaqI polymorphism in interleukin-1 beta (IL-1ß) gene and 86 bp variable number tandem repeat (VNTR, rs2234663) polymorphism in the IL-1 receptor antagonist (IL-1RA) gene were analyzed by polymerase chain reaction. RESULTS: The IL-1ß TaqI polymorphism was not significantly different in patients compared with the control group. The significant difference between patients and controls was observed for both, genotype and allele frequencies of IL-1RA VNTR polymorphism (chi-square P<0.01). We found that carriers of IL-1RA allele 2 (odds ratio, 0.47; 95% confidence interval, 0.29 to 0.76; P=0.004) have a favorable association with COM, using multivariate logistic analysis that included both polymorphisms, age and sex. The IL-1RA allele frequency distribution was significantly different with regard to cholesteatoma. CONCLUSION: The carriers of allele 2 of VNTR IL-1RA polymorphism had a decreased odds ratio for COM, which is in agreement with findings in other inflammatory disease and its previous association with higher IL-1RA levels. Possible down-regulation of IL-1 mediated proinflammatory signaling pathways via IL-1RA in COM as well as results of our study should be further investigated and replicated.

Biofilm formation on tympanostomy tubes depends on methicillin-resistant Staphylococcus aureus genetic lineage.

Bacterial biofilm formation has been implicated in the high incidence of persistent otorrhoea after tympanostomy tube insertion. The aim of the study was to investigate whether biofilm formation on tympanostomy tubes depends on the genetic profile of methicillin-resistant Staphylococcus aureus (MRSA) strains. Capacity of biofilm formation on fluoroplastic tympanostomy tubes (TTs) was tested on 30 MRSA strains. Identification and methicillin resistance were confirmed by PCR for nuc and mecA genes. Strains were genotypically characterised (SCCmec, agr and spa typing). Biofilm formation was tested in microtiter plate and on TTs. Tested MRSA strains were classified into SCCmec type I (36.7 %), III (23.3 %), IV (26.7 %) and V (13.3 %), agr type I (50 %), II (36.7 %) and III (13.3 %), and 5 clonal complexes (CCs). All tested MRSA strains showed ability to form biofilm on microtiter plate. Capacity of biofilm formation on TTs was as following: 13.3 % of strains belonged to the category of no biofilm producers, 50 % to the category of weak biofilm producers and 36.7 % to moderate biofilm producers. There was a statistically significant difference between CC, SCCmec and agr types and the category of biofilm production on TTs tubes (p < 0.001): CC5, SCCmecI type and agrII type with a moderate amount of biofilm, and CC8 and agrI type with a low amount of biofilm. Biofilm formation by MRSA on TTs is highly dependent on genetic characteristics of the strains. Therefore, MRSA genotyping may aid the determination of the possibility of biofilm-related post-tympanostomy tube otorrhea.

Long term complications of ventilation tube insertion in children with otitis media with effusion.

BACKGROUND/AIM: Otitis media with effusion (OME) is characterized by the prolonged presence of fluid (longer than 12 weeks) of different viscosity in the middle ear, without perforation of the eardrum or signs of acute inflammation. The conservative treatment does not always provide satisfactory recovery, so surgical treatment may be unavoidable. The aim of the study was to determine the incidence, type and frequency of complications caused by ventilation tube insertion as a part of treatment for OME in children, and specifically, to evaluate the evolution of these changes over the extended period of time. METHODS: During a 5-year period (1986-1991), 84 children with chronic bilateral OME, aged from 6 months to 12 years, were enrolled in the study and treated with ventilation tube insertion. All the patients were periodically checked every 6 months over a 3-8 year period following the intervention (otomicroscopic examination, audiometry, tympanometry), and reexamined in 2013 (22-27 years after the primary surgical intervention). RESULTS: The complications observed in this study (51%) were atrophic scarring of the tympanic membrane, myringo- and tympanosclerosis, retraction of the eardrum, persistent perforations, granulation tissue formations, development of chronic otitis and sensorineural hearing loss. CONCLUSION: The incidence of complications after ventilation tube insertion was 51% in this study. Atrophic scars and myringosclerosis were the most prominent complications. Despite high complications rate ventilation tube insertion still remains the treatment of choice in children with otitis media with effusion.

Polymorphisms in Toll-like receptors 2 and 4 genes and their expression in chronic suppurative otitis media.

OBJECTIVE: Toll-like receptors (TLRs) have a prominent role in inducing innate immune response. It has been suggested that regulation of TLRs is involved in the pathogenesis of chronic otitis media. TLR 2 and TLR 4 polymorphisms were connected with susceptibility to acute otitis and chronic otitis with effusion. The objective of this study was to establish expression of TLR 2 and 4 on middle ear mucosa in different types of chronic suppurative otitis media (CSOM), and the influence of gene polymorphisms TLR 2 Arg753Gln and TLR 4 Thr399Ile and Asp299Gly to susceptibility to CSOM. MATERIAL AND METHODS: Middle ear mucosa and full blood samples were obtained from 85 patients with chronic suppurative otitis media with and without cholesteatoma. Control group for mucosal TLR expression consisted of 71 samples of middle ear mucosa taken from patients with otosclerosis, and control group for DNA polymorphism consisted of 100 full blood samples in healthy subjects. DNA polymorphism detection was done with restriction fragment length polymorphism in RT PCR. Expression of TLR 2 and 4 was determined with immunohistochemical staining. RESULTS: TLR 2 and TLR 4 expression on the middle ear mucosa was not influenced by age of the patients with chronic otitis media. Incidence of TLR 2 Arg753Gln polymorphism was significantly higher in patients with chronic otitis media, compared to control group. Significant association between TLR 2 Arg753Gln polymorphism and different types of mucosal changes in patients with chronic otitis media was established. TLR 2 and 4 expression on experimental group mucosa was significantly different compared to control group, where there was no expression (p=0.000). Strong dependence of TLR 2 and TLR 4 expression on middle ear mucosa with different mucosal changes and immunohistochemical activity after staining was detected. CONCLUSION: Certain polymorphisms in TLR genes could be indicative for susceptibility to chronic otitis media. Expression of TLR 2 and 4 on middle ear mucosa was more dependable on different types of mucosal changes and type of CSOM than on bacteria found in the specimens. This can indicate that the type of mucosal changes are closely correlated with TLRs activity in middle ear.

Epithelial-myoepithelial carcinoma--review of clinicopathological and immunohistochemical features.

INTRODUCTION: Epithelial-myoepithelial carcinoma is a low-grade malignant salivary gland neoplasm with a biphasic cell population that encompasses around 1% of all salivary neoplasms. METHOD: We present different cases of epithelial-myoepithelial carcinoma, with special emphasis on histopathology, differential diagnosis, relevant prognostic factors and follow-up. RESULT: This study included 8 patients who were diagnosed with epithelial-myoepithelial carcinoma and treated surgically including a follow-up period of at least 19 months. CONCLUSION: Clinical and histopathological characteristics of these rare tumors are extremely valuable for accurate diagnosis and further therapy planning.

[Auricular Acantholytic Squamous Cell Carcinoma with Neck Metastasis and Lethal Outcome - Case Report].

INTRODUCTION: Acantholytic squamous cell (adenosquamous) carcinoma of the skin are relatively rare subtype of squamous cell carcinoma, usually found in elderly on sun-exposed areas of the skin, predominately head, neck and upper extremities. Incidence of metastasis is 2-14%. CASE OUTLINE: A case of a 76-year-old male, with the signs of left-sided facial palsy and cervical mass on the same side, is presented. Five months prior to the visit, due to acantholytic squamous cell carcinoma, an excision of the ulceration of the superior third of the left auricle was performed. Patient underwent surgical treatment, after pathohistological and radiological confirmation of the infiltrative neck metastasis. Postoperatively, rapid locoregional progression of the disease was noted in the patient, with a lethal outcome. CONCLUSION: Squamous cell carcinoma (including acantholytic subtype) with lesions bigger than 4 cm in size in auricular-temporal region, signs of deep tissue invasion, and lymphovascular and perineural invasion have higher local metastatic potential. More frequent oncological check-ups with radiological examination are necessary in detecting locoregional metastasis.

Expression of toll-like receptors 2, 4 and nuclear factor kappa B in mucosal lesions of human otitis: pattern and relationship in a clinical immunohistochemical study.

OBJECTIVES: The objectives were to detect and compare the expression of toll-like receptors (TLRs) 2, 4 and nuclear factor kappa B in mucosal lesions of chronic otitis. METHODS: Fifty-five tissue samples obtained from children and adults operated on for otitis were investigated by semiquantitative immunohistochemical methods using polyclonal antibodies for TLR 2, 4 and NFkappaB. Kruskal-Wallis, Mann-Whitney, and Kendall's tau rank correlation tests were used. RESULTS: Stronger expression of TLR2, 4 was found in inflamed mucosa than in the control for children and adults (TLR2: H = 23.86, P < .0011; TLR4: H = 22.80, P < .00 1) (TLR2: H = 17.53, P < .001; TLR4: H = 11.99, P < .001); in cholesteatoma perimatrix compared to tubotympanic lesions in children (TLR2: H = 11.06, P = .004; TLR4: H = 10.61, P = .005) and adults (TLR2: H = 10.73, P = .013; TLR4: H = 9.65, P = .021). No differences were found in NFkB expression (H = 0.042, P = .99). Significant correlations were found for all pairs of molecules in cholesteatoma and tubotympanic mucosa of adults (TLR2, 4: P = .002, P < .001; TLR2-NfkappaB: P = .032, P = .021; TLR4-NFkB: P = .035, P = .0013), only TLR4-NFkappaB in tubotympanic otitis of children (P = .026). CONCLUSIONS: Toll-like receptors 2,4 and NFkB mediate inflammation in cholesteatoma and mucosal lesions oftubotympanic otitis in children and adults. Significant correlations betweenall pairs of molecules in all samples were detected in adults, but only TLR4-NFkappaB in children.

Pars tensa retractions without cholesteatoma in children: predictors for ossicular chain destruction, air conduction thresholds, and postoperative retractions.

OBJECTIVE: Determine predictive values of preoperative stages of pars tensa retractions, coexisting attic retraction and preoperative air conduction for ossicular destruction in isolated and combined pars tensa retraction, and predictors for successful tympanic grafts after surgery. STUDY DESIGN: Prospective case series study. SETTINGS: Tertiary referral center. PATIENTS: Forty-eight children ears without cholesteatoma were included in the study: 23 with isolated pars tensa retraction (median age, 11), 25 with combined pars tensa and attic retractions (median age, 13). INTERVENTION(S): Otomicroscopy, pure tone audiometry, and impedancmetry were carried out preoperatively. Three surgical procedures for isolated retractions were used: ventilation tube insertion alone or together with fascia graft or cartilage graft. Two surgical procedures for combined retractions were used: ventilation tube insertion alone and with cartilage graft. MAIN OUTCOME MEASURES: Incidence of ossicular destruction, postoperative retraction of the grafts. RESULTS: Stage of pars tensa retraction and preoperative air conduction thresholds do not predict long incus process defect in isolated group. Coexistence of an attic retraction predicts combined, long incus process and stapes superstructure defect (Chi = 3.943, p = 0.047, OR = 12.00). Retractions of grafts are predicted by mode of surgery, favoring cartilage graft (isolated group: Chi = 4.306, p = 0.0372,OR = 4.69; combined group Chi = 4.7836, p = 0.0287, OR = 0.1364). Stage of pars tensa retraction predicts poor outcome of fascia graft (Chi = 4.5347, p = 0.0332, OR = 12.00). CONCLUSION: Absence of correlation between stage of pars tensa retraction and air conduction thresholds with ossicular defects justifies surgical exploration of the auditory ossicles, even in lower stages of retraction. Combined ossicular defect is expected in combined retractions. The usage of cartilage graft proved to be more appropriate.

Unintentional conversion of benign paroxysmal positional vertigo caused by repositioning procedures for canalithiasis: transitional BPPV.

BPPV when diagnosed before any repositioning procedure is called primary BPPV. Primary BPPV canalithiasis treatment with repositioning procedures sometimes results in unintentional conversion of BPPV form: transitional BPPV. Objectives were to find transitional BPPV forms, how they influence relative rate of canal involvement and how to be treated. This study is a retrospective case review performed at an ambulatory, tertiary referral center. Participants were 189 consecutive BPPV patients. Main outcome measures were detection of transitional BPPV, outcome of repositioning procedures for transitional canalithiasis BPPV and spontaneous recovery for transitional cupulolithiasis BPPV. Canal distribution of primary BPPV was: posterior canal (Pc): 85.7% (162/189), horizontal canal (Hc): 11.6% (22/189), anterior canal (Ac): 2.6% (5/189); taken together with transitional BPPV it was: Pc: 71.3% (164/230), Hc: 26.5% (61/230), Ac: 2.2% (5/230). Transitional BPPV forms were: Hc canalithiasis 58% (24/41), Hc cupulolithiasis 37% (15/41) and common crux reentry 5% (2/41). Treated with barbecue maneuver transitional Hc canalithiasis cases either resolved in 58% (14/24) or transitioned further to transitional Hc cupulolithiasis in 42% (10/24). In follow-up of transitional Hc cupulolithiasis we confirmed spontaneous recovery in 14/15 cases in less than 2 days. The most frequent transitional BPPV form was Hc canalithiasis so it raises importance of barbecue maneuver treatment. Second most frequent was transitional Hc cupulolithiasis which very quickly spontaneously recovers and does not require any intervention. The rarest found transitional BPPV form was common crux reentry which is treated by Canalith repositioning procedure. Transitional BPPV taken together with primary BPPV may decrease relative rate of Pc BPPV, considerably increase relative rate of Hc BPPV and negligibly influence relative rate of Ac BPPV. Transitional BPPV forms can be produced by repositioning maneuvers (transitional Hc cupulolithiasis) or by the subsequent controlling positional test (transitional Hc canalithiasis and common crux reentry); underlying mechanisms are discussed.

Clinical outcome of early glottic carcinoma in Serbia.

OBJECTIVE: Proposed methods for treating early glottic carcinoma are cordectomy through laryngofissure, laser cordectomy, and radiotherapy. The aim of the study was to conduct comprehensive study to evaluate oncological and functional results of different treatment modalities for Tis and T1 glottic carcinoma, identify prognostic factors for the outcome of treatment and decide where we stand in applying worldwide standards of early glottic carcinoma treatment. METHODS: Prospective study was conducted on 221 patients treated with Tis and T1 glottic carcinoma from 1998 to 2003 (72 patients were treated endoscopically with CO2 laser, 75 patients with cordectomy through laryngofissure and 74 with radiotherapy), with follow-up period from 38 to 107 months. Important demographic and clinical variables were analyzed. Voice quality after the treatment was assessed using multidimensional voice analysis. RESULTS: Comparing oncological results of three modalities of treatment, there were no significant differences. Functional results of treatment were better after laser cordectomy and primary radiotherapy than following the open cordectomy. Five-year survival rate was almost identical in all three groups of patients, and important prognostic factors for survival were age and histological grade of the tumor. CONCLUSION: Considering that the choice of treatment in our country is also greatly influenced by other paramedical factors, such as distance from treatment facility, reliability of follow-up, significant time delay of radiotherapy because of small number of radiology centers and strong patients' surgeon and treatment preference, we consider endoscopic laser surgery highly efficient and preferred choice of treatment for early glottic carcinoma.

Predictors for sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions.

OBJECTIVE: To determine predicting value of otitis type, age, gender, ear suppuration, disease duration, mucosal changes, cholesteatoma spreading, labyrinthine fistula, size, localization of tympanic membrane perforation, type and stage of its retraction and ossicular chain disruption with sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions. STUDY DESIGN: Retrospective case review study. SETTING: Tertiary referral center. PATIENTS: Approximately 264 adult patients with unilateral chronic ear disease, 60 adult patients with tympanic membrane retractions, 78 with cholesteatoma, and 126 with tubotympanic otitis. INTERVENTIONS: Otomicroscopy, pure tone audiometry, impedancemetry were carried out preoperatively. Wall up, wall down tympanoplasty, or two-stage surgery was applied depending on pathology. MAIN OUTCOME MEASURE: Bone conduction thresholds for 512 to 4,096 Hz. RESULTS: Mean values of bone conduction thresholds for frequencies 512 to 4,096 Hz were significantly higher in otitis groups than in healthy ears (p = 0.000), without differences between the groups. Ossicular disruption correlated with sensorineural hearing loss in cholesteatoma and tubotympanic otitis for all frequencies; long incus process destruction in tubotympanic ears showed strong negative correlation with sensorineural hearing loss for 512 to 2,048 Hz (linear regression coefficient, intercept was -2.84, -2.48, and -2.41; p = 0.0024, 0.0207, and 0.0076, respectively). Perforation size correlated with sensorineural hearing loss for 512 to 2,048 Hz in tubotympanic otitis (Log regression p = 0.0008, 0.0252, and 0.0267; odds ratio, 1.13, 1.11, and 1.06). Atelectasis correlated with sensorineural hearing loss for 4,096 Hz (p = 0.022). CONCLUSION: Predictors for sensorineural hearing loss in chronic otitis are otitis itself, age, ossicular disruption, especially of long incus process, extensive labyrinthine fistula, perforation size, and type of retraction.

Voice quality after treatment of early glottic carcinoma.

OBJECTIVES: Increasing incidence of laryngeal carcinoma and advancement in diagnostics and therapy methods, have led to constant exploration in that field. Early glottic carcinoma can be treated successfully with several procedures: cordectomy through laryngofissure, laser cordectomy, and radiotherapy. Our objective was to assess the voice quality after these different modalities of treatment. STUDY DESIGN: Prospective controlled study with 69 patients, treated in a 1-year period for glottic Tis and T1a carcinoma at the tertiary medical centre. METHODS: Nineteen of our patients were treated endoscopically with CO(2) laser (types III-IV cordectomy according to recommended European Laryngological Society classification of endoscopic cordectomies). Thirty-five patients underwent cordectomy through laryngofissure, 15 patients had radiotherapy. Multidimensional computer analysis of voice and speech was conducted 1, 6, and 12 months after the treatment. Three programs included 14 parameters, which were observed. RESULTS: While comparing the parameters between the groups, there were significant differences in the values of fundamental frequency (Hz), jitter (%), normalized noise energy (dB), standard deviation of fundamental frequency (Hz), percent silent time (%), and sound-pressure level in the different follow-up periods (P<0.05). CONCLUSION: In the long run, patients treated with radiotherapy show better voice quality in comparison with other two groups.

Temporalis fascia graft perforation and retraction after tympanoplasty for chronic tubotympanic otitis and attic retraction pockets: factors associated with recurrence.

OBJECTIVES: To correlate the recurrence of temporalis fascia graft perforation and retraction in adults and children after tympanoplasty for chronic tubotympanic otitis and deep attic retraction pockets with age, pathologic process, mucosal lesions, mucociliary transport time, chronic sinusitis, and lateral attic wall reconstruction. DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: Two hundred seventy-four adult ears and 41 child ears were operated on for chronic tubotympanic otitis, 50 adult ears were operated on for traumatic tympanic membrane rupture, and 56 adult ears were operated on for attic retraction pockets. INTERVENTIONS: Underlay tympanoplasty with or without mastoidectomy and lateral attic wall reconstruction for attic retraction pockets. Mucociliary transport time was investigated using saccharin testing. MAIN OUTCOME MEASURES: Recurrent perforation, recurrent attic retraction, and temporalis fascia graft retraction were evaluated. RESULTS: Higher incidences of recurrent perforation were found in adults operated on for tubotympanic otitis vs traumatic tympanic membrane rupture (P = .02) and in children (P = .004), especially those 9 years and younger (P = .02). A risk factor in adults was chronic sinusitis (risk ratio, 35.0; 95% confidence interval, 32.1-38.2; P = .004). Temporalis fascia graft retraction correlated with slower mucociliary transport time in adults (P < .001). A lower incidence of recurrent attic retraction was associated with lateral attic wall reconstruction (P < .001). CONCLUSIONS: Recurrent temporalis fascia graft perforation after tympanoplasty for tubotympanic otitis may be related to age and coexisting chronic sinusitis. Temporalis fascia graft retraction correlates with slower mucociliary transport time in the eustachian tube. Lateral attic wall reconstruction minimizes recurrent attic retraction in adults.

[Surgical approach to parapharyngeal space tumors].

INTRODUCTION: Parapharyngeal space tumors are very rare comprising 0.5% of head and neck tumors. Tumors of this symptomatology as well as considerable surgical issue owing to inaccessibility. PATIENTS AND METHODS: Retrospective twenty-year study of patients with parapharyngeal space tumors included 69 patients. Data were obtained from medical records, and were pointed to diagnostic procedures, surgical approach and pathohistological findings. Symptoms and clinical signs were also investigated. RESULTS: Preoperative diagnostics is very important for precise tumor localization and relation to adjacent structures. Computerized tomography was the most common method used, and recently, magnetic resonance imaging and indication-based contrast angiography have been applied. All of 69 patients with parapharyngeal space tumors were treated surgically. The most often approach to this tumor was transcervical (62%), then transoral approach and combination transcervical transoral approach. Pathohistological examination verified that most of the tumors were benign (75%) and origin of these tumors was most frequently salivary (42%). CONCLUSION: For making a decision on surgical approach, diagnostic methods, other than thorough examination, such as computerized tomography (CT) and/or magnetic resonance imaging (MR), are necessary to be applied.

[Impact of rhinosinusal polyposis on CT score in patients with chronic rhinosinustis].

BACKGROUND/AIM: Chronic sinusitis is a disease characterized with mucosal inflammation of nasal and paranasal sinuses for at least 12 weeks. In order to assess the extent and severity of inflammatory changes in paranasal sinuses CT score according to Lund-Mackay is the most commonly used. Recent studies show the possibility of existing different subtipes of chronic rhinosinusitis, pointing out the presence of nasal polyps and their influence on the severity of chronic rhinosinusitis. The aim of this research was to examine the influence of sinonasal polyposis on the extensity of inflammatory changes on computerized tomography (CT), evaluated by the Lund-Mackay CT score. METHODS: A prospective study compared the Lund-Mackay CT score values between the patients with chronic rhinosinusitis associated with nasal polyps and those without them. We determined mean values of the total CT score in both groups of the patients, as well as mean values of CT score for each group of sinuses and ostiomeatal complexes. RESULTS: The study included 90 patients, 47 males and 43 females, 45-year old on average, diagnosed with chronic rhinosinusitis on the basis of diagnostic algorithm. The group with uncomplicated chronic rhinosinusitis (without nasal polyps) consisted of 30 patients and the group with complicated chronic rhinosinusitis (with nasal polyps) of 60 patients. Observing these two groups of patients revealed statistically highly important intergroup difference in CT score for each group of sinuses and ostiomeatal complexes. The mean value of total CT score in the group with uncomplicated chronic rhinosinusitis was 4.37 while in the group with complicated chronic rhinosinusitis it was 16.05 (p < 0.01). CONCLUSION: Chronic rhinosinusitis complicated by sinonasal polyposis is characterized with more extensive inflammatory changes on CT and, consequently, with higher CT score for each group of sinuses and ostiomeatal complexes, as well as higher total CT score.

Risk factors for the occurrence of undifferentiated carcinoma of nasopharyngeal type: a case-control study.

INTRODUCTION: The incidence rate of nasopharyngeal carcinoma in Serbia is less than one per 100,000 citizens, which classifies it as a region with low incidence for this disease. OBJECTIVE: The aim of this study was to test some hypotheses of the risk factors for undifferentiated carcinoma of nasopharyngeal type (UCNT) in the low incidence population. METHODS: A case-control study was used for the research. The study included 45 cases with histopathological diagnosis of UCNT and 90 controls. Cases and the controls were individually matched by sex, age (+/- 3 years), and place of residence (city-village). Data were gathered about sociodemographic characteristics, occupational exposure to harmful agents, habits, diet, personal history, and family history. In the analysis of the data, conditional univariate and multivariate logistic regression analyses were applied. RESULTS: According to the results of multivariate logistic regression analysis UCNT was significantly positively associated with "passive smoking" of tobacco in the family during childhood, frequent consumption of industrially manufactured food additives for enhancing flavour and frequent consumption of white bread. UCNT was significantly negatively associated with frequent consumption of margarine, olive oil and cornbread. CONCLUSION: In our low incidence population, an independent risk factor for the occurrence of UCNT was "passive smoking" of tobacco in the family during childhood, use of industrially manufactured food with additives for enhancing flavour and consumption of white bread. Multicentric study enrolling a greater number of cases would be desirable.